This document summarizes surgical procedures of the pharynx, including adenoidectomy and tonsillectomy. It describes the indications, contraindications, techniques and complications of adenoidectomy. For tonsillectomy, it outlines the types, absolute and relative indications, technique, postoperative care, complications and management of hemorrhage. It also discusses peritonsillitis and peritonsillar abscess, including etiology, pathogenesis, clinical features, diagnosis and treatment.

2. Surgical Procedures of the Pharynx
By
Dr. Asmatullah Achakzai
MBBS, DLO, MCPS, FCPS
Assistant Professor ENT Department
Bolan Medical College, Quetta

7. Adenoidectomy
Indications
• Adenoid facies
• Adenoids causing nasal obstruction and mouth breathing
• Septic focus: Otitis media, chronic rhinosinusitis
• Snoring
• Sleep apnea syndrome

8. Contraindications
• Age < 3 years
• Bleeding disorders
• Acute infection
• Cervical spine pathology like unstable spine, Mucopolysaccharidosis, etc.
• Epidemic of poliomyelitis
Technique Types
• Conventional: Curettage
• Endoscopic: Transnasal or transoral.

10. Steps of Adenoidectomy Curettage
• Orotracheal intubation.
• Position: Supine with extention of neck and atlantoaxial joint
• Place the Boyle-Davis mouth gag in position and the bipod stand is not
used
• Palpate the nasopharynx to confirm the size of adenoid with respect to the
choana and the septum.
• St. Clair Thomson's adenoid curette with/ without cage is used.

11. Steps of Adenoidectomy Curettage
• Insert the curette behind the soft palate till the posterior end of septum
is felt.
• Neck is flexed to avoid cervical lordosis thus preventing injury to the
anterior spinal ligament during curettage.
• Push curette backwards to trap adenoids inside the curette
• Curette with sweeping motion—Downwards and forwards
• Curettage is repeated till choanae one patient on palpation.

16. Complications
• Hemorrhage: Primary and reactionary. Secondary hemorrhage is very rare.
• Aspiration
• ET orifice injury: Otitis media with effusion, suppurative otitis media
• Injury to soft palate, posterior pharyngeal wall, etc. may occur.
• Injury to anterior longitudinal ligament causing subluxation of the
atlanto-occipital joint which may lead to quadriplegia.

17. Endoscopic Adenoidectomy
This is the recent development in the surgical management of adenoid hypertrophy. It was first
described by Nayak et al in 1998 for a case of Scheie syndrome (MPS I S) which is associated with
instability of the atlanto-axial joint and a traditional adenoidectomy is contraindicated as it needs proper
positioning of the patient. Comparative study between the conventional versus endoscopic technique
showed less blood loss and better post operative airway improvement as there is direct visualization and
clearance of the airway without injuring the eustachian tube orifice (Nayak et al 2005).

18. Tonsillectomy
Types
• Dissection method
• Cryosurgery
• Monopolar cautery assisted tonsillectomy
• Bipolar cautery assisted tonsillectomy with or without aid of microscope
• Laser assisted tonsillectomy
• Coblation tonsillectomy (Radiofrequency ablation)
• Harmonic scalpel assisted tonsillectomy
• Microdebrider assisted tonsillectomy
• Guillotine tonsillectomy

19. Absolute Indications
• Respiratory obstruction
• Peritonsillar abscess (4-6 weeks)
• Sleep apnea syndrome

20. Relative Indications
• Chronic tonsillitis
Not responding to medical treatment
More than 4 to 6 acute tonsillitis per year
Associated with cervical lymphadenopathy
Acting as septic focus for rheumatic heart disease, glomerulonephritis,
arthritis, etc. (13-hemolytic streptococcus)
Failure to thrive due to excessively enlarged tonsil

21. Relative Indications
• Primary tuberculosis of the tonsil
• Carrier of diphtheria
• Tumors of tonsils
– Benign—Papilloma
– Malignant—Small tumors confined to tonsils
– Suspected lymphoma in unilateral tonsillar enlargement

22. Relative Indications
• Tonsillar cyst, Tonsillolith, embedded FB in the tonsils, etc.
• Surgical approach
– Elongated styloid process
– Resection of ossified stylohyoid ligament
– Glossopharyngeal neurectomy
– As part of Uvulo-palato-pharyngo-plasty (UPPP).

23. Contraindications (ABCDEF)
• Active infection/Acute exacerbation, Aneurysm of internal carotid artery, Age
below three years, Active menstruation.
• Bleeding and clotting disorders
• Cervical spine pathology
• Diphtheritic tonsillitis. Drugs: Patients under aspirin, oral contraceptives, etc.
• Endemic of polio
• Failure to control systemic diseases like hypertension, diabetes, bronchial
asthma, LRTI, etc.

