Tonsillectomy.pptx

EAR NOSE THROAT AND HEAD NECK SURGERY

1. Tonsillectomy Dr.Satish Kumar Ray 1 st year Resident,ENT -HNS Moderater : Dr.Bikash Gurung Pokhara Academy of Health Sciences

2. Overview Anatomy History Indication Tonsillectomy techniques Steps of tonsillectomy Post-operative care Complication

3. Tonsil Palatine Lingual tonsils Adenoids Tubal Diffuse aggregates of pharyngeal submucosal lymphoid tissue ↓ Waldeyer’s ring ↓ A complete circle of lymphoid tissue surrounding the entrance to the gastrointestinal and respiratory tracts

4. PALATINE TONSIL Paired aggregates of lymphoid tissue Located  pocket between palatoglossus and palatopharyngeus muscles  overlying folds of mucosa ↓ Anterior and Posterior tonsillar pillars Common structure with lymphoid tissue elsewhere ↓ Gastrointestinal and respiratory tracts  adenoids , Peyer’s patches ,appendix

5. The stratified squamous non keratinizing mucosal covering of the tonsils  irregular convoluted invaginations  parenchyma  pits or crypts. 12–15 crypts  medial surface of tonsil. One of the crypts  very large and deep ↓ crypta magna or intratonsillar cleft . Microorganisms, desquamated epithelium and food debris are frequently present within the crypts

6. Relation of palatine tonsil Medial surface crypts Lateral surface fibrous capsule Between the capsule and the bed of tonsil loose areolar tissue Upper pole  extends into soft palate  medial surface is covered by a semilunar fold  potential space called supratonsillar fossa . Lower pole  attached to the tongue  separated from the tongue by a sulcus called tonsillolingual sulcus

7. Bed of tonsil Tonsil is related laterally to its capsule (1), loose areolar tissue containing paratonsillar vein (2), superior constrictor muscle (3), styloglossus (4), glossopharyngeal nerve (5), facial artery (6), medial pterygoid muscle (7), angle of mandible (8) and submandibular salivary gland (9), pharyngobasilar fascia (10), buccopharyngeal fascia (11

8. Blood supply The tonsil is supplied by five arteries 1. Tonsillar branch of facial artery. This is the main artery. 2. Ascending pharyngeal artery from external carotid. 3. Ascending palatine, a branch of facial artery. 4. Dorsal linguae branches of lingual artery. 5. Descending palatine branch of maxillary artery.

9. VENOUS DRAINAGE Drain into paratonsillar vein  common facial vein and pharyngeal venous plexus LYMPHATIC DRAINAGE Drain into upper deep cervical nodes particularly the jugulodigastric ( tonsillar ) node situated below the angle of mandible. NERVE SUPPLY Lesser palatine branches of sphenopalatine ganglion (CN V) and glossopharyngeal nerve provide sensory nerve supply

10. Normal flora Extremely variable in health & disease Surface of the tonsil in disease is GABHS Other surface organisms include Haemophilus , Staphylococcus aureus,alpha haemolytic streptococci, Branhamella sp., Mycoplasma,Chlamydia , various anaerobes and a variety of respiratory viruses.

11. Function Lymphoid germinal centres  submucosally contain both B and T lymphocytes. Responsible for the final differentiation, induced by exposure to antigen  B cells IgG and IgA plasma cells Allow positive selection of B cells Generate B cells which express polymeric IgA  migrate to the upper respiratory tract mucosa ↓ associated ‘front line’ mucosal surfaces

12. HISTORY OF TONSILLECTOMY Celsus in ‘De Medicina ’ (14–37 AD ) ‘ induration’of the tonsils  dissection with the fingernail. If not possible  grasped with a hook and pulled out with ‘bistoury’. Morrel McKenzie Improved instrumentation – snares and ‘guillotines’ popularization of the operation Sir Felix Semon (1849–1921 ) Removed the tonsils  several of Queen Victoria’s grandchildren  fashionable in the drawing rooms of the aristocracy.

