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1. By –DR. BANSARI AKBARI 1 ST YEAR RESIDENT PG GUIDE- DR. VATSAL PATEL

2. Indications :- They are divided into:

A. ABSOLUTE 1. Recurrent infections of throat. This is the most common indication. Recurrent infections are further defined as:
(a) Seven or more episodes in 1 year, or (b) Five episodes per year for 2 years, or
(C)Three episodes per year for 3 years,
(d) Two weeks or more of lost school or work in 1 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.
3. Tonsillitis which causes febrile seizures.

3. 4.Hypertrophy of tonsils causing:
(a) airway obstruction (sleep apnoea ),
(b) difficulty in deglutition and interference with speech.
5. Suspicion of malignancy. A unilaterally enlarged ton- sil may be a lymphoma in children and an epidermoid carcinoma in adults. B. RELATIVE :- Diphtheria carriers, who do not respond to antibiotics. Streptococcal carriers. Chronic tonsillitis with bad taste or halitosis which is unresponsive to medical treatment. 4. Recurrent streptococcal tonsillitis in a patient with valvular heart disease.

4. C . AS A PART OF ANOTHER OPERATION 1. Palatopharyngoplasty which is done for sleep apnea syndrome. 2. Glossopharyngeal neurectomy . Tonsil is removed first and then IX nerve is severed in the bed of tonsil.
3. Removal of styloid process.

5. CONTRAINDICATIONS:- 1. Hemoglobin less than 10gm% 2. Presence of acute infection in upper respiratory tract even acute tonsillitis. Bleeding is more in the presence of acute infection.
3. Children under 3 years of age. They are poor surgical risks.
4. Overt or submucous cleft palate. 5. Von Willebrand disease. Bleeding disorders, e.g. leukamia , purpura , aplastic anaemia , haemophilia or sickle cell disease.
6.Uncontrolled systemic disease, c.g. diabetes, cardiac disease, hypertension or asthma.

6. ANAESTHESIA- Usually done under general anaesthesia with endotracheal intubation. In adults, it may be done under local anaesthesia POSITION :-
Rose’s position, i.e. patient lies supine with head extended by placing a pillow under the shoulders. A rubber ring is placed under the head to stabilize it . Hyperextension should always be avoided.

7. OPERATIVE STEPS:- 1. Boyle-Davis mouth gag is introduced and opened. It is held in place by Draffin’s bipods or a string over a pulley. 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.
4. A blunt curved scissor may be used to dissect the tonsil from the peritonsillar tissue and separate its upper pole.
5. Now the tousil 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 at 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.

8. COMPLICATIONS :- A. 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 hr and can be controlled by simple measures such as removal of the clot, application of pressure or vasocon - strictor . Presence of a clot prevents the clipping action of the superior constrictor muscle on the vessels which pass through it (compare postpartum uterine bleed- ing ). If above measures fail, ligation or electrocoagula - tion of the bleeding vessels can be done under general anaesthesia .
3. Injury to tonsillar pillars, uvula, soft palate, tongue or superior constrictor muscle due to had surgical technique.
4. Injury to teeth. 5.Facial oedema .
6.Aspiration of blood.
7.Surgical emphysema.

9. B. DELAYED

1. Secondary haemorrhage . Usually seen between the fifth to tenth postoperative day. It is the result of sepsis and premature separation of the membrane.
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.

10. 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. 2. DIET. When patient is fully recovered he is permitted to take liquids, e.g. cold milk or ice cream. Diet is gradually built from soft to solid 3. ORAL HYGIENE. Patient is given salt water gargles three to four times a day. A mouth wash with plain water after every feed helps to keep the mouth clean. 4. ANALGESICS.
5. ANTIBIOTICS.

11. Methods of tonsillectomy :- Cold. Dissection and snare
Guillotine method Intracapsular (capsule preserving)
tonsillectomy
Harmonic scalpel
Plasma-mediated
ablation technique Hot Electrocautery Laser tonsillectomy (CO or KTP) Coblation tonsillectomy
Radio frequency
Cryosurgical technique