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1. Journal club Analysis of Different Techniques of Tonsillectomy: An Insight

2. Palatine Tonsils History Embryology Anatomy Immune functions of tonsil Tonsillectomy

3. History A disease which is similar to tonsillitis in clinical presentation in Ayurveda is  Tundikeri  which is described under  Mukha Roga . Dealing with the treatment of the disease  Tundikeri ,  Acharya   Sushruta mentions that  Tundikeri  is the  Bhedya Roga  and it should be treated as per the line of treatment of the disease  Galashundika

4. Cornélio Celsus , in the 1st century B.C., was the first to describe tonsillectomy surgery. He reported the procedure performance for dissection and removal of the structures. Celsus applied a mixture of vinegar and milk in the surgical specimen to hemostasis and also described his difficulty doing that due to lack of proper anesthesia.

5. Some recommendations for removing tonsils in that time included night enuresis (bed-wetting), convulsions, laryngeal stridor, hoarseness, chronic bronchitis and ashma . Other techniques for removing tonsils arouse in the Middle Ages, such as the ones using cotton lines to connect the base. The lines were daily tighted and then tonsils fell.

6. Hildanus , in 1646, and Heister in 1763, presented devices similar to a guillotine-cutter for uvulotomy . These instruments were modified by Physick , who, in 1828, in the United States, created the tonsilotome , used successfully in tonsillectomies.

7. Tonsillectomy was initially performed by general surgeons, but at the end of 19th century it became an ENT doctor´s care, due to the best techniques of illumination that we knew. Important steps in the progress of the tonsillectomy were taken using mouth-gag and tongue-depressors, besides the positioning of patient with leaning and suspended head. This position was first described by Killian in 1920, but only adopted after improvements on anesthesia techniques.

8. Joseph Beck was the first one to describe the use of a device with cutting wire inside a rigid ring known as Beck-Mueller´s ring. An instrument that also gained publicity in that period was Sluder´s guillotine. At the beginning of 20th century, the use of forceps and scalpels resulted in less bleeding From 1909, tonsillectomy surgery became a common and safe procedure, when Cohen adopted ligature of bleeding vessels to control perioperative hemorrhage.

9. Embryology Development begin in early in the third month of fetal life. Arise from • The endoderm lining of the second pharyngeal pouch, • The mesoderm of the second pharyngeal membrane , • Adjacent regions of the first and second arches. At fourth month, Epithelium of the second pouch proliferates to form solid endodermal buds, growing into the underlying mesoderm; these buds give rise to tonsillar stroma. Central cells of the buds later die and slough, converting the solid buds into hollow tonsillar crypts, which are infiltrated by lymphoid tissue. Follicles of lymphoid tissue - begin to collect around buds in the 5th month of foetal life.

10. Theories regarding origin of lymphoid tissue in tonsils 1. Gulland's theory - Most recent and accepted theory. Epithelial endodermal cells, which form the glandular buds of the tonsil, give rise to broods of lymphoid cells. 2. Older theory – These lymphoid cells arise from the blood or surrounding connective tissue, creep in and form follicles round the glandular endodermal buds.

11. Size of the tonsil The size of the tonsil varies according to the age, individuality, and pathologic status. Actual size of the tonsil is bigger than the one that appears from its surface . At the fifth or sixth year of life, the tonsils rapidly increase in size, reaching their maximum size at puberty. At puberty, the tonsils measure 20-25 mm in vertical and 10-15 mm in transverse diameters.

12. Indications of Tonsillectomy A. Absolute Recurrent infections of throat Peritonsillar abscess Tonsillitis causing febrile seizures Hypertrophy of tonsils causing obstruction Suspicion of malignancy B. Relative Diphtheria carriers, Streptococcal carriers Chronic tonsillitis with bad taste or halitosis Recurrent streptococcal tonsillitis in a patient with valvular heart disease C. As a Part of Another Operation Palatopharyngoplasty Glossopharyngeal neurectomy . Removal of styloid process.

