Tonsillectomy, Adenoidectomy

and Quinsy

Dr. Krishna Koirala2016/12/12

History• Cornelius Celsus (30 A.D. )

– Described tonsillectomy by finger dissection and used vinegar for hemostasis

• Philip Physick (early 1800s)

– Developed tonsillectomy

• Wilhelm Meyer (1867)

– Reported removal of adenoid through nose with a ring knife

• George Waugh(1909)

– Described complete tonsillectomy

Tonsillectomy

Indications

• Local indications

• Focal indications

• Systemic indications

• As part of other surgery

Local indications1. Recurrent tonsillitis meeting Paradise criteria

: ( 7 episodes in 1 yr or 5 episodes / yr for 2 yrs or 3 episodes / yr for 3 yrs)

2. After second attack of Quinsy

3. Intra tonsillar abscess4. Malignant or benign tumour or unilateral

tonsillar enlargement of suspicious cause

5. Tonsil enlargement with stridor or dysphagia

6. Tonsillolith or tonsillar cyst with halitosis

7. Impacted foreign body

Systemic indications

1. Rheumatic fever with arthritis

2. Sub-acute bacterial

endocarditis

3. Glomerulonephritis

4. Diphtheria carrier

As an approach to other surgeries

1. Styloid process excision (Eagle’s

syndrome)

2. Glossopharyngeal neurectomy

3. Uvulopalatopharyngoplasty

4. Branchial fistula excision

Contraindications• Age < 3 yr

– Limited space; immunity is lost; blood loss not tolerated; lingual tonsils hypertrophy

• Acute infection : More bleeding

• Aneurysm of internal carotid or tonsillar artery

• Bleeding disorders : Hemophilia

• Cleft palate : Rhinolalia aperta

Contraindications• Cervical spondylosis : affects surgical position

• Diabetes mellitus; hypertension; tuberculosis

• Epidemic of polio : bulbar poliomyelitis

• Female patient during menstruation

• Granular pharyngitis : infection flares up

• Hemoglobin < 10 g / dl

Subcapsular vs Intracapsular Tonsillectomy

• Subcapsular total tonsillectomy

– Removes tonsil tissue completely

• Intracapsular tonsillectomy

– Removes 90% of tonsils leaving behind a layer of tonsil tissue

– Protects tonsillar bed and reduces post-op pain and recovery time

– Not appropriate for recurrent tonsillitis

Subcapsular tonsillectomy

Intracapsular tonsillectomy

Methods of TonsillectomyHot

• Dissection and snare

• Microdebrider

• Harmonic scalpel

• Cryosurgery

• Cold knife

• Guillotine

Cold

• Electro-cautery

• Laser

• Coblation

• Radiofrequency

Tonsillectomy by Dissection and Snare

Technique

Rose Position and Incision

Blunt dissection

Cutting of triangular ligament

Snaring and Hemostasis

Steps of tonsillectomy • 1. Rose position: patient kept supine with

extension of neck and atlanto-occiptal joint

• 2. Boyle Davis mouth gag inserted and fixed with Draffin’s bipod & Mac Gauren’s plate

• 3. Incision made between tonsil and anterior pillar

• 4. Tonsil dissected from its base, till lower pole with tonsil dissector

Steps of tonsillectomy contd….

5. Lower tonsil pedicle snared with

Eve’s tonsillar snare

6. Tonsil removed and fossa packed with

H2O2 soaked gauze for 5 min

7. Bleeder ligated with silk suture or

cauterized by bipolar cautery

Micro- debrider

Ultrasonic Harmonic scalpel

Cryosurgery

Cold knife dissection and snare method

Guillotine

Electro-cautery

Laser tonsillectomy

Bipolar radiofrequency

Post-operative care1. Keep the patient in left lateral position with head

low

2. Inform surgeon immediately in case of

– Fever above 100 0F

– Difficulty in breathing or swallowing

– Excessive bleeding from oral cavity

3. Eat soft foods and ice-cream

4. Encourage swallowing and gum chewing

5. Drink plenty of cold fluids

6. Avoid citrus fruit juice

Surgical• Hemorrhage

– Primary (operative)– Reactionary ( < 24

hrs)• Injury to lip / teeth /

uvula / pillars• Surgical emphysema• Tonsil remnant

Anesthetic

• Aspiration

• Cardiac arrest

Early Complications (within 24 hrs)

Late Complications (After 24 hrs)

Surgical • Secondary hemorrhage• Scarring of soft palate

leading to velopharyngeal insufficiency

• Lingual tonsil hypertrophy• Tonsil fossa infection• Granular pharyngitis

Anesthetic•Lung collapse

Hemorrhage after Tonsillectomy

• Primary hemorrhage

– Occurs during surgery, due to injury to blood vessels

– Normal = 80 ml.

