TONSILLECTOMY-INDICATIONS, CONTRAINDICATIONS,METHODS,SURGICAL STEPS AND COMPLICATIONS

This presentation is mainly for medical students to prepare for their practical examination and VIVA ,OSCE.
This covers the topic of TONSILLECTOMY-INDICATIONS, CONTRAINDICATIONS,METHODS,SURGICAL STEPS AND COMPLICATIONS.
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1. OPERATIVE PROCEDURES SERIES TONSILLECTOMY - INDICATIONS -CONTRAINDICATIONS -METHODS -SURGICAL STEPS -COMPLICATIONS Dr.S.Kalyan Kumar MS ENT Gold Medalist KK’s ENT TUTORIALS

2. TONSILLECTOMY Tonsillectomy is surgery to remove the Palatine tonsils. The procedure is mainly performed for recurrent tonsillitis, throat infections and obstructive sleep apnea (OSA)

3. ABSOLUTE INDICATIONS Recurrent infections of tonsils (Most common indication) - Seven or more episodes in one year; five episodes per year for 2 years; three episodes per year for 3 years; two weeks or more of lost school or work in one year. Quinsy -Can be done immediately (Hot tonsillectomy) or after an interval of 6weeks (Interval tonsillectomy). Hypertrophy of tonsils causing airway obstruction (sleep apnoea) or difficulty in deglutition or interference with speech.

4. ABSOLUTE INDICATIONS Suspicion of malignancy. Tonsillitis causing febrile seizures. Benign tumours or cysts of the tonsil. Foreign body embeded in the substance of tonsil which can not be removed. Tonsillolith or intra- tonsillar abscess. Unilateral enlargement of tonsil.

5. RELATIVE INDICATIONS Diphtheria Carriers, who do not respond to antibiotics. Streptococcal carriers. Chronic tonsillitis with bad taste or halitosis which is unresponsive to Medical treatment. Recurrent streptococcal tonsillitis in a patient with valvular heart disease Persistent jugulodigastric lymphadenopathy following chronic tonsillitis Tuberculous jugulodgastric lymphadenitis: Tonsillectomy can be done under cover of ATT. Chronic otitis media: Due to enlarged tonsils empinging upon the Eustachian tube.

6. RELATIVE INDICATIONS Chronic pharyngitis and laryngitis, Glomerulonephritis, Chronic bronchitis, if it follows after acute tonsillitis. Rheumatic arthritis. Stunted growth or weak built. Dermatological conditions where the tonsils are thought to be a septic focus.

7. RELATIVE INDICATIONS As a part of another operation Removal of styloid process. Glossopharyngeal neurectomy. Uvulopalatopharyngoplasty. Branchial fistula: It is done in branchial fistula to remove the complete tract one end of the tract being in posterior faucial pillar.

8. CONTRAINDICATIONS Haemoglobin levels < 10gm% Acute Tonsillitis Children under 3 yrs of age Overt or Submucous Cleft Palate Bleeding disorders At the time of Polio Epidemic Aneurysm or abnormal vasculature of tonsil Uncontrolled systemic disease e.g., diabetes,cardiac disease,hypertension or Asthma Tonsillectomy is avoided during the period of menses Normal tonsils

9. REASON FOR CONTRAINDICATION IN POLIO EPIDEMIC Polio viruses get concentrated in tonsils and other Lymphoid tissues during an epidemic even in Normal persons. Tonsillectomy in this situation can trigger off Bulbar involvement causing paralytic polio due to entry of virus into the blood stream.

10. DIFFERENT METHODS OF TONSILLECTOMY DISSECTION AND SNARE METHOD(Most commonly performed) GUILLOTINE METHOD CRYOSURGICAL TECHNIQUE INTRACAPSULAR TONSILLECTOMY BY MICRODEBRIDER HARMONIC SCALPEL OR ULTRASONIC SCALPEL TONSILLECTOMY LASER TONSILLECTOMY ELECTROCAUTERY TONILLECTOMY TONSILLECTOMY WITH RADIOFREQUENCY (RF) COBLATION METHOD

