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

4. 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

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

6. Contraindications
PHYSIOLOGICAL:
1. Below 4 years of age.
2. During menses.
3. During pregnancy
4. 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.

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

8. 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.

9. Guillotine instruments

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

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

12. Procedure

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

14. CRYOSURGICAL TONSILLECTOMY
 Very cold probe
 Removes tonsil by
repeated freezing and
thawing
 Using CO2, N2O & liquid
nitrogen media temp
reaches to -82 & -189
oC
 Used in bleeding
disorders

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

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

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

18. HARMONIC SCALPEL TONSILLECTOMY
 Ultra sonic vibrations
used to dissect &
coagulate tissues.
 Temperature
generated is 50-1000c
as compared to 150-
4000c in
electrocautery

19. 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

20. 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

21. Post tonsillectomy hemorrhage
TYPES:
Primary
Reactionary
Secondary

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

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

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

25. 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.

26. 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

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

28. 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

29. 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.

30. What to do ?
Secondary:
 Rest
 Sedation
 Antibiotics
 Removal of clots
 Gargles with H2O2
if still not controlled- put gauze pad over tonsillar
fossa and both pillars are stitched over it. This is
later removed after 24-48hrs.

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

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

33. SUBMUCOSAL CLEFT PALATE

34. 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

35. 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

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

38. 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

39. 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

40. 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