Tonsillectomy

It utilizes a thin layer of ionized sodium to ablate tissues

The newer methods of tonsillectomy include:

a. Coblation         b. Harmonic scapel            c.Ligasure (Thermal Welding)

d. Laser               e. Intra-capsular methods

Coblation

Uses radiofrequency (RF) energy to ionize NaCI in a saline medium, then the energy of these ions (plasma) is used to break molecular tissue bonds

•    May also be used for direct hemostasis

•    RF energy is supposed to stay in the irrigation to minimize collateral heating

•    Temperatue is not supposed to exceed 70 C (cautery is routinely 200-400 C)

•    Most studies indicate less pain than electrocautery, some cite equivalent pain to cold knife

•    Intraoperative blood loss comparable to electrocautery

•    No electrical connection to patient

•    Very high cost compared to electrocautery or cold knife ($150-200/piece)

•    Operative times up to twice as long than electrocautery

•    Aggressive marketing campaign targeted to lay public

Actinomyces are normal inhabitants of the gastrointestinal tract that grow under anaerobic and microaerophilic conditions.

Although they are gram-positive rods, they grow as branching filaments and have been confused with fungi.

The yellow colonies (sulfur granules) are found in low-oxygen niches like the tonsils and in actinomycotic abscesses.

Aspergillus fumigatus may be present in the respiratory tract as an opportunistic pathogen; however, fungus balls are generally seen only in pre-existing cavities (e.g., bronchiectasis, TB), not in the tonsils.

Blastomyces dermatitidis is a respiratory pathogen that is seen as thick-walled yeasts within granulomas.

Candida albicans, also a normal inhabitant of the oral cavity, would present as whitish plaques and would appear microscopically as budding yeasts.

Recurrent throat infections, peritonsillar abcess, tonsillitis causing febrile seizures, hypertrophy of tonsils causing sleep apnoea or speech interference and any suspicion of malignancy are absolute indications for tonsillectomy.

Secondary haemorrhage usually seen between the 5th to 10th postoperative day.
It is the result of sepsis & premature separation of the membrane.

Usually, it is heralded by bloodstained sputum but may be profuse. Simple measures like removal of clot, topical application of dilute adrenaline or hydrogen peroxide with pressure usually suffice.
For profuse bleeding, general anaesthesia is given & bleeding vessel is electrocoagulated or ligated. Sometimes, approximation of pillars with mattress sutures may be requered.
Sometimes, external carotid ligation may also be required.
Systemic antibiotics are given for control of infection.

Several studies have shown that children undergoing an elective surgical procedure with an acute upper respiratory tract infection has an increased incidence of laryngospasm, bronchospasm or oxygen desaturation.

Performing tonsillectomy during the poliomyelitis epidemic is an absolute contraindication.

Unimmunized children may develop polio following tonsillectomy.

A tonsillectomy may be performed long after the epidemic has passed and the child is immunized against polio.

• Recurrent episodes of acute tonsillitis that is more than four attacks a year 
• Patients with recurrent sore throats and rheumatic fever and when tonsils cause repeated attacks of otitis media.
• Presence or history of a peritonsillar abscess or diphtheria carriers.
• Massive tonsillar hypertrophy causing respiratory obstruction in children
• Sleep apnea
• Glossopharyngeal neuralgia

Ans. is ‘c’ i.e., Recurrent upper respiratory infection

Indications of tonsillectomy

If more than six attacks of tonsillitis in a year for two consecutive years.

o Recurrent sore throat     

o Tonsillar or pentonsillar abscess                 

o Retention cyst of tonsil                  

o Diphtheria carriers

o Tonsillolith        

o Suspicious malignancy  

o Obustructive sleep apnea

D i.e. Cancel surgery for 3 weeks and patient to be on antibiotic 

Surgery should be postponed if there is evidence of acute infection or suspicion of a clotting dysfunction (eg. recent aspirin ingestion)Q.

Child with an upper respiratory tract infection (URI) has an irritable airway and is at increased risk for laryngospasm, bronchospasm, post intubation croup, atelectasis, pneumonia & episodes of desaturation.

Because bronchial hyper reactivity may last for upto 6 weeks after a URI, cancellation will make a difference only if surgery is delayed for this amount of time or longerQ.

There are no absolute contraindications to tonsillectomy. As such tonsillectomy is an elective operation and should not be undertaken in presence of respiratory tract infections or during the period of incubation of after contact with one of the infectious disease, if there is tonsillar inflammations.

It is much safer to wait some 3 weeks after an acute inflammatory before operating, because of the greatly increased risk of postoperative haemorrhage.

Also, these patients may develop a laryngospasm with airway manipulation. This complication carries the potential for significant morbidity and even mortality.

The tonsils should be removed 6-8 weeks following a Quinsy. – Turner 10th/ed p 86

Tonsils are removed 4-6 weeks following an attack of Quinsy. – Dhingra 6th/ed 

Most people would practise interval tonsillectomy for these patients, deferring surgery for 6 weeks following resolution of an attack. – Head and Neck Surgery by Chris de Souza  

The main complication is hemorrhage which occurs in 3-5% patients

Reactionary hemorrhage occurs within a few hours of the operation and may be severe.

It may occur after operation and is treated by a return to the theater when the vessel is ligated under anesthesia.

• Reactionary haemorrhage mostly occurs due to dislodgement of any clot or because BP of patient comes back to normal after hypotensive anaesthesia.
• Secondary haemorrhage mainly occurs due to infection.

Indications for blood transfusion in a case of Tonsillectomy

–          End-stage renal disease

–          Hypertension                                                  

–          Reduced hemoglobin and hematocrit               

Ans. is ‘c’ i.e., Paratonsillar vein

“Excessive bleeding at the time of operation usually arises because of trauma to an aberrant vessel or paratonsillar vein”.

Complications of tonsillectomy

Complications of tonsillectomy may be :-

• Immediate
• Delayed

Immediate complications

• Primary haemorrhage Occurs at the time of operation. It can be controlled by pressure, ligation or electrocoagulation of the bleeding vessels.
• Reactionary haemorrhage : Occurs within a period of 24 hours.
• Injury to tonsillar pillars, uvula, soft palate, tongue or superior constrictor muscle due to bad surgical technique.
• Injury to teeth.
• Aspiration of blood.
• Facial oedema : Some patients get oedema of the face particularly of the eyelids.
• Surgical emphysema

Dalaved complications

• Seconclaty haemorrhage : Usually seen between the 5^th to 10^th post-operative day. It is the result of sepsis and premature separation of the membrane. Usually, it is heralded by bloodstained sputum but may be profuse.
• Infection : Infection of tonsillar fossa may lead to parapharyngeal abscess or otitis media.
• Lung complications : Aspiration of blood, mucus or tissue fragments may cause atelectasis or lung abscess.
• Scarring in soft palate and pillars.
• Tonsillar remnants : Tonsil tags or tissue, left due to inadequate surgery, may get repeatedly infected.
• Hypertrophy of lingual tonsil : This is a late complication and is compensatory to loss of palatine tonsils.