11. DIFFERENT METHODS OF TONSILLECTOMY COLD METHODS HOT METHODS DISSECTION AND SNARE METHOD(Most commonly performed) GUILLOTINE METHOD CRYOSURGICAL TECHNIQUE INTRACAPSULAR TONSILLECTOMY BY MICRODEBRIDER HARMONIC SCALPEL OR ULTRASONIC SCALPEL TONSILLECTOMY LASER TONSILLECTOMY ELECTROCAUTERY TONSILLECTOMY TONSILLECTOMY WITH RADIOFREQUENCY (RF) COBLATION METHOD

12. DISSECTION AND SNARE METHOD Most commonly performed ( You can see the surgical video in our channel’s Conventional Tonsillectomy by dissection and snare method )

13. GUILLOTINE METHOD

14. GUILLOTINE METHOD

15. The guillotine was held in the right hand and inserted from the right side of the mouth when removing the left tonsil. The lower pole and the posterior border of the tonsil were engaged in the fenestra of the guillotine to draw the tonsil forward. GUILLOTINE METHOD

16. CRYOSURGICAL TECHNIQUE Tonsil is frozen by application of CryoProbe and then allowed to Thaw. Two applications each of 3-4 min are applied .Tonsillar tissue will under go necrosis and later fall off leaving a granulating surface. Bleeding is less due to thrombosis of vessels caused by freezing.This method is useful in patients with Bleeding disorders. -82 degree centigrade caused by Carbondioxide -196 degree centigrade caused by liquid nitrogen

17. INTRACAPSULAR TONSILLECTOMY BY MICRODEBRIDER This technique has an advantage over conventional tonsillectomy of leaving a biological dressing or residual tonsillar tissue and capsule to protect the underlying musculature with its vessels and nerves The surgeon uses the microdebrider to precisely remove greater than 95 percent of the tonsils, leaving a thin layer of connective tissue intact to protect the throat muscles, which helps reduce postoperative pain and recovery time.

18. HARMONIC SCALPEL OR ULTRASONIC SCALPEL TONSILLECTOMY The harmonic scalpel is a device that uses ultrasonic energy to cut tissue and coagulate tissue at temperatures lower than those associated with electrocautery and lasers. Uses hot ultrasonic energy to vibrate a special blade.The blade cuts the tonsil tissue and stops bleeding.

19. LASER TONSILLECTOMY There are various types of lasers have been used in tonsillectomy procedure like CO2, KTP, NDYAG, and diode. The advantages of the diode laser are good thermal effect on the perifocal tissues with shallow depth of penetration, thus carries few side effects to the deep tissues.

20. ELECTROCAUTERY TONILLECTOMY This method uses heat to remove the tonsils and stop any bleeding. Monopolar and Bipolar cautery probes can be used for the surgery.

21. TONSILLECTOMY WITH RADIOFREQUENCY (RF) Bipolar radiofrequency is an effective and safe technique in total tonsillectomy with acceptable intra-operative and post-operative results regarding pain and bleeding and can be used in pediatric population with no major morbidities.

22. COBLATION METHOD Coblation (a word derived from "controlled ablation" involves using low-temperature radiofrequency and a saline solution to gently and precisely remove the problematic tissues. The risk of injury to surrounding tissue is much lower than with cautery, and patients return to their normal activities more quickly. For video of coblation tonsillectomy refer earlier videos in our channel

23. ANAESTHESIA Usually done under general anaesthesia with endotracheal intubation. ( TransNasal or Trans Oral) In adults, it may be done under local anaesthesia .

24. POSITION OF THE PATIENT Rose’s Position 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.

25. STEPS OF SURGERY Boyle-Davis mouth gag is introduced and opened. It is held in place by Drafffin Bipod Stand. Tonsil is grasped with tonsil-holding forceps and pulled medially . Surgical video can be watched in our channel’s earlier videos-Conventional Tonsillectomy

26. 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. The tonsil is dissected from its bed with the help of tonsillar dissector. Once the tonsil is attached only at its lower pole, tonsillar snare is used to crush and cut the pedicle before removing the tonsil.

27. A Cotton ball soaked with H2O2 is placed in the tonsillar fossa and pressure applied for few minutes. Bleeding points are cauterized or tied with silk. Procedure is repeated on the other side.

28. POST OPERATIVE CARE Following surgery, the patient is kept in tonsillar position, where head is kept low and the patient lies in lateral position to prevent aspiration of blood. Nil orally for 6 hours.