24. Technique
• General anesthesia is preferred, though few centers perform tonsillectomy under local
anesthesia in compliant patients
• Nasotracheal /orotracheal intubation with tube fixed in the midline.
• Rose position: Supine with extension of the neck and extension of the head at atlanto-
occipital joint
• Boyle-Davis mouth gag is placed after choosing the correct size tongue blade so as to retract
the base of the tongue and expose both the tonsillar fossae. Specialized tongue blade with
groove for the endotracheal tube (Doughty's tongue blade) may be used in case of
orotracheal intubation which avoids compression of the endotracheal tube.

26. Technique
• Draffin's bipod stand is used to stabilize the Boyle-Davis mouth gag in position.
• Superior pole of the tonsil is held using Dennis-Browne tonsil holding forceps or
Luc's forceps and the tonsil is gently pulled medially to facilitate retraction of the
tonsil from the anterior pillar and in showing a thin white line between the pillar
and the tonsil (loose areolar tissue plane).
• Incision is given along that line using a 11 number blade and the incision is
converted to a U shaped passing through the upper pole and the pillars.

30. Symptoms Cont…
• Using a Mollison's tonsillar dissector with anterior pillar retractor, the tonsillar capsule is
exposed and the tonsil is dissected along the loose areolar cleavage plane till the inferior
pole of the tonsil is reached.
• Tonsillar scissors may be required to divide tough fibrous band attached to the tonsillar
capsule from the fossa. Fibrous band is divided close to the tonsillar capsule.
• Eve's tonsillar snare is applied with its loop around the inferior pole and the tonsillar
attachment is divided.
• Hemostasis is achieved either by bipolar cautery or by catching the bleeder using a
straight tonsillar hemostat and then replaced by Negus curved tonsillar artery forceps
which helps in ligation of the bleeder. The silk knot can be carried to the site using a
Negus ligature carrier.

31. Postoperative Care
 Lateral position: In the postoperative period the patient is placed in the
lateral position to avoid any aspiration.
 Vital signs are monitored frequently. Look for tachycardia, weak and
rapid pulse and increased respiratory rate, blood pressure, fever, etc.
 Look for frequent swallow reflex which if present may suggest bleeding
in the tonsillar fossa.
 Oral or parenteral antibiotics and analgesics are given.
 Cold feeds after 4 hours which helps in vasoconstriction.
 Saline or dilute hydrogen peroxide gargles may be advised to keep the
operated site clean.
 Maintain good hydration.

32. Complications (Immediate)
 Primary and reactionary hemorrhage
 Aspiration of blood/saliva
 Injury to structures Teeth, lips, gums, palate, etc.
 Injury to posterior pillars may cause change in speech and nasopharyngeal reflux
 Pain throat with or without referred otalgia
 Dehydration
 Fever is not common and is usually related to local infection
 Postoperative airway obstruction may occur because of uvular edema, hematoma,
aspirated material
 Pulmonary edema
 Secondary hemorrhage occurs usually on 5th - 7th day.

33. Complications (Delayed)
• Lingual tonsillitis (compensatory hypertrophy).
• Nasopharyngeal stenosis
• Velopharyngeal insufficiency
• Residual tonsillitis

34. Tonsillectomy Hemorrhage
• Hemorrhage may be classified into primary, reactionary and secondary.
Primary Haemorrhage.
• This occurs during surgery often from the paratonsillar veins.
• This is often due to
–Poor selection of the case: (patient with acute attack of tonsillitis or
pharyngitis, bleeding disorders, hypertension or if. the patient is on
NSAIDS including aspirin, anticoagulant therapy and oral
contraceptives, etc.).
–Improper technique (dissection not in the proper cleavage plane,
injury to the superior constrictor muscles and paratonsilaar veins,
presence of tonsillar remnants and mucosal tags)

35. Tonsillectomy Hemorrhage Cont.…
• To stop primary hemorrhage is packed with wet gauze and wait for 5 minutes
till the bleeding and clotting time is over. This will stop the bleeding in most
of the cases.
• If bleeding persists, ligate/ cauterize the bleeding vessel.