• Reactionary hemorrhage

– Within 24 hr of surgery (commonly within 8 hr)

• Secondary hemorrhage

– Occurs after 24 hrs of surgery , usually on 6th - 8th day ,due to infection

Causes for reactionary hemorrhage

• Slippage of ligature

• Displacement of clot

• Re-opening of collapsed blood vessels

– Caused by high B.P. due to cough / retching and wearing off effect of hypotensive anesthesia

• Clots in tonsillar fossa

– Prevent contraction of superior constrictor muscle (required for hemostasis)

Management of Post- op tonsillar bleeding

• Remove blood clots from tonsillar fossa• H2O2 gargle (causes thermal cautery and

vasoconstriction by releasing nascent oxygen)• Pressure gauze packing of fossa for 5 min• If bleeding continues, shift the patient to

operation theatre

• In operation theatre• Treat shock, blood transfusion if required• Head low, continuous pharynx suction• Ryle's tube insertion, remove aspirated

blood• Intubate + inflate cuff + put throat pack• Remove all blood clots from tonsil fossa to

identify any bleeder

Bleeder identifiedYes No

Ligation or bipolar cautery

Adrenaline pack or AgNo3 application or Tincture

benzoin paint Bleeding still

continuesSuture both pillars over gelfoam kept in

fossaBleeding still

continuesExternal carotid artery ligation distal to superior thyroid artery (so that retrograde thrombus aneurysm involves superior thyroid artery and not Internal carotid artery)

Adenoidectomy

• First do adenoidectomy then only tonsillectomy (hemostasis performed by blind nasopharynx packing)

• Indications: Adenoids with– Adenoid facies – Sleep apnea / snoring– Rhinolalia clausa – Recurrent sinusitis– Refractory O.M.E. – C.S.O.M.

Tonsillectomy & Adenoidectomy positions

Procedure

Procedure• Rose position but atlanto-occipital joint

neutral

• Mouth gag inserted, finger palpation done

– To assess the size of adenoids

– To bring the adenoid mass in midline

– To check the position of Eustachian tube

• Adenoid curetted keeping head slightly flexed to avoid trauma to atlanto-occipital joint

• Nasopharyngeal pack kept for 5 min for hemostasis

Microdebrider adenoidectomy

Complications• Hemorrhage 10, R0, 20 post nasal pack

• Damage to E.T. orifice scarring O.M.E.

• Subluxation of Atlanto-Occipital joint torticollis (Griesel disease)

• Velopharyngeal insufficiency nasal twang + regurgitation from nose

• Nasopharyngeal scarring & stenosis

• Adenoid remnant and recurrence ( up to 40%)

Contraindications• Acute infection

• Bleeding disorders

• Cleft palate: symptoms will be worsened

Peritonsillar abscess (Quinsy)

Etiopathogenesis• Collection of pus between tonsillar capsule

and superior constrictor muscle

• Pathology: Aerobic + anaerobic organisms

– De novo

– Acute tonsillitis blockage of crypts intra tonsillar abscess peritonsillitis quinsy

– Abscess of Weber's salivary gland in supra tonsillar fossa quinsy

Clinical features• Symptoms: Young adult with severe

odynophagia, fever, halitosis and muffled voice

• Signs:

– Peritonsillar area swollen and congested

– Tonsil hidden behind the anterior pillar, pushed medially and congested

– Jugulo -digastric lymph node enlarged and tender

– Trismus – Torticollis

Management• Diagnosis:

– Wide bore needle aspiration (18G) reveals pus

• Medical treatment:

– Urgent admission, I.V. fluids

– I.V. ceftriaxone + ornidazole

– Antihistamine - decongestant + analgesic

– Antiseptic mouth gargle ( Betadine )

Incision and Drainage• Incision made with # 11 blade or Thilenius

peritonsillar abscess drainage forceps

• Nick made above and lateral to junction of 2

imaginary lines, horizontal along base of uvula

and vertical along anterior tonsillar pillar

• Incision widened with sinus forceps & pus drained

Incision line and quinsy forceps

Surgical treatment

1. Interval tonsillectomy after 4 – 6 wk.

2. Hot tonsillectomy or abscess

tonsillectomy is avoided as it leads to

– More bleeding

– Septicemia

Complications of quinsy

1. Parapharyngeal abscess

2. Retropharyngeal abscess

3. Laryngitis and laryngeal edema

4. Lung abscess

5. Internal jugular vein thrombosis

6. Septicemia