29. POST OPERATIVE CARE Strict watch over the temperature, pulse and respiration every hour for first 4-5 hours. A rising pulse is a Sign of haemorrhage. Swallowing movements over anterior part of neck indicate that the blood is being swallowed. Broad spectrum antibiotics are given for 5-7 days. Analgesics. Diluted Hydrogen Peroxide/AntiSeptic Mouth gargles for next 10-15 days.

30. WHY H2O2 IS USED PER OPERATIVELY AND FOR GARGLING POST OPERATIVELY It is used as an oxidizer, bleaching agent and antiseptic. It is an unstable compound. It releases the nascent oxygen. Local application of 3% hydrogen peroxide on the tonsillar bed after tonsillectomy is beneficial as it decreases the procedure time and the volume of blood loss as well as number of ties used. Gargling with hydrogen peroxide helps soothe a sore throat . The antibacterial properties of hydrogen peroxide kill the bacteria that can cause sore throats. The bubbling action creates a foam – caused by the release of oxygen – This foam can help loosen mucus and makes the mucus less sticky and easier to drain. 20ml of hydrogen peroxide gargle which should be diluted with water in a ratio of 1:6. this gargle should be used every 4 hours

31. IMMEDIATE COMPLICATIONS Primary Hemorrhage Reactionary Hemorrhage Injury to Oral cavity and Oropharyngeal Structures ( Tonsillar Pillars,Uvula,Soft Palate,Tongue,Superior and inferior constrictor muscle and teeth) Aspiration (of Blood,Tonsil tissue and tooth) Pulmonary edema (in case of OSA and Corpulmonale ) Edema of Tongue , Nasopharynx and Palate Edema of face and eyelids Surgical Emphysema (due to Superior Constrictor muscle injury)

32. PRIMARY HEMORRHAGE Bleeding during the operation is usually controlled by pressure, ligation or electro-coagulation. Application of tannic acid, bismuth subgallate or hemostatic agents (Ethamsylate,Tranexamic Acid Intravenously, BOTROCLOT Drops, H202 Soaked cotton balls for local application ) may be helpful. Coagulopathy must be ruled out.

33. REACTIONARY HEMORRHAGE Bleeding after the recovery from anesthesia on the day of surgery is usually controlled by removing the clot, applying pressure or vasoconstrictor. Clot may prevent the clipping action of the superior constrictor muscle on the vessels. Immediate postoperative bleeding from nose and mouth or vomiting of dark colored blood and rising pulse rate indicate bleeding from the operative site. In cases of refractory bleeding, patient is taken back to operation room and ligation or electrocoagulation of the bleeding vessels is done under general anesthesia.

34. DELAYED COMPLICATIONS Secondary hemorrhage Infection (may cause Parapharyngeal abscess) Pulmonary complications (Aspiration of blood,mucus or tissue fragments may lead to atelectasis or lung abscess ) Scarring ( of soft palate and pillars) Hypertrophy of lingual tonsil (compensatory to the loss of palatine tonsils) Tonsillar remnants Hypertrophy of remnant tonsil ( If plica triangularis near the lower pole of tonsil is not removed along with tonsil, it may get hypertrophied)

35. SECONDARY HEMORRHAGE Bleeding seen between 5th-10th postoperative days is the result of sepsis and premature separation of the membrane. Clinical features: The common presentation is blood-stained sputum but bleeding may be profuse. Management: If bleeding 1s not controlled after removal of clot and topical application of dilute adrenaline, hydrogen peroxide and with pressure,then patientistaken to operation room. Under general anesthesia, bleeding vessel is electrocoagulated or ligated . Approximation of pillars with mattress sutures or external carotid ligation may be required in rare cases. Transfusion of blood or plasma may be needed. Systemic antibiotics control the infection.

36. DEAR STUDENTS In this short time, i may not cover all the topics but tried to cover most of the relavant things.But this is not a replacememt for standard text books and classical clinical teaching. But this will certainly facilitate your exam preparation and for better understanding of the subject.This is just a recap of what you have learnt. Hope this is useful for you. Thanks for Watching. You can watch videos of Conventional Tonsillectomy and Coblation Tonsillectomy in our channel’s earlier videos for better understanding of Surgical Procedure.

37. OPERATIVE PROCEDURES SERIES TONSILLECTOMY - INDICATIONS -CONTRAINDICATIONS -METHODS -SURGICAL STEPS -COMPLICATIONS Dr.S.Kalyan Kumar MS ENT Gold Medalist KK’s ENT TUTORIALS

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