13. Absolute Indications 1. Recurrent infections of throat. This is the most common indication. Recurrent infections are further defined as: (a) Seven or more episodes in one year, or (b) Five episodes per year for 2 years, or (c) Three episodes per year for 3 years, or (d) Two weeks or more of lost school or work in one year. 2. Peritonsillar abscess. In children, tonsillectomy is done 4-6 weeks after abscess has been treated. In adults, second attack of peritonsillar abscess forms the absolute indication.

14. 3. Tonsillitis causing febrile seizures. 4. Hypertrophy of tonsils causing airway obstruction (sleep apnoea ) difficulty in deglutition interference with speech. 5. Suspicion of malignancy . A unilaterally enlarged tonsil may be a lymphoma in children and an epidermoid carcinoma in adults. An excisional biopsy is done.

15. Relative Indications 1 . Diphtheria carriers , who do not respond to antibiotics. 2. Streptococcal carriers , who may be the source of infection to others. 3. Chronic tonsillitis with bad taste or halitosis which is unresponsive to medical treatment. 4. Recurrent streptococcal tonsillitis in a patient with valvular heart disease.

16. As a Part of Another Operation 1. Palatopharyngoplasty which is done for sleep apnoea syndrome. 2 . Glossopharyngeal neurectomy . Tonsil is removed first and then IX nerve is severed in the bed of tonsil. 3. Removal of styloid process .

17. Contraindications 1. Haemoglobin level less than 10 g%. level less than 10 g%. 2. Acute infection in upper respiratory tract, acute tonsillitis. Bleeding is more in the presence of acute infection. 3. Children under 3 years of age. 4. Overt or submucous cleft palate. 5. Bleeding disorders, e.g. leukaemia , purpura , aplastic anaemia , haemophilia . 6. At the time of epidemic of polio. 7. Uncontrolled systemic disease, e.g. diabetes, cardiac disease, hypertension or asthma. 8. Tonsillectomy is avoided during the period of menses.

18. Anaesthesia Usually done under general anaesthesia with endotracheal intubation. In adults, it may be done under local anaesthesia . Rose's position , i.e. patient lies supine with head extended by placing a pillow under the shoulders. In this position both the head and neck are extended.

19. Rose's position for tonsillectomy. Neck is extended by a sand bag under the shoulders and the head is supported on a ring. Downloaded from: StudentConsult (on 6 December 2012 06:54 PM) © 2005 Elsevier Rose's position

20. Advantages of Rose position: 1. There is virtually no aspiration of blood or secretions into the airway. 2. Both hands of the surgeon are free. This position helps in proper application of the Boyles Davis mouth gag. 3. The surgeon can be comfortably seated at the head end of the patient

21. Boyle-Davis mouth gag

22. Set of instruments for tonsillectomy .(1) Knife in kidney tray, (2) & (3) Toothed and non-toothed Waugh's forceps, (4) Tonsil holding forceps, (5) Tonsil dissector and anterior pillar retractor, (6) Luc's forceps, (7) Scissor, (8) Curved artery forceps, (9) Negus artery forceps, (10) Tonsillar snare, (11) Boyle Davis mouth gag with three sizes of tongue blades, (12) Doyen's mouth gag, (13) Adenoid curette, (14) Tonsil swabs, (15) Nasopharyngeal pack, (16) Towel clips. Downloaded from: StudentConsult (on 6 December 2012 06:54 PM) © 2005 Elsevier

23. Steps of Operation (Dissection and Snare Method) 1. Boyle-Davis mouth gag is introduced and opened. It is held in place by Draffin's bipods . 2. Tonsil is grasped with tonsil-holding forceps and pulled medially. 3. Incision is made in the mucous membrane where it reflects from the tonsil to anterior pillar. It may be extended along the upper pole to mucous membrane between the tonsil and posterior pillar.

