Tonsillectomy

definition
preoperative evaluation
operation
postop. care
complications

1. Tonsillectomy By Dr . muhanned A lali S . H . O BTC ( B ASRAH T RAINING C ENTER)

2. TONSILLECTOMY IS DEFINED AS ; THE SURGICAL EXCISION OF PALATINE TONSILS WHAT IS TONSILLECTOMY ?

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

9. GRADING

10. Medical Anatomical Hematological Cardiac PSG & airway Pre-operative assessment

11. A – Medical

12. 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

13. Anatomical Examination of the oropharynx Uvula and palate Tonsil size Submucus cleft

14. 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

15. 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

16. 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 IV Desmopressin (0.3ugm/kg) Serum Sodium Pre-operative care in specific condition

17. 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

18. 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

19. 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

20. 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.

21. 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.

22. 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.

23. 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.

24. 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

25. 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..

26.  TECHNIQUES OF TONSILLECTOMY  COLD METHODS  HOT METHODS

27.  COLD METHODS  Dissection and snare(most common)  Guillotine method.  Intracapsular tonsillectomy with debrider .  Harmonic scalpel(ultrasound)  Plasma mediated ablation technique.  Cryosurgical technique

28.  HOT METHODS  Electrocautery.  Laser tonsillectomy or tonsillotomy .  Coblation tonsillectomy.  Radio frequency

29. The operation

30.  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)

31. 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.

32.  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

33.  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.

34.  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

35.  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

36. Innovative Techniques  Intracapsular Tonsillectomy  Harmonic Scalpel  Laser  Coblation  Guiding Principle: reduce morbidity  Hemorrhage  Pain  Diet  Activity  Cost

37.  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

38.  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

39. 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

40.  Kothari et al, 2002 K 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

41. 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