36. Reactionary Hemorrhage
 This occurs in the postoperative within 24 hours. Usually it occurs within 6 to
8 hours after the surgery.
This can be due to the following:
 Failure to ligate all vessels
 Slippage of sutures
 Hypotensive anesthesia-BP returns to normal postoperatively
 Increased arterial or venous pressure during recovery.
 Clot in the fossa-Prevents contraction and retraction of the vessels and can
precipitate bleeding
 Injured muscle may cause diffuse ooze after recovery from anesthesia.
 Mismatched blood transfusion

37. Management
• Remove the clot and apply pressure with a small pack held in an artery forceps.
Usually the bleeding stops. Hydrogen peroxide gargle is helpful in removing the
clot postoperatively and is also a mild cauterizing agent. Vital signs should be
maintained. Treat hypovolemia and blood loss. If bleeding persists, shift patient to
operation theater and ligate/ cauterize the bleeding vessels.

38. Secondary Hemorrhage
• This is due to sepsis of the tonsillar fossa and usually occurs on 5th to 7th
postoperative day. Premature separation of the slough may precipitate this bleeding.
• Management - Start parenteral broad spectrum antibiotics including tinidazole or
metronidazole.
• Cold liquid diet
• General management is as for reactionary hemorrhage.
• In case of persistent bleeding, shift patient to operation theater and inter-pillar suturing may be
required in extreme cases.

39. Peritonsillitis and Peritonsillar Abscess
(Quincy)
Definition
• Peritonsillitis is defined as an acute inflammatory process associated with
cellulitis involving the loose areolar tissue in the peritonsillar space which lies
between superior constrictor muscle and the tonsillar capsule. The resultant
spread of infection involving looser areolar tissue causing collection of pus
within the space is called quincy or peritonsillar abscess.

40. Etiology
1. Recurrent attacks of acute tonsillitis
2. Penetrating trauma or foreign body
3. Common in adults in the 2nd and 3rd decade and is rare in infants and
young children.
4. Dental infection like periodontitis

41. Etiology
5. Tonsillolith or cyst
6. Infectious mononucleosis
7. Leukemia and other causes of immunocompromised state.
8. Inflammation of accessory salivary tissue called Weber gland that is situated just
above the superior pole in the soft palate, has been recently implicated for.

42. Pathogenesis
Recurrent attacks of acute tonsillitis may cause crypta magna to be obstructed
leading to intratonsillar abscess and subsequent spread of infection to the peritonsillar
space. Though this has been well accepted in the past, recent studies shows that the
supratonsillar space of the soft palate, immediately above the superior pole of the
tonsil and the surrounding muscles, especially the internal pterygoids can be site of
initial infection. Group A beta-hemolytic streptococcus is frequently isolated.

43. Clinical Features
Symptoms
• General: Fever, chills and rigor, malaise bodyache and toxic features are often present.
Local
1. Acute severe unilateral odynophagia
2. Referred otalgia
3. Neck pain
4. Trismus due to pterygoid muscle spasm
5. Muffled speech (hot-potato speech)
6. Dribbling of saliva

44. Signs
• Anterior pillar cannot be distinguished easily from the rest of the tonsils due to
edema and swelling of the overlying mucosa
• Tonsil is pushed medially and downward due to involvement of supratonsillar
space.
• Involved tonsil is often congested and follicles/ membrane may be present at
the crypts

45. Signs
• Uvula is congested, edematous and deviated to the opposite side
• Mucosa is edematous.
• Trismus causes difficulty in further examination.
• Tender, enlarged, discrete cervical lymphadenitis may be seen.
• If untreated, the abscess may rupture causing purnilent fetid discharge.

46. Differential Diagnosis
• Peritonsillar cellulitis (Peritonsillitis)
• Parapharyngeal abscess
• Parapharyngeal neoplasm
• Severe tonsillitis

48. Investigations
• Throat swab for culture and sensitivity
• Complete blood picture
• Rule out diabetes mellitus
• CT imaging if there is suspicion of a parapharyngeal abscess

49. Treatment
• IV antibiotics and analgesics and analgesics.
• If dysphagia is severe: Hospitalization IV fluids
• Wide bore needle aspiration
• Incision and drainage: This is done using quinsy knife or an ordinary Hard -Park
knife with only about a centimeter of the t! of the knife exposed and the rest
covered by a plaster to prevent deep penetration of the knife.

50. Treatment
A stab incision is given at one of the following points:
1. Imaginary horizontal line drawn at the base of the uvula which, intersects at a
vertical line drawn along the anterior pillar. Incision is given at the point of
intersection of these two lines.
2. At the point of maximum bulge in the supra-tonsillar area.
• Hot (abscess) tonsillectomy: Some people advocate tonsillectomy during the
active abscess stage. tonsillectomy after 6 weeks.

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