24. 4. A blunt curved scissor may be used to dissect the tonsil from the peritonsillar tissue and separate its upper pole. 5. Now the tonsil is held at its upper pole and traction applied downwards and medially. Dissection is continued with tonsillar dissector or scissors until lower pole is reached 6. Now wire loop of tonsillar snare is threaded over the tonsil on to its pedicle, tightened, and the pedicle cut and the tonsil removed. 7. A gauze sponge is placed in the fossa and pressure applied for a few minutes. 8. Bleeding points are tied with silk. Procedure is repeated on the other side.

25. Post-operative Care 1. Immediate general care (a) Keep the patient in coma position until fully recovered from anaesthesia . (b) Keep a watch on bleeding from the nose and mouth. (c) Keep check on vital signs, e.g. pulse, respiration and blood pressure.

26. 2. Diet When patient is fully recovered he is to take liquids, e.g. cold milk or ice cream. Sucking of ice cubes gives relief from pain. Diet is gradually built from soft to solid food. They may take custard, jelly, soft boiled eggs or slice of bread soaked in milk on the 2nd day. Plenty of fluids should be encouraged.

27. 3. Oral hygiene Betadine or salt water gargles 4-6 times a day. A mouth wash with plain water after every feed helps to keep the mouth clean. 4. Analgesics Pain, locally in the throat and referred to ear, can be relieved by analgesics like paracetamol . An analgesic can be given half an hour before meals. 5. Antibiotics A suitable antibiotic can be given orally or by injection for a week. Patient is usually sent home 24 hours after operation unless there is some complication. Patient can resume his normal duties within 2 weeks

28. M ethods for tonsillectomy Cold Hot Dissection and snare Electrocautery Guillotine method Laser tonsillectomy (CO 2 or KTP) Intracapsular (capsule preserving) tonsillectomy Coblation tonsillectomy Harmonic scalpel Radio frequency Plasma-mediated ablation technique Cryosurgical technique

29. Guillotine method . Largely abandoned. It can be done only when tonsils are mobile and tonsil bed has not been scarred by repeated infections.

30. Intracapsular tonsillectomy . With the use of powered instruments (micro debrider with a 45 degree hand piece ) tonsil is removed but its capsule is preserved in the hope to reduce post-operative pain.

31. micro debrider micro debrider -tip blade

32. Harmonic scalpel . It is an ultra sound coagulator and dissector that uses ultra sonic vibrations to cut and coagulate tissues . The cutting operation is made possible by a sharp knife with a vibratory frequency of 55.5 KHz ovar a distance of 89 micro meters. Coagulation occurs due to transfer of vibratory energy to tissues. This breaks hydrogen bonds of proteins in tissues and generates heat from tissue friction.

33. Harmonic scalpel knife Harmonic scalpel tonsillectomy

34. Cryosurgical technique . Tonsil is frozen by application of cryoprobe and then allowed to thaw. Two applications, each of 3-4 minutes, are applied. Tonsillar tissue will undergo necrosis and later fall off leaving a granulating surface. Bleeding is less due to thrombosis of vessels caused by freezing. - 82 degrees centigrade by carbondioxide - 196 degrees centigrade by liquid nitrogen

35. Electrocautery . Both unipolar and bipolar electrocautery has been used. It reduces blood loss but causes thermal injury to tissues.

36. Laser tonsillectomy . It is indicated in coagulation disorders. Both KTP-512 and CO 2 lasers have been used but the former is preferred. Technique is similar to one used in dissection method. Laser tonsillotomy . Another method is laser tonsillotomy which aims to reduce the size of tonsils. It is indicated in patients who are unable to tolerate general anaesthesia . Tonsils are reduced by laser ablation up to anterior pillars by stage repeated applications.

37. Coblation tonsillectomy . It is also other wise known as cold abalation . This technique utilises a field of plasma, or ionised sodium molecules, to ablate tissues. The heat generated varies from 40 - 80 degrees centigrade, much lower than that of electro cautery . The major advantage of this procedure is reduced bleeding and reduced post operative pain .

38. Coblation tonsillectomy

39. Complications Immediate 1. Primary haemorrhage . Occurs at the time of operation. It can be controlled by pressure, ligation or electrocoagulation of the bleeding vessels. 2. Reactionary haemorrhage . Occurs within a period of 24 hours and can be controlled by simple measures such as removal of the clot, application of pressure or vasoconstrictor. 3. Injury to tonsillar pillars, uvula, soft palate , tongue or superior constrictor muscle due to bad surgical technique.

