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

Formation of a blood clot or Dislodgement of blood clot from lumen Reactionary Within 24 hours of surgery CAUSES OF REACTIONARY HEMORRHAGE (VIVA): 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