ADENOIDECTOMY AND
TONSILLECTOMY
Dr Joel G Mathew
ADENOIDECTOMY
ADENOIDECTOMY - INDICATIONS
• Adenoid hypertrophy causing:
• Otitis media with effusion (SOM)
• Upper airway obstruction and
obstructive sleep apnoea
• Recurrent acute otitis media
• Recurrent rhinosinusitis (Abolishing
infective episodes)
ADENOIDECTOMY - CONTRAINDICATIONS
• Acute upper respiratory infections
• Acute epidemic of Poliomyelitis>Paralytic polio (Exposed nerves)
• Bleeding disorders and Anaemia
• Cleft Palate
• Overt cleft palate
SUBMUCOUS CLEFT PALATE (COVERT)
• Abnormal nasal speech,
• Bifid uvula
• Thin strip of mucosa in the
middle of roof of mouth
• Notch at the back of hard
palate.
ADENOIDECTOMY - PROCEDURE
• Anaesthesia – General
Anaesthesia
• If combined,
Adenoidectomy before
Tonsillectomy
POSITION – ROSE’S POSITION
Supine with head extended by placing a
pillow or sandbag beneath the
shoulders.
Advantage –
Larynx lies at a higher level than oral
cavity – no risk of aspiration.
Excellent exposure
Both hands of surgeon are free.
Hyperextension is avoided
Makes cervical vertebral bodies
prominent-Damage to ligaments or
cartilages of vertebral spine or
bodies -> Grisel’s syndrome
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
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.
• 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.
OTHER TECHNIQUES OF ADENOIDECTOMY
• Suction coagulator/diathermy
• Endoscopic transnasal or transpalatal adenoidectomy with microdebrider
• Coblator plasma field device
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
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.
TONSILLECTOMY
TONSILLECTOMY-INDICATIONS
Absolute Indications:
 Obstructive
symptoms and
Obstructive sleep
apnoea
 Malignancy or
suspected
malignancy
 Recurrent
peritonsillar abscess
 Tonsillitis causing
febrile seizures in
children
Relative Indications:
Recurrent tonsillitis:
 >= 7 episodes in 1 year
 >=4 episodes per year for 2 consecutive
years
 >= 3 episodes per year for 3 consecutive
years
Halitosis due to chronic tonsillitis
Tonsilloliths
Tonsillar cysts
Dental and orofacial abnormalities
Dipheria carriers
Rheumatic fever and Acute
glomerulonephritis
TONSILLECTOMY AS PART OF ANOTHER
PROCEDURE
• Excision of elongated styloid process (Eagle syndrome) – Nagging throat pain and a
palpatory finding in the tonsillar fossa. Confirmed by palpation and injection of
anaesthetic.
• Glossopharyngeal neuralgia
• UPPP (Uvulopalatopharyngoplasty)or LAUP (Laser-assisted uvulopalatoplasty) or
CAUP (Coblation assisted uvulopalatoplasty)
CONTRAINDICATIONS
• Bleeding disorders
• Cleft palate or submucous cleft palate
• Velopharyngeal insufficiency
• Acute infection
• Uncontrolled systemic disease
• Anaemia
• Extremes of age
PROCEDURE
• Anaesthesia: General anaesthesia
• Position-Rose’s position-supine with head extended by placing a pillow or sandbag
under the shoulder
• Operative techniques
• DISSECTION AND SNARING -> Classical
• Diathermy
• Coblation tonsillectomy
• Ultrasonic dissection
• Laser tonsillectomy
• Capsulotomy techniques
• Guillotine method (Ancient)
DISSECTION AND SNARE METHOD
• Boyle Davis mouth gag is inserted, opened and held in position
with Draffin’s bipod stand
• Upper pole of tonsil is held with tonsil holding forceps and pulled
medially
• Mucosa is incised with blunt scissors, knife, forceps or diathermy
at the point where it reflects from tonsil to anterior pillar. Incision
is continued inferiorly towards base of tongue.
• The tonsil is separated from its bed by blunt dissection, upto the
lower pole
• The plane of dissection is the loose areolar tissue separating
tonsil from its bed.
• Once lower pole is reached, a tonsillar snare is passed over the tonsil holding
forceps, placed over the tonsil, threaded down to the lower pole, tightened to crush
the pedicle, and the tonsil is removed
• Gauze packs are kept in the tonsillar fossa
• Bleeding points are looked for, and bleeding arrested with non absorbable sutures
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
COMPLICATIONS OF TONSILLECTOMY
• HEMORRHAGE
• Primary
• During the surgery
• Controlled by pressure packing, ligation, cauterisation
• Reactionary
• Within 24 hours of surgery
• CAUSES OF REACTIONARY HEMORRHAGE (VIVA):
1.
2.
3.
4.
5.
Formation of a blood clot or Dislodgement of blood clot from lumen
Vasodilation of blood vessel
Postoperative rise in blood pressure
Increased venous pressure by coughing or retching
Slipping of ligature
• Management of Reactionary haemorrhage:
• Blood is cross matched
• Tonsillar fossa is inspected and clot removed
• Pressure with a swab soaked in 1:1000 Adrenaline
• Administration of hemostatic agents (Ethamsylate, Tranexamic acid)
• May require taking to the operation theatre and ligation under General Anaesthesia.
• Most dangerous form of haemorrhage because:
• It may be missed (Patient may still be under the effect of GA)
• It may cause fatal aspiration
• Large hemorrhages may require ligation or electrocoagulation under GA. Two GAs at a
short interval is dangerous.
• Secondary haemorrhage (>24 hours – 2 weeks)
• Cause: Infection of the granulating tonsillar bed
• Treated with Antibiotics
• OTHER COMPLICATIONS OF TONSILLECTOMY:
• Injury to:
• Temporo-mandibular joint
• Lips and commisures of mouth
• Tongue, uvula, soft palate
• Very rarely Glossopharyngeal nerve, pharyngeal venous plexus, carotid sheath
• Grisel syndrome (Non traumatic atlanto axial dislocation)
• Aspiration of blood-> Pneumonia, collapse of lung, or lung abscess
• Hematoma and oedema of uvula
• Referred earache
• Velopharyngeal insufficiency
• Tonsillar remnants