ADENOTONSILLITIS

ADENOTONSILECTOMY

By
Dr B.Sowmya
(PG in ENT)
 INTRODUCTION

 Adenoid or the
nasopharyngeal tonsil is a
part of WALDEYER’S
RING
 Location: It is situated in
roof of
nasopharynx(epipharynx)
 It’s a pink globular mass of
lymphoid tissue with vertical
ridges, lined by ciliated
columnar epithelium.
 Embryology

 Adenoid begin forming in 3rd mnth

of intra uterine life.
 Fully formed by the 7th mnth.
 It shows physiological
enlargement upto the age of 6yrs
and then tends to atrophy at
puberty.
 Blood supply to adenoid is by
 1. Ascending pharyngeal artery
 2. Ascending palatine artery
 3. Pharyngeal branch of internal maxillary artery
 4. Artery of pterygoid canal
 5. Contributions from tonsillar branch of facial artery

 Venous drainage from the adenoid is through the pharyngeal

plexus which in turn drain into the internal jugular vein.

 Lymphatics drain into upper jugular nodes directly or indirectly

via retropharyngeal and parapharyngeal nodes.
 FUNCTIONS
 It is an immunological asset
providing protection through B and
T cell activity in response to
antigens.
 There is a decline in functional
activity accompanied by marked
involution of the organ at or before
the onset of puberty
Differences between Tonsil and Adenoid

  Tonsil   Adenoid
  1. Encapsulated   1. Unencapsulated
  2. Two   2. one
  3. Has crypts   3. Has furrows
  4. Present in oropharynx   4. Present in nasopharynx
  5. Lined by squamous epithelium   5. Lined by ciliated
columnar epithelium
  6. Has no efferent lymphatics   6. Has both afferent and
efferent lymphatics
 ADENOIDITIS
 Inflammation of the adenoids is
known as adenoiditis.
 Adenoids can contribute to recurrent
sinusitis and chronic persistent or
recurrent ear disease because they can
harbor a chronic infection. The type
and amount of pathogenic bacteria
seem to vary based on the disease
present and the age of the child.
 Overall, the most commonly cultured
bacteria have been Haemophilus
influenzae, group A beta-hemolytic
Streptococcus, Staphylococcus
aureus, Moraxella catarrhalis, and
Streptococcus pneumoniae
 CLINICAL FEATURES

 C/F: Nasal obstruction

Hypertrophied gland
Post nasal catarrhal discharge
Lack of resonance of voice
Cervical lymphadenitis
Secondary Infections
Due to hypertrophy:
 Feeding problems in children resulting
in malnutrition
 Noisy respiration
 Impaired speech- closed nose voice
 Adenoid facies

The features of adenoid facies

include elongated face, pinched
nostrils, open mouth, high
arched palate, shortened
upper lip, and vacant
expression.
Due to post nasal catarrhal discharge

 Nocturnal cough
 Nausea and vomiting
 Headache
Due to secondary infections
 NOSE: Sinusitis
Chronic maxillary sinusitis is commonly associated with
adenoids.
Epistaxis: When adenoids are acutely inflamed, epistaxis can
occur with nose blowing.
Voice change: Voice is toneless and loses nasal quality.

 EAR:
Tubal obstruction: Adenoid mass blocks the eustachain tube
leading to retracted tympanic membrane and conductive hearing
loss
Acute otitis media
Chronic otitis media
Secretory otitis media
 General Symptoms
Pulmonary hypertension: nasal
obstruction due to adenoid
hypertrophy can cause pulmonary
hypertension and cor pulmonale
Aprosexia: i.e Lack of concentration.
 SIGNS

 POSTERIOR
RHINOSCOPY:
Lobulated pink mass with
lacing of muco pus

 EAR: Retracted tympanic

membrane
Clinical GRADing of adenoid
sizes
GRADE DESCRIPTION
Grade I Adenoid tissue filling one third
of the vertical portion of choanae
Grade II Adenoid tissue filling from one
third to two-thirds of the
choanae
Grade III From two-thirds to near complete
obstruction of choanae.
Grade IV Complete choanal obstruction.
 DIAGNOSIS
 Examinations of
postnasal space and an
adenoid mass can be seen
with miror.
 A rigid or a flexible
nasopharyngoscope is
also useful to see details
of the nasopharynx.
 Soft tissues lateral
radiograph of nasopharynx.

 Detailed nasal examination

MEDICAL:
Nasal Decongestants
Anti biotics
Anti histaminics
SURGICAL:
Adenoidectomy
PALATINE TONSIL
 The Palatine Tonsil is one of the
mucosa associated lymphoid
tissues(MALT), which is situated
in the lateral wall of oropharynx
between anterior and posterior
pillars.
 Tonsil is extended upwards into
the soft palate,downwards into
the base of the tongue,anteriorly
into palatoglossal arch.
 Tonsil is one of the chief
immunocompetent tissues in the
oropharynx.
 It forms part of the waldeyer’s
ring.
 EMBRYOLOG
 The tonsilY
pillars are formed from 2 nd

and 3 bronchial arches, through

rd

dorsal extension of mesenchyme into

the forming
soft palate.
The tonsillar crypts develop by 3-6
months as solid ingrowths from
surface epithelium.
 Lymphocytes appear near epithelium
during 3rd month but organises to
nodular form after 6 months
 By 5th month, tonsillar capsule is
formed from mesenchyme.
 RELATIONSHIPS
OF TONSIL
 It has two surfaces-medial and lateral
and
two poles-upper and lower.
 MEDIAL SURFACE:

Is covered by non-keratinising stratified

squamous epithelium which dips into
substance of tonsil in the form of