40. 4. Injury to teeth. 5. Aspiration of blood. 6. Facial oedema . Some patients get oedema of the face particularly of the eyelids. 7. Surgical emphysema. Rarely occurs due to injury to superior constrictor muscle.

41. B . Delayed Complications Secondary haemorrhage . Usually seen between the 5th to 10th post-operative day. It is the result of sepsis and premature separation of the membrane. Simple measures like removal of clot, topical application of dilute adrenaline or hydrogen peroxide with pressure usually suffice. For profuse bleeding, general anaesthesia is given and bleeding vessel is electrocoagulated or ligated . Sometimes, approximation of pillars with mattress sutures may be required. Sometimes, external carotid ligation may also be required. Transfusion of blood or plasma, depending on blood loss, is given. Systemic antibiotics are given for control of infection .

42. 2. Infection. Infection of tonsillar fossa may lead to parapharyngeal abscess or otitis media. 3. Lung complications. Aspiration of blood, mucus or tissue fragments may cause atelectasis or lung abscess. 4. Scarring in soft palate and pillars . 5. Tonsillar remnants. Tonsil tags or tissue, left due to inadequate surgery, may get repeatedly infected. 6. Hypertrophy of lingual tonsil. This is a late complication and is compensatory to loss of palatine tonsils. Sometimes, lymphoid tissue is left in the plica triangularis near the lower pole of tonsil, which later gets hypertrophied. Plica triangularis should, therefore be removed during tonsillectomy

43. Journal club Analysis of Different Techniques of Tonsillectomy: An Insight

44. TITLE : Analysis of Different Techniques of Tonsillectomy: An Insight . AUTHORS/AFFILIATION : Ajaz Ul Haq , Chetan Bansal , Apoorva Kumar Pandey , V. P. Singh Department of ENT, Shri Guru Ram Rai Institute of Medical Sciences, Dehradun , Uttarakhand,India Department of ENT, ONGC Hospital, Dehradun,Uttarakhand , India Max Hospital , Dehradun , India

45. Was the purpose stated clearly? Yes Outline the purpose of the study. The objective of this study is to compare three different surgical techniques of tonsillectomy namely the Cold dissection snare technique (CDST), Bipolar electro-dissection technique (BEDT) and Harmonic scalpel technique (HST) and to identify the method which is safe, with less operative time, which offers decreased intra-operative blood loss and with lowest post-operative morbidity and complications.

46. How does the study apply to your research question/clinical practice? Tonsillectomy is one of the most commonly performed surgical procedure in otolaryngology especially in children. This is an age old procedure which has seen continuous changes in the surgical technique from guillotine method to snare technique to coblation tonsillectomy, and is still evolving day by day. But there are no consensus as to which technique is the best or most appropriate for tonsillectomy.

47. Was relevant background literature reviewed? Yes Describe the justification of the need for this study. Knowledge of different approaches and disadvantages and advantages of each helps in choosing the most feasible approach.

