1. Tonsillectomy

2. Tonsillectomy It’s the surgical removal of tonsils.
- It is usually done for treatment of chronic infection of tonsils ,obstructive sleep apnea , supporative ottits media etc.

3. Indications A. Absolute Recurrent infections of throat
Peritonsillar abscess
Tonsillitis causing febrile seizures
Hypertrophy of tonsils causing obstruction
Suspicion of malignancy
B. Relative
Diphtheria carriers,
Streptococcal carriers
Chronic tonsillitis with bad taste or halitosis
Recurrent streptococcal tonsillitis in a patient with valvular heart disease
C. As a Part of Another Operation
Palatopharyngoplasty
Glossopharyngeal neurectomy.
Removal of styloid process.

4. Contraindications 1. Haemoglobin level less than 10 g%.
2. Acute infection in upper respiratory tract, acute tonsillitis. Bleeding is more in the presence of acute infection.
3. Children under 3 years of age.
4. submucous cleft palate.
5. Bleeding disorders, e.g. leukaemia, haemophilia.
6. At the time of epidemic of polio.
7. Uncontrolled systemic disease, e.g. diabetes, cardiac disease, hypertension or asthma.
8. Tonsillectomy is avoided during the period of menses.

6. Position Rose’s position :
Anaesthesia
Position
Rose’s position :
Patient lies supine with head extended by placing a pillow under the shoulders.
A rubber ring is place under the head to stabilize it.
Hyperextension should always be avoided
Usually done under General anaesthesia with endotracheal intubation.
In adults it may be done under local anasthesia

7. Equipments for tonsillectomy
Set of instruments for tonsillectomy.(1) Knife in kidney tray, (2) & (3) Toothed and non-toothed Waugh's forceps, (4) Tonsil holding forceps, (5) Tonsil dissector and anterior pillar retractor, (6) Luc's forceps, (7) Scissor, (8) Curved artery forceps, (9) Negus artery forceps, (10) Tonsillar snare, (11) Boyle Davis mouth gag with three sizes of tongue blades, (12) Doyen's mouth gag, (13) Adenoid curette, (14) Tonsil swabs, (15) Nasopharyngeal pack, (16) Towel clips.

8. Advantages of Rose position:
1. There is virtually no aspiration of blood or secretions into the airway.
2. Both hands of the surgeon are free. This position helps in proper application of the Boyles Davis mouth gag.
3. The surgeon can be comfortably seated at the head end of the patient

9. Techniques of tonsillectomy
Cold Methods
Dissection and snare
Guillotine method
Intracapsular tonsillectomy with debrider
Harmonic scalpel
Plasma-mediated ablation technique
Cryosugical technique
Hot Methods
Electrocautery
Laser tonsillectomy
Coblation tonsillectomy
Radiofrequency

10. (Dissection and Snare Method)
Steps of Operation
(Dissection and Snare Method)
1. Boyle-Davis mouth gag is introduced and opened. It is held in place by Draffin's bipods .
2. Tonsil is grasped with tonsil-holding forceps and pulled medially.
3. Incision is made in the mucous membrane where it reflects from the tonsil to anterior pillar. It may be extended along the upper pole to mucous membrane between the tonsil and posterior pillar.

11. (Dissection and Snare Method)
Steps of Operation
(Dissection and Snare Method)
4. A blunt curved scissor may be used to dissect the tonsil from the peritonsillar tissue and separate its upper pole.
5. 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

12. (Dissection and Snare Method)
Steps of Operation
(Dissection and Snare Method)
6. Now wire loop of tonsillar snare is threaded over the tonsil on to its pedicle, tightened, and the pedicle cut and the tonsil removed.
7. A gauze sponge is placed in the fossa and pressure applied for a few minutes.
8. Bleeding points are tied with silk. Procedure is repeated on the other side.

13. Post-operative Care 1. Immediate general care
(a) Keep the patient in coma position until fully recovered from anaesthesia.
(b) Keep a watch on bleeding from the nose and mouth.
(c) Keep check on vital signs, e.g. pulse, respiration and blood pressure.

14. Post-operative Care 2. Diet
When patient is fully recovered he is to take liquids, e.g. cold milk or ice cream.
Sucking of ice cubes gives relief from pain.
Diet is gradually built from soft to solid food. They may take custard, jelly, soft boiled eggs or slice of bread soaked in milk on the 2nd day.
Plenty of fluids should be encouraged.

