TONSILLECTOMY

METHODS :

1. Guillotine method
2. Dissection method
3. Laser tonsillectomy
4. Electro coagulation method
5. Harmonic scalpel tonsillectomy
6. Cryosurgery
7. Electro frequency coagulation

Figure:Tonsillectomy operation

Indications of Tonsillectomy :

1. Repeated attack of acute tonsillitis more that 3 times per year for consecutive two years, every time causing 3 days or more work loss.
2. Chronic tonsillitis.
3. Hugely enlarged tonsils causing mechanical obstruction- difficulty in swallowing/ difficulty in respiration.
4. Single attack of peritonsillar abscess or Quinsy (operation is indicated  6 weeks after recovery)
5. Unilateral enlargement of tonsil when malignancy is suspected.

    6. Persistant carriers of streptococcus or diphtheria bacilli.

    7. In case of remote complications eg. Rheumatic fever or Acute Nephritis

    8. As an approach of some operations-

     - eg. Avulsion of glossophayngeal neuralgia, avulsion of elongated styloid process

    9. As a part of other operation e.g. Uvulopharyngopalatoplasty.

Contraindications :

Absolute : Some bleeding disorders

Relative contraindications :

1. Acute upper respiratory infections
2. Bleeding disorders (specially trait)
3. Epidemic of polio around the vicinity of hospitals
4. Uncontrolled Diabetes Mellitus
5. Uncontrolled Hypertension
6. Pregnancy
7. Menstruation
8. Systemic diseases
9. Debilitated conditions of patient

Complications of tonsillectomy :

Anaesthetic complications :

1. Injury to different structures :

              - Lip, teeth, gum, cheek, palate, posterior pharyngeal wall, larynx up to trachea.

2. Cardiac arrest

3. Respiratory arrest

Surgical complications :

1. Injury to different structures : Lip, teeth, angle of mouth, palate
2. Hemorrhage – primary, reactionary and secondary.
3. Laryngeal oedema
4. Parapharyngeal abscess, retropharyngeal abscess , Cellulitis of neck
5. Pulmonary complications- aspiration of blood or vomitus, lung collapse, lung abscess.

Primary haemorrhage : Bleeding during operation.

 Due to -

1. Hurried operation
2. Extensive fibrosis
3. Acute upper respiratory infection
4. Bleeding disorder

Management :

1. Ligate/cauterize all the bleeding vessels
2. Pillar to pillar ligation if failed
3. Blood transfusion if there is bleeding disorder

Reactionary haemorrhage :

Bleeding within 24 hours after operation.

Patient is usually admitted in the hospital.

How to confirm?

1. Increase pulse rate
2. Decrease blood pressure
3. Repeated swallowing( we will suspect blood)
4. Rattling noise during respiration or noisy respiration
5. Examination of throat- Blood clot is seen

Causes : The bleeding results from :

•         Failure to ligate all bleeding vessels

•         Oozing from the vessels after relaxation of the stretched faucial tissues

•         Failure of a vessel to contract and retract after crushing or cutting

•         Postoperative rise of blood pressure. Coughing and straining dislodge a clot

•         Slipping of a ligature

Management :

1. Examine the throat under good illumination. If there is any blood clot remove it.
2. Hydrogen per oxide gargling.
3. If failed then apply wet gauge (with hydrogen per oxide) pressure over the tonsillar fossa for 10 minutes.
4. If failed then to open IV channel, start IV fluid, send blood for grouping & cross matching and arrange blood for transfusion.
5. Take the patient to operation theatre and call senior/experienced anaesthetist.
6. Under general anaesthesia, ligate all the bleeding vessels. If failed then pillar to pillar ligation.

Anaethesia for reactionary haemorrhage is always dangerous as throat is full of blood clot and blind intubation may require.

Secondary haemorrhage :

Bleeding from 24 hours after operation up to 10 day. Usually occurs after 5-6 days.

Cause : Infection.

Management :

1. Admit the patient in the hospital.
2. Pressure over the tonsils by hydrogen soaked gauge piece.
3. Send tonsil swab for culture and sensitivity and start IV antibiotics, IV fluid, Start hydrogen per oxide & antiseptic gargling, keep patient nothing by mouth.

      4.After C/S report comes, change antibiotics

      5. To relieve anxiety : Sedative

      6. If bleeding does not stop then under general anaesthesia, try for haemostasis. If      failed then pillar to pillar ligation.

Secondary haemorrahge usually stops after IV antibiotics and gargling Posoperative care :

1. Keep the patient in tonsillar position.
2. Check whether any bleeding from nose or mouth
3. Record vital signs, pulse, blood pressure and respiration
4. Diet – 2 hours after operation and when patient is fully recovered, then liquid diet and ice cream.

      Usually 1^st day – liquid diet

                    2^nd to 5^th day – Semisolid diet

                    5^th day onwards – Normal diet

        Plenty of water by mouth

5. Maintain oral hygiene : with hydrogen per oxide/ povidone Iodine mouth wash.

6. Antibiotic : Broad spectrum antibiotic for 10 days

7. Analgesic – Tab Diclofenac sodium or Paracetamol 1 tab 3 times daily after food till necessary if not contraindicated.

Patient is usually discharged 24 hours after operation.