Tonsillectomy

Presented by: Nur Insyirah Abdullah

Tonsil
Palatine tonsil:dense compact bodies of lymphoid tissue that located in the wall of oropharynx bounded by palatoglossus fold anteriorly & palatopharyngeus fold posteriorly Part of Waldeyers ring (ring of lymphoid tissue found in the pharynx). It provide defense against pathogen as it involved in the production and development of both B cell and T cell.

The details of arterial supply of tonsils; each tonsil is supplied by 5 arteries. Dorsal linguae branches of Lingual artery Tonsillar branch of Facial artery Ascending palatine branch of Facial artery Ascending pharyngeal artery from external carotid Descending palatine branch of Maxillary artery

 The lateral surface of the tonsil is covered by fibrous capsule, and it is separated from the oropharynx by loose areolar tissue. This separation makes dissection of tonsil easy during tonsillectomy

Tonsillectomy
Tonsillectomy is defined as surgical excision of the palatine tonsil

Indication
Absolute Relative As part of other operation

Absolute Indication
Recurrent infection of throat: - 7 or more episodes in 1 year or - 5 episodes per year for 2 years or -3 episodes per year for 3 years or -2 weeks or more of lost school or work in one year Peritonsillar abscess Tonsilitis cause febrile seizure Hypertrophy of tonsil causing: - airway obstruction - difficulty of deglutition - interfere with speech Suspicious of malignancy -a unilateral enlargedtonsil may be a lymphoma in children and epidermoid carcinoma in adults

Relative indication
Diphteria carriers who doesnt respond to antibiotics Streptococcal carriers Chronic tonsilitis Recurrent streptococcal in patient with valvular heart disease

As part of another operation

Palatopharyngoplasty Glossopharyngeal neurectomy Removal of styloid process

Contraindication
Hemoglobin less than 10% Presence of acute infection in upper respiratory tract Children under 3 years of age Overt or submucous cleft palate Bleeding disorder Uncontrolled systemic disease Tonsillectomy is avoided during the period of menses

Methods of operation
Dissection and snare (most common) Guilotine method Intracapsular (capsular preserving) tonsillectomy with debrider Harmonic scalpel Plasma mediated ablation technique Cryosurgery technique Electrocautery Laser tonsillectomy Coblation tonsillectomy Radio frequency

Anaesthesia
Usually done under general anaesthesia with the endotracheal intubation In adult, it may be done under local anaesthesia

Position
Roses position: Patient lies supine with the head extended by placing a pillow under the shoulder. A rubber ring is placed under the head to stabilise it

Steps of operation
Boyle-Davis mouth gag is introduced and opened. It is held in place by Draffins bipod or a string over a pulley Tonsil is grasped with tonsil holding forcep and pulled medially Incision is made in the mucous membrane where it reflects from the tonsil to anterior pillar. It may extended along the upper pole to mucous membrane between the tonsil and posterior pillar

 A blunt curved scissor may be used to dissect the tonsil from the peritonsillar tissue and separate its upper pole Now the tonsil is held at its upper pole and traction applied downwards and medially. Dissection is continued with tonsillar dissector or scissors until lower pole is reached Now wire loop of tonsillar snare is threaded over the tonsil on to its pedicle,tightened and the pedicle cut and the tonsil removed.

 A gauze sponge is placed in the fossa and pressure applied for a few minutes Bleeding points are tied with silk. Procedure is repeated on the other side

Post-operative care
Immediate general care Diet Oral hygiene Analgesics Antibiotics

Patient is usually sent home 24 hours after operation unless there is some complication.

Complication
Immediate -Primary hemorrhage -Reactionary hemorrhage -Injury to the tonsillar pillar,uvula,soft palate tongue or superior constrictor muscle -Injury to teeth -Aspiration of blood -Facial oedema -Surgical emphysema Delayed -Secondary hemorrhage -Infection -Lung complication -Scarring in soft palate and pillar -Tonsillar remnant -Hypertrophy of lingual tonsil