Tonsillectomy is the surgical removal of the palatine tonsils. It is indicated for recurrent throat infections, tonsillitis causing medical issues, or enlarged tonsils obstructing breathing.
Pre-operative assessment involves evaluating the patient's medical history, examining the throat, and in some cases checking coagulation or doing a sleep study. Certain conditions like bleeding disorders or Down syndrome require special pre-operative management.
The surgery involves using various techniques like dissection and snare to separate the tonsils from surrounding tissue and remove them. Post-operative care focuses on pain management, diet, hygiene and watching for potential complications like bleeding or infection. Newer techniques aim to reduce morbidity through less invasive procedures
3.
DIVIDED INTO 3:
1.ABSOLUTE.
2.RELATIVE.
3.AS A PART OF ANOTHER OPERATION.
INDICATIONS OF TONSILLECTOMY
4.
Recurrent infections of the throat. Paradise et al
> 7 ep. In 1 year or
5 ep. / year for 2 years or
3 ep. / year for 3 years or
>2 weeks of lost school or work in 1 year
Clinical features of each episode
Fever
Lymphadenopathy
Tonsillar/pharyngeal exudate
Positive-hemolytic streptococcus test
Medically treated
1.ABSOLUTE
5.
Peritonsillar abscess.
Tonsillitis causing febrile seizures.
Hypertrophy of tonsils causing
-airway obstruction
-difficulty in deglutition.
-interference with speech.
Suspicion of malignancy:
unilaterally enlarged tonsil
(Lymphoma in children/epidermoid ca in adult)
Cont…
6.
Diptheria carriers who do not respond to antibiotics.
Streptococcal carriers, who may be source of
infection to others.
Chronic tonsilltis with bad taste or halitosis which is
unresponsive to medicines.
Recurrent strep tonsillitis in pts with valvular heart
disease.
2.RELATIVE
7.
Palatopharyngoplasty which is done for sleep
apnoea syndrome.
Glossopharyngeal neurectomy.
Tonsil is removed first and then IX nerve is severed in the
bed of tonsil.
Removal of styloid process.
3.AS A PART OF OTHER
OPERATION
8.
Hb level less than 10 g%.
Presence of a/c infection in URI.
Children under 3 yrs of age.
Overt or submucous cleft palate.
Bleeding disorders eg:leukemia, hemophilia...
At the time of epidemic of polio.
Uncontrolled systemic diseases.
During the period of menses.
CONTRAINDICATIONS
14.
B –
potential CI e.g velopharyngeal,hematologic or
infection
Condition with increasing risk for postponing the
surgery e.g acute pharyngitis,fever,cough and
wheeze
C – management of pre -operative anxiety and
postoperative pain discussed with the patient and
family
16. Hematologic
Family or past history for unusual bleeding &
bruising
AAO-HNS & SFORL ; lab. Study indicated only
when the pt. or family hx is suggestive
Family hx is unavailable
Lab .studies ; PT, aPTT,INR, PLATLATE COUNT,
BT
Studies reveal that preoperative evaluation of coagulation
profile is NOT effective in identifying children who will
have post op. hg and it is NOT cost effective
17. Cardiac evaluation
Otherwise healthy children do not require a preoperative
cardiac evaluation for tonsillectomy and/or adenoidectomy
(T&A).
PSG & airway
A 2011 guideline recommends PSG in children who are
obese, have Down syndrome, craniofacial abnormalities,
neuromuscular disorders, sickle cell disease, or
mucopolysaccharidoses.
The PSG useful in ;
Level of post op. Care and the need for post op. oxymetry
Postponing or avoiding surgery
When the parental hx and physical ex. Are discordant
18.
Bleeding disorders
VWD and platelet function defect leads to increasing
perioperative hg.
Post op. hg in mild vwd who receive prophylactic
intervention can approach those unaffected
Autosomal dominant bleeding disorder
Increased bleeding time and prolonged aPTT.
Perioperative management
o IV Desmopressin (0.3ugm/kg)
o Serum Sodium
Pre-operative care in
specific condition
19.
Sickle cell disease
Risk for pain crisis ,acute chest syndrome, priapism and
strok if they became hypoxic ,acidotic or hypovolemic
during perioperative period
Pead.heamtologist included in periop. Period
To solve ;
Preoperative blood transfusion
Preoperative hydration
Preop. PSG
20.
Down syndrome
Risk of anaesthia related comp. due to soft and
skeletal alterations
OSA is common with DS so requir PSG
Increasing risk of delayed hospital stay due to
pulmonary comp.
Possibility of delayed oral intake
21. Emotional and pain preparation
Anxiety leads to increase post op. pain experience
So decrease in anxiety leads to decrease in post op.
pain
A prospective study of 241 children aged 5-12 yrs
who undergoes T&A surgery shows
More anxiety=
More postop. Pain
More consumption of pain medication
Hi incidence of delirium after op.
Hi post op. anxiety and sleep problem
22.
Other Tests
Antibodies for streptolysin-O (ASLO) have been
studied as possible indicators for tonsillectomy. [2]
These antibodies are correlated with previous
infection with group A beta-hemolytic streptococcus
(GABHS)..
When the diagnosis of recurrent GABHS is
questioned, high ASLO titers can shed light on the
patient's history.
23.
Imaging Studies
Imaging studies include plain radiography, CT
scanning, and MRI in an appropriate patient with a
tonsillar mass suggestive of malignancy.
In addition, a patient with a pulsatile area adjacent to
the tonsil should undergo magnetic resonance
arteriography (MRA) before routine tonsillectomy to
evaluate for an aberrant internal carotid artery.
24.
Histologic Findings
Histologic examination of the tonsils is unnecessary
unless cancer is suspected. If tonsils are asymmetric,
they should be submitted separately and examined
histologically to rule out cancer.
25.
Evaluation for allergy
Several studies have shown a higher-than-expected
incidence of allergy in children with adenotonsillar
disease. Therefore, evaluation for allergy may be
helpful, but only in children with the signs and
symptoms of allergic disease.
26.
Anaesthesia
The total duration of anesthesia should be as brief as is
practicable, certainly less than 30 minutes.
Total intravenous anesthesia with propofol and
remifentanil is associated with fast 'wake up' and little
'hangover
Propofol has the added merit of being an antiemetic agent.
perioperative
27.
Steroid therapy
single intravenous dose of dexamethasone was an effective,
relatively safe and inexpensive treatment for;
reducing morbidity from pediatric tonsillectomy.
an antiemetic.
Many units use a single dose of 2-4 mg
Cont..
32.
Boyle-Davis mouth gag is introduced and
opened.It is held in place by Draffins bipods or a string
over a pulley.
STEPS OF OPERATION
(DISSECTION AND SNARE
METHOD)
33.
Tonsil is grasped with tonsil holding forceps and pulled medially.
Incision is made in the mucous membrane where it reflects from
the tonsil to anterior pillar.
A blunt curved scissors may be used to dissect the tonsil from
the peritonsillar tissue and seperate its upper pole.
The tonsil is held in the upper pole and traction applied
downwards and medially.Dissection is continued until lower pole is
reached.
Wire loop of tosillar snare is threaded over the tonsil on to its
pedicle, tightened and the pedicle cut and tonsil removed.
A guaze is placed in the fossa and pressure applied for few mnts.
Bleeding points are tied with silk.
Procedure is repeated on the other side.
34.
IMMEDIATE GENERAL CARE
-keep the patient in coma position until fully recovered
from anesthesia.
- keep a watch on bleeding from nose and mouth.
-keep check on vitals ie pulse,BP,and RR.
POST OP CARE
35.
Diet
-after fully recovered; cold milk or icecream.
-sucking of ice cubes gives relief from pain.
-gradually from soft to solid food.
-plenty of fluids should be encouraged.
36.
Oral hygeine
-Pt is given Condy’s or hot water gargles 3-4 times a
day.
-Mouth wash with plain water after every feed.
Analgesics
-Pain, locally in the throat and reffered to ear can be
relieved by analgesics like paracetamol.
Antibiotics
-A suitable antibiotic can be given orally or by injection
for a week
37.
COMPLICATIONS
EARLY
•Primary h’ge(0.56%)
•Reactionary h’ge!!!!
•Injury to tonsillar
pillars,uvula,soft
palate,tongue or superior
costrictor muscle.
•Injury to teeth
•Aspiration of blood.
•Facial oedema.
DELAYED
•Secondary h’ge.(16.8%)
•Infection
(halitosis+fever)
•Lung complications
•Scarring in soft palate
and pillars.
•Tonsillar remnants.
•Hypertrophy of lingual
tonsil
39.
• Koltai et al, 2002
• Microdebrider at 1500 rpm in oscillating mode
• Hemostasis with suction cautery
Tonsil capsule is not violated thereby
avoiding pharyngeal muscle exposure to
secretions, injury, and inflammation As a
result, postoperative pain and recovery
time reduced
tonsillar regrowth with snoring
Intracapsular Tonsillectomy
40.
• Ultrasonic dissector and coagulator
• Vibratory energy
• Cutting: sharp blade with frequency of
55.5kHz
• Temp. of surrounding tissue is 80
• Coagulating: vibration breaks H-bonds,
thermal energy
Harmonic Scalpel Tonsillectomy
41.
No significant difference in intraoperative blood loss and postoperative
ability to eat and drink
Level of activity for the first postop day significantly lower in harmonic
scalpel group
Postoperative pain scores tended to be lower in harmonic scalpel
group
Willging et al
42.
• Kothari et al, 2002K
• KTP laser provides little benefit over dissection tonsillectomy
except to minimize intraoperative bleeding
higher postop pain scores
greater difficulty resuming postoperative diet
More risk for secondary bleeding
Limitations
• Technical expertise
Laser Tonsillectomy
43.
COBLATION TONSILLECTOMY
Technology combines radiofrequency
energy and saline to create a plasma
field. The plasma field remains at a
relatively low temperature 40-70°
as it precisely ablates the targeted tonsil
tissue.
The COBLATION plasma field
removes target tissue while minimizing
damage to surrounding areas.
The probes or 'wands' are single use
and there is a cost consideration
Haemorrhage' was defined as a bleed
that prolonged the patient's hospital stay, required blood
transfusion, a return to the operating theatre, or in the
case of 'secondary' haemorrhage readmission to hospital.
