Tonsillectomy & adenoidectomy ashly

tonsillectomy-indications, contraindications, methods, harmonic scalpel, diathermy, harmonic scalpel, laser, procedure, complications, management of haemorrhage
adenoidectomy-indications, contraindications, methods, procedure, complications,grisel syndrome

1. DR.ASHLY ALEXANDER ENT PG RESIDENT GMC BHOPAL Tonsillectomy & Adenoidectomy

2. Tonsillectomy Indications Local (cause in tonsil) Recurrent tonsillitis Physiological hypertrophy interfering with speech, breathing and swallowing Tumour of tonsil Tonsillolith FB embedded in tonsil Tonsillar remnants from previous tonsillectomy causing symptoms

3. Indications Cause when tonsil is normal 4-6 wks after quincy to prevent recurrence 4-6 months after diphtheria to prevent carrier state Before cleft palate repair to release tension As a part of UPPP As an appproch to glossopharyngeal nerve As an approach to styloid process Persistently enlarged JDLN OM with tonsillitis

4. Indications Systemic causes Rheumatic arthritis secondary to chronic tonsillitis. Nephritis secondary to chronic tonsillitis. Subacute bacterial endocarditis secondary to chronic tonsillitis. Certain cases of PUO

5. Contraindications PHYSIOLOGICAL: Below 4 years of age. During menses. During pregnancy Unimmunised child PATHOLOGICAL: 1. Blood dyscrasias . 2. Uncontrolled systemic diseases like DM, HTN, asthma & cardiac & renal diseases. 3. Acute URTIs. 4. During polio epidemic. 5. Infectious fevers.

6. Methods of tonsillectomy Guillotine Dissection & snare Diathermy Cryosurgery Laser Intracapsular Radiofrequency coblation Harmonic scalpel

7. GUILLOTINE TONSILLECTOMY One of the initial methods. Now abandoned. Named after guillotine – an instrument used to decapitate opponents during french revolution. Had high risk of excessive bleeding .

8. Guillotine instruments

9. DISSECTION & SNARE METHOD Most commonly used method today. Tonsil dissected along its bed & ultimately removed with snare.

10. ROSE POSITION Supine with head extended by placing a pillow or sandbag beneath the shoulders. Semi sitting position in LA

11. Procedure

12. Diathermy tonsillectomy Also called tonsillectomy with electrocautery Uses temp of 150-400 degree celcius

13. CRYOSURGICAL TONSILLECTOMY Very cold probe Removes tonsil by repeated freezing and thawing Using CO 2 , N 2 O & liquid nitrogen media temp reaches to -82 & -189 oC Used in bleeding disorders

14. Laser Tonsillectomy Usually CO2 or KTP lasers are used Laser seals all bleeders effectively

15. INTRA CAPSULAR TONSILLECTOMY USING MICRO DEBRIDER. • Tonsil is removed within its capsule. • Micro debrider with 45° handpiece is used.

16. Using radiofrequency coblation Also called cold ablation Utilises a field of plasma or ionised sodium molecules to ablate tissues Heat generated varies from 40-80 o C

17. HARMONIC SCALPEL TONSILLECTOMY Ultra sonic vibrations used to dissect & coagulate tissues. Temperature generated is 50-100 c as compared to 150- 400 c in electrocautery

18. POSTOPERATIVE CARE Patient is nursed in the lateral position Kept nil orally until fully recovered from GA (4-6 hours). Monitor vitals Watch for bleeding: Earliest sign-”Frequent swallowing” Ice cold fluids and ice cream given on the first day Oral antibiotics and analgesics

19. Complications Injury to neighbouring structures Aspiration of blood Reffered otalgia Remnant tonsil Post tonsillectomy hemorrhage Focal infections- transient bacterimia , septicaemia , meningitis , cavernous sinus thrombosis Surgical trauma to teeth, lips,tongue Soft palate & uvula

20. Post tonsillectomy hemorrhage TYPES: Primary Reactionary Secondary

21. Why called so? Primary – occurs at the operating table Reactionary - occurs as the reaction on recovery from anaesthesia Secondary - occurs secondary to infection

22. Where ? Primary : in operating room or recovery room. Reactionary : in the recovery room or in the ward. Secondary : at home

23. When ? Primary – within half an hour of the operation Reactionary - within 24hrs of the operation Secondary - at 5 th day of operation or onwards

24. Why ? PRIMARY: 1. Due to excessive trauma to the tissues & paratonsillar vein during surgery. 2. Due to wrong selection of cases. e.g : i . During menstruation. ii. During acute infection. iii. In patients having bleeding & clotting disorders.