48. Background literature 1. Vithayathil AA, Maruvala S (2017) Comparison between cold dissection snare method and bipolar electrodissection method in tonsillectomy. Res Otolaryngol 6(2):17–22 2. Clenney T, Schroeder A, Bondy P et al (2011) Post-operative pain after adult tonsillectomy with plasmaknife compared to monopolar electrocautery . Laryngoscope 121(7):https://doi.org/10.1002/lary.21806 3. Gurpinar B, Salturk Z, Akpinar ME, Yigit O, Turanoglu AK (2017) Comparison of tonsillectomy techniques and their histopathological healing patterns. Otolaryngol Open J(3):47–53 4. Baugh RF, Archer SM, Mitchell RB et al (2011) American Academy of Otolaryngology-Head and Neck Surgery Foundation Clinical practice guideline: tonsillectomy in children. Otolaryngol Head Neck Surg 144(1 Suppl ):S8 5. Ralph F, Wetmore. (2016) Tonsils and Adenoids. In: Kliegman Robert M, Behrman RE, Jenson HB, Stanton FB. Nelson textbook of pediatrics. 20th ed. Philadelphia: Saunders; Chap 383, p 2024. 6. Scottish Intercollegiate Guidelines Network. Management of sore throat and indications for tonsillectomy. SIGN publication No. 34. Available from: http://www.sign.ac.uk . 7. American Academy of Otolaryngology Head and Neck Surgery (2000) Clinical indicators compendirum . Alexandria, VA: American Academy of Otolaryngology Head and Neck Surgery, 8. Sharma K, Kumar D (2011) Ligation versus bipolar diathermy for hemostasis in tonsillectomy: a comparative study. Indian J Otolaryngol Head Neck Surg. 63(1):15–19 9. Curtin JM (1987) The history of tonsil and adenoid surgery. Otol Clin North Am 20:415–419 10. Crowe SJ, Watkins SS, Rothholz AS (1917) Relation of tonsillar and nasopharyngeal infection to general systemic disorders. Bull Johns Hopkins Hosp 28:1

49. Describe the study design. Was the design appropriate for the study question? Prospective comparitive study January 2018 to july 2019 ( 1 year 6 months ) Consent taken from the guardians Inclusion and exclusion criteria are stated

50. Inclusion criteria (1) Patient aged 4–40 years (2) Recurrent or chronic pharyngotonsillitis with minimum number of episodes of sore throat at least 7 episodes in the previous year, at least 5 episodes in each of the previous 2 year, or at least 3 episodes in each of the previous 3 year for children and 3–4 episode per year for 2–3 years for adults (3) As a part of ear surgery, uvulopalatopharyngoplasty and quinsy surgery (4) As part of Adenotonsillectomy

51. Exclusion criteria (1) Children suffering from tonsillitis of age less than 4 years and more than 40 years (2) Neoplasms of tonsil (3) Underlying bleeding and clotting disorders (4) Submucous cleft palate (5) Chronic systemic illnesses (6) Severe anemia

52. Was the sample described in detail? •Yes •Sampling - size - 150 •Prospective comparitive study • January 2018 to july 2019 ( 1 year 6 months ) •Type of approach chosen according to patients choice ( not mentioned )

53. Are the inclusions, Interventions and outcomes relevant/applicable to your setting? Yes it is applicable in our setting as we have more tonsillitis cases

54. Intervention was described in detail? •Yes Description of the intervention. •Prospective comparitive study - First 50 cases (cases 1 to 50) were done using Cold dissection snare technique - Patients no 51 to 100 were done using Bipolar electro dissection technique - last 101 to 150 cases were done using Harmonic scalpel technique. All the cases were performed by same surgical team.

55. All cases were performed under general anesthesia after oral endotracheal intubation under all aseptic precautions. Patient was positioned at the edge of the operating table and Rose’s position was achieved by applying sand bag between the shoulders. Davis-Boyle mouth gag was inserted into the patient’s mouth and fixed into position using Draffin bipod for adequate exposure of the oro -pharynx. In cases of adenotonsillectomy , adenoidectomy was done first and then tonsillectomy. Time and blood measurement was done separately for both the procedures.

56. In Cold dissection snare technique (CDST), tonsillectomy was done by palatoglossal incision using toothed Waugh forceps. Peritonsillar loose areolar plane was dissected from superior pole to inferior pole by mollison’s blunt dissector. Inferior pedicle was snared with the help of Eve’s tonsillar snare. After removal tonsillar fossa was packed with gauze for a few minutes depending on bleeding and clotting time of the patient. On removal of gauze, bleeders were ligated manually using suture material till hemostasis is achieved.

57. In Bipolar electro -dissection technique (BEDT), dissection and coagulation were done with the same bipolar forceps. Using the bipolar forceps, a palatoglossal incision was given, the peritonsillar loose areolar plane was dissected from superior to inferior pole. Minimum voltage current was used to allow coagulation. Fibro vascular bundles were coagulated and dissected. Low energy bipolar cautery technique of 25 watts was used to reduce heat trauma to the tonsillar bed and post-op pain. Tonsillar pericapsular plane dissection was also bluntly performed. Vascular bundles of tonsillar capsule and bed were coagulated to achieve hemostasis .

58. In harmonic scalpel technique (HST), ultrasonic cut ‘N seal device which is a handheld device, is used which utilizes ultrasonic energy at the blade tip to cut and coagulate the vessels or tissues simultaneously at low temperature heat (50–100 degrees Celsius). This technology controls bleeding by coaptive coagulation at low temperature. Coagulation occurs by means of protein denaturation when the blade vibrates at 55.5 kHz. This consists of a generator, a hand piece with a connecting cable, a blade system and a foot pedal. Tonsil retracted medially using Dennis Brown tonsil holding forceps. Using the harmonic hand piece, a palatoglossal incision was given, the peritonsillar loose areolar plane was dissected from superior to inferior pole and tonsillectomy performed using ultrasonic dissection. Hemostasis achieved simultaneously. The scalpel has lower temperature heat (50–100 degrees Celsius) as compared to standard electro cautery (400 to 6,000 degrees Celsius).

59. Were the outcome measures reliable? •Yes Describe the outcomes and their reliability and applicability. • Outcomes were documented which are reliable and can be used in clinical practice.

60. Operative time was recorded from the time of 1st incision to complete hemostasis of tonsillar bed. Intraoperative blood loss was measured by calorimetric method. In this the numbered plain soaked cotton balls and gauze balls used for pressure hemostasis were weighed pre and post operatively with the help of weighing balance and then adding the total so obtained (1gm = 1 ml). Blood collected in the suction bottle post operatively was also measured by total amount minus the amount of normal saline in the bottle. Both these amount of blood were added together to know the total intraoperative blood loss. The incidence and severity of any postoperative bleeding in the tonsillar fossa was recorded. Bleeding was classified as primary within first 24 h and secondary after 24 h during the phase of healing of the tonsil bed.

61. Post-operative pain was analyzed for all the patients using Wong Bakers FACES [14] pain rating scale on day 1st, 5th, 10th and 15th (1 = No pain, 10 = Suffering). This is a visual analogue scale from 1 to 10 that uses faces to identify the level of pain and discomfort experienced by the patient.

62. The duration of stay of the operated patients in the hospital extended from 1 to 3 days under the observation and then the patients were checked by operating surgeon before discharging postoperatively. They were advised to return back if there is any bleeding or any other compli - cation and were called for follow up on day 7th, day 14th and 1 month after the operation. Same surgical team per- formed each tonsillectomy and its follow up. All the patients received prophylactic antibiotic therapy in the postoperative period for 5 days.

63. The first cold liquid diet (water, milk, ice-cream) was given 4–6 h after the operation. The patients were allowed to return to their normal diet gradually till the post- oper - ative 5th day; if unable, the soft diet was continued until they were able to receive the normal diet. The patients were reminded about the standard postop- erative care. The patient was advised about routine mouth care and betadine mouth gargle after meals. Furthermore they were instructed to report to hospital if patient is not feeding well, if there is an episode of bleeding, increasing pain, dysphagia, vomiting and infection.

64. Results

65. Conclusions were appropriate given study methods and results • Yes What did the study conclude? What are the implications of these results for practice? Harmonic Scalpel Technique (HST) is the latest technique as it is associated with quicker procedure, less intraoperative blood loss and less post-operative pain. Morbidity in terms of post-operative hemorrhage and other complications (vomiting, dehydration, halitosis, odynophagia , infection of tonsillar bed) were also minimal with HST. ,

66. What were the main limitations or biases in the study? No Do you agree with the author’s interpretations? •Yes

67. Do you propose further studies on this topic? If so, why and how? •Yes further studies are needed to compare different approaches with conventional methods to know the feasibility and safest, quickest best approach.

68. THANK YOU