15. Post-operative Care 4. Analgesics
3. Oral hygiene
Condy's or salt water gargles 3-4 times a day.
A mouth wash with plain water after every feed helps to keep the mouth clean.
4. Analgesics
Pain, locally in the throat and referred to ear, can be relieved by analgesics like paracetamol. An analgesic can be given half an hour before meals.
5. Antibiotics A suitable antibiotic can be given orally or by injection for a week.
Patient is usually sent home 24 hours after operation unless there is some complication. Patient can resume his normal duties within 2 weeks

16. Other methods for tonsillectomy
Guillotine method. Largely abandoned. It can be done only when tonsils are mobile and tonsil bed has not been scarred by repeated infections.
Electrocautery. Both unipolar and bipolar electrocautery has been used. It reduces blood loss but causes thermal injury to tissues.

17. Other methods of tonsillectomy
3. Laser tonsillectomy. It is indicated in coagulation disorders. Both KTP-512 and CO2 lasers have been used but the former is preferred. Technique is similar to one used in dissection method.
4. Laser tonsillotomy. Another method is laser tonsillotomy which aims to reduce the size of tonsils. It is indicated in patients who are unable to tolerate general anaesthesia. Tonsils are reduced by laser ablation up to anterior pillars by stage repeated applications.
5. Intracapsular tonsillectomy. With the use of powered instruments (micro debrider with a 45 degree hand piece ) tonsil is removed but its capsule is preserved in the hope to reduce post-operative pain.

18. Other methods of tonsillectomy
6. Harmonic scalpel.
It is an ultra sound coagulator and dissector that uses ultra sonic vibrations to cut and coagulate tissues.
The cutting operation is made possible by a sharp knife with a vibratory frequency of 55.5 KHz ovar a distance of 89 micro meters.
Coagulation occurs due to transfer of vibratory energy to tissues. This breaks hydrogen bonds of proteins in tissues and generates heat from tissue friction.
7. Plasma-mediated ablation technique. In this ablation method, protons are energized to break molecular bonds between tissues. It is a cold method and does not cause thermal injury

19. Other methods of tonsillectomy
8. Coblation tonsillectomy.
It is also other wise known as cold abalation. This technique utilises a field of plasma, or ionised sodium molecules, to ablate tissues. The heat generated varies from degrees centigrade, much lower than that of electro cautery. The major advantage of this procedure is reduced bleeding and reduced post operative pain.
9. Cryosurgical technique.
Tonsil is frozen by application of cryoprobe and then allowed to thaw. Two applications, each of 3-4 minutes, are applied. Tonsillar tissue will undergo necrosis and later fall off leaving a granulating surface. Bleeding is less due to thrombosis of vessels caused by freezing.
- 82 degrees centigrade by carbondioxide
- 196 degrees centigrade by liquid nitrogen

20. Complications A. Immediate
1. Primary haemorrhage. Occurs at the time of operation. It can be controlled by pressure, ligation or electrocoagulation of the bleeding vessels.
2. Reactionary haemorrhage. Occurs within a period of 24 hours and can be controlled by simple measures such as removal of the clot, application of pressure or vasoconstrictor.
3. Injury to tonsillar pillars, uvula, soft palate, tongue or superior constrictor muscle due to bad surgical technique.

21. 4. Injury to teeth.
5. Aspiration of blood.
6. Facial oedema. Some patients get oedema of the face particularly of the eyelids.
7. Surgical emphysema. Rarely occurs due to injury to superior constrictor muscle.

22. Delayed Complications
1. Secondary haemorrhage. Usually seen between the 5th to 10th post-operative day. It is the result of sepsis and premature separation of the membrane.
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 and bleeding vessel is electrocoagulated or ligated.
Sometimes, approximation of pillars with mattress sutures may be required.
Sometimes, external carotid ligation may also be required.
Transfusion of blood or plasma, depending on blood loss, is given.
Systemic antibiotics are given for control of infection.

23. Delayed Complications
2. Infection. Infection of tonsillar fossa may lead to parapharyngeal abscess or otitis media.
3. Lung complications. Aspiration of blood, mucus or tissue fragments may cause atelectasis or lung abscess.
4. Scarring in soft palate and pillars.
5. Tonsillar remnants. Tonsil tags or tissue, left due to inadequate surgery, may get repeatedly infected.
6. Hypertrophy of lingual tonsil. This is a late complication and is compensatory to loss of palatine tonsils. Sometimes, lymphoid tissue is left in the plica triangularis near the lower pole of tonsil, which later gets hypertrophied. Plica triangularis should, therefore be removed during tonsillectomy

24. Thank You