25. Why ? Rectionary : due to slippage of ligature or dislodgement of clot 1.Elevation of BP on recovery from anesthesia 2.Post surgery violent efforts 3.Violent coughing & sneezing

26. Why ? Secondary : Due to infection - Slough seperates prematurely causing the erosion of underlying blood vessels

27. What to do ? Primary Preventive measures: Put the patient on operation after meticulous history, physical examination & investigation so that wrong selection of the case is avoided. Do the surgery in proper tissue plane, avoiding undue trauma to the tissues . Curative measures Coagulants. Fresh blood. Fresh frozen plasma. Specific deficient coagulation factors. Angiographic embolization

28. What to do ? REACTIONARY: Get prepared for tranfusing the blood. Try to locate the site of bleeding. Remove the blood clots. Cold water gargles. Gargles with hydrogen per oxide. Cold sponges at the corresponding angle of jaw. If still not controlled: Shift the patient to operating room for ligating the bleeding point .

29. What to do ? Secondary : Rest Sedation Antibiotics Removal of clots Gargles with H 2 O 2 if still not controlled- put gauze pad over tonsillar fossa and both pillars are stitched over it. This is later removed after 24-48hrs.

30. ADENOIDECTOMY INDICATIONS Adenoid hypertrophy causing: • Otitis media with effusion (SOM) • Upper airway obstruction and OSA • Recurrent ASOM • Recurrent rhinosinusitis

31. CONTRAINDICATIONS 1.Acute URI 2.Acute epidemic of Poliomyelitis 3.Bleeding disorders & Anaemia 4.Cleft Palate 5.Overt cleft palate

32. SUBMUCOSAL CLEFT PALATE

33. TECHNIQUE OF ADENOIDECTOMY The surgeon stands behind the patient. Boyle-Davis mouth gag is inserted, opened and held in place by Draffin’s bipod stand Palate is palpated to exclude a submucous cleft palate. The soft palate is retracted by a suction catheter introduced through the nose, and pulled out of the oral cavity. The adenoid is palpated with a finger

34. St Clair Thomson adenoid curette with guard is introduced into the nasopharynx above the upper end of adenoid tissue,“held like a dagger” With a downward and forward sweeping movement, adenoids are shaved off. A smaller sized curette is used to curette the adenoids around the choana and the Eustachian cushions Nasopharynx is packed with gauze packs for a few minutes for haemostasis

35. OTHER TECHNIQUES OF ADENOIDECTOMY Suction coagulator/diathermy Endoscopic transnasal or transpalatal adenoidectomy with microdebrider Coblator plasma field device

36. POSTOPERATIVE CARE The patient is kept in lateral position Kept nil orally until fully recovered from GA (4-6 hours). Monitor vitals Watch for bleeding: Earliest sign-”Frequent swallowing” Oral antibiotics and analgesics

37. COMPLICATIONS Haemorrhage ( < 0.7%) – Managed by postnasal packing Surgical trauma: Teeth, Soft palate , Uvula, Eustachian cushions- stenosis , secretory otitis media Cervical spine- atlantoaxial dislocation Velopharyngeal insufficiency Hypernasal speech, swallowing difficulty and rarely nasal regurgitation Adenoid remnant ( Upto 29%) Pulmonary complications- Aspiration,“Coroner’s clot” Infection of Nasopharynx

38. GRISEL’S SYNDROME Non traumatic subluxation of atlanto axial joint Results from any condition that results in hyperaemia and pathological relaxation of the transverse ligament of the atlanto -axial joint. Due to infection in the periodontoid vascular plexus that drains the region-> paraspinal ligament laxity. Presents with persistent neck pain and torticollis 1-2 weeks following surgery. More common in Down’s syndrome patients X-ray and CT of Cervical spine confirms diagnosis. Treatment: Cervical immobilisation , analgesics and antibiotics. Arthrodesis in intractable cases

39. TH A NK YOU