13. The SIGN guidelines for tonsillectomy Based on Paradise criteria patients for tonsillectomy  both adults and children should meet all the following criteria sore throats are due to tonsillitis the episodes of sore throat are disabling and prevent normal functioning seven or more well-documented, clinically significant, adequately treated sore throats in the preceding year, or five or more such episodes in each of the preceding 2 years, or three or more such episodes in each of the preceding 3 years

14. Indications for tonsillectomy Recurrent acute tonsillitis Peritonsillar abscess Further indications for tonsillectomy In adults with gross tonsil hypertrophy and OSA, or as part of uvulopalatopharyngoplasty (UPPP) or laser-assisted uvulopalatoplasty Severe haemorrhagic tonsillitis Severe infectious mononucleosis with upper airway obstruction Large symptomatic tonsoliths ( tonsillar Concretions) As long-term management of IgA nephropathy

15. Tonsillectomy can be indicated for biopsy purposes in the following scenarios Asymmetrical adult tonsil with normal mucosa in the absence of cervical adenopathy Asymmetrical adult tonsil with mucosal abnormality and or cervical adenopathy As an oncological procedure for Ca tonsil For obstructive sleep apnoea (OSA) in children in conjunction with adenoidectomy

16. Hypertrophy of tonsil

17. Tonsillectomy techniques Undergoing something of a revolution. Dissection tonsillectomy (first described by Edwin Pynchon in 1890) with haemostasis performed with ties or diathermy  standard Recently  explosion of different dissection instruments  effort  reduce postoperative pain and haemorrhage Current trials Any these techniques is consistently clinically greatly superior to any other technique

18. Dissection techniques Nondissection techniques Dissection techniques cold dissection techniques sharp/ bluntsnares and haemostasis with ties or diathermy mono or bipolar diathermy or electrocautery dissection  Monopolar  Bipolar forceps tonsillectomy  bipolar scissor tonsillectomy Radiofrequency/ electrosurgery tonsillectomy  somnoplasty tonsillectomy: bipolar thermal radiofrequency ablation  coblation (plasma-mediated ablation)tonsillectomy  argon plasma coagulator tonsillectomy harmonic scalpel (ultrasound) tonsillectomy Laser dissection tonsillectomy: CO2 laser, potassium titanyl phosphate (KTP) and Nd -YAG laser tonsillectomy Nondissection techniques include: guillotine tonsillectomy; intracapsular partial tonsillectomy

19. Tosillectomy technique

20. PRINCIPLES OF DISSECTION TONSILLECTOMY 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

21. The incision Tonsil is grasped with Luc's or similar forceps Drawn -medial direction exposing an area of mucosa medial to the free edge of the anterior faucial pillar. Incision  halfway between the upper and lower 'poles' Scissors or other sharp instrument depth of the surgical 'capsule' of the tonsil. Preserve as much as possible of the mucosa Incision downwards to the base of the tongue and upwards to the upper pole.

22. Beginning of blunt dissection When capsule has been identified Howarth's nasal raspatory or similar blunt dissector  separate tonsil and its capsule  surrounding peritonsillar tissues

23. Mobilization of upper pole upper pole must first be mobilized  keep the dissector as close as possible to the capsule throughout the dissection. 'Digging' into the fossa  bleeding and more postoperative scarring

24. Continuing the dissection Gripping  upper pole  draw the tonsil towards the midline  extends the dissection by separating the peritonsillar tissues  capsule, until the lower pole is approached.

25. Mobilization of lower pole Lower pole of the tonsil there is a firm fibrous triangular fold  hold up the dissection at this point. Triangular fold  cut with scissors Dissection carried on to the base of the tongue.

26. Removal of tonsil A cold-wire snare is threaded over the tonsil  finally removed by closing the snare at the level of the tonsillolingual sulcus. This ensures  lingual 'tongue' of lymphoid tissue is removed with the tonsil proper ↓ Failure to do so may result in 'recurrence

27. Control of haemorrhage Most primary bleeding from tonsillectomy  venous Minor bleeding  controlled naturally by the contraction and retraction of the smaller vessels  occur spontaneously if a gauze swab  fossa for 2 or 3 minutes. Main paratonsillar vein  'holed' or sectioned  ligated with silk thread (right fossa). Minor persistent bleeding from smaller vessels  quickly and effectively with insulated diathermy forceps (left fossa)

28. The various dissection techniques Developed  minimize tissue trauma  postoperative pain and bleeding while remaining simple and of short duration. All the techniques have their advocates and detractors

29. Diathermy or electrocautery dissection Refers to using a heated instrument to cut or coagulate tissues. Heat generated 150-400 ˚c Pros significant reduction in intraoperative blood loss and operating time Cons Increase in haemorrhage , pain and slower healing The recent Cochrane review identified 22 studies comparing tonsillectomy by diathermy and dissection Reduced intraoperative bleeding but increased pain in the diathermy group Increased risk of secondary haemorrhage Method of choice in patients at high risk of bacteraemia .

30. Radiofrequency tonsillectomy Somnoplasty tonsillectomy Use radiofrequency waves at 460 kHz and have a bipolar electrode. The electrode has a temperature sensor for adjustment of output power  control of tissue temperature and total energy delivered Target temperature held constant at 85 ˚c Pros  significantly less pain (mucosa is not breached) Cons  trials were too small to make meaningful comments on haemorrhage rates

31. Coblation (plasma-mediated ablation)tonsillectomy Using radiofrequency signals  electrodisassociation effect to generate a plasma of excited ions or an ionized field. The coblator handpiece  electrode as well as an irrigation and suction channel  fragment and suction tissue from the field Heat generated  40 -70 ˚c Pros  reduced postoperative pain, more rapid healing and quicker resumption of normal activities Cons  3.4 times greater haemorrhage rate than cold steel dissection bipolar diathermy which was 3.1 times >cold steel dissection.

32. Argon plasma coagulator tonsillectomy Requires an argon plasma coagulation (APC) dissector, an argon gas source & high frequency voltage generator. APC dissector  rigid tube with a ceramic tip through which argon flows to the tip  electrode serves as one pole frequency voltage source Pros  limited penetration & good coagulative properties  minimizing blood loss & postoperative pain. less postoperative haemorrhage >diathermy Cons  more complications and longer operating time

33. Harmonic scalpel (ultrasound) tonsillectomy Two mechanisms to cut and coagulate tissue. sharp blade vibrating at 55.5 kHz over a distance of 80 mm. The rapid forward and backward motion of the cutting tip in contact with tissue  fragmentation and separation of tissue planes Coagulation  mechanical disruption hydrogen bonds and thus protein denaturation

34. Harmonic scalpel (ultrasound) tonsillectomy Temperature rise  frictional changes(50–100 ˚c) Pros  improved visibility less force and tissue tension for incisions >traditional Cons  intraoperative blood loss and postoperative haemorhage rates were similar

35. Guillotine tonsillectomy most suitable for protuberant tonsils in the paediatric population The tonsil is pushed fully through the guillotine  closed All tonsil tissue is through the guillotine and no anterior pillar mucosa is caught in the guillotine. If the tonsil cannot be completely fitted through the guillotine  abandoned. Once the guillotine is closed  a minute to compress vessels in the lower pole before cutting off the tonsil

36. Pros  less pain and greater speed Cons  excessive trauma to pillars, postoperative bleeding from an inadequately removed lower pole and persistent infection in tonsil remnants

37. Hemorrhage

38. Postoperative care Introduction Postoperative pain & analgesia Antiemetic therapy post-tonsillectomy Diet post-tonsillectomy Adjunctive therapy: local anaesthesia , antibiotics and steroids

39. Postoperative care Tonsillectomy  Discussion  day case or overnight stay –ongoing Favours Economic benefits Minimal morbidity Low reactionary haemorrhage rate after eight hours (0.49percent) Reasonable ability to control pain and nausea

40. The criteria for day case tonsillectomy an available competent adult at home to manage potential problems access to a car to return the patient to hospital; access to a telephone a home-to-hospital driving time of less than 20minutes; no medical contraindications

41. Postoperative care Monitoring for haemorrhage  most important aspect of post-tonsillectomy care Clinical observation Excessive swallowing Pallor Increases in pulse rate Monitoring blood volumes  coughing or vomiting up blood ,assess the bleeding point. Record blood losses in theatre, in recovery and ward

42. Total expected patient blood volumes  100mL/kg All cases of reactionary haemorrhage in children  theatre in order to obtain reliable control. In adults  greater blood volume  short period of conservative treatment  attempted prior to surgical reintervention .

43. POSTOPERATIVE PAIN/ANALGESIA REQUIREMENTS Little information practiceindividualized paracetamol (20 mg/kg) and diclofenac (1 mg/kg), except in asthmatics, two hours preoperatively as well as the uniform postoperative prescription of up to 100 mg/kg of paracetamol and 3 mg/kg of diclofenac in 24 hours with DF118 as rescue analgesia

44. POSTOPERATIVE PAIN/ANALGESIA REQUIREMENTS NSAIDs, for example ketoprofen combined with full dosages of paracetamol and codeine as rescue analgesia was sufficient Median time for cessation of pain  11 (3–24) days Median duration of analgesia taken of 12 (5–25) days. Median time for cessation of pain on drinking  (1–18) & on eating solids 11 (1–20) days. First normal night of sleep at 7(0–18) days Normal daily activities 12 (2–24) days

45. ANTIEMETIC THERAPY POST-TONSILLECTOMY Prophylactic single-dose antiemetic therapy using ondansetron or other selective 5HT type 3 receptor antagonists DIET POST-TONSILLECTOMY No evidence  rate of recovery or complication rates

46. ADJUNCTIVE THERAPY: LOCAL ANAESTHESIA, ANTIBIOTICS AND STEROIDS Perioperative injection LA  pain reduction, diminished perioperative bleeding and facilitation of dissection New metaanalysis Postoperative oral antibiotics  pain(no role) but earlier return to normal activity 1 day single intraoperative dose of dexamethasone - ↓ emesis first 24 hours & ↑ soft or solid diet on postoperative day 1 Intravenous hydration for 24 hours postsurgery reduced postoperative pain

47. Complication

48. Reactionary haemorrhage Bleeding peroperatively and within the first 24 hours  most feared complication ↓ Risk of airway obstruction Shock Death if inappropriately treated or untreated.

49. SECONDARY HAEMORRHAGE More common than is widely appreciated 9 percent of cases  1.4 percent were severe requiring a return to theatre. ↑ with age, peaking between 30 and 34 years Serious haemorrhage ↑ in older age Most (70 percent) present between days 4 and 7

50. POSTOPERATIVE FEVER No association between colony count, core cultures, blood cultures and fever suggesting that fever is not caused by infection n ot require antibiotics

51. Tonsillectomy outcomes Short term deficits in cellular and humoral immunity up to  six months in children following adeno -tonsillectomy

52. Bibliography Scott-Brown's Otorhinolaryngology and Head and Neck Surgery Rob & Smith’s Operative Surgery Dhingra’s Diseases Of Ear, Nose And Throat & Head And Neck Surger

53. Next presentation Case presentation by Dr. Bimal Pokharel on Friday

54. Thank you

55. General anaesthesia  In adults, cuffed endotracheal tubes are preferable Appropriate exposure  Boyle Davis mouth gag. In all techniques apart from guillotine tonsillectomy Tonsil is grasped and retracted forcefully towards the midline  in dentification intended plane of dissection, ↓ Soft areolar tissue between the capsule of the tonsil & the constrictor muscle of the pharynx. The surgical plane is then entered  minimal loss of or trauma to the mucosal tissue of the anterior pillar of the fauces and uvula. Instruments  directed at the tonsil rather than laterally into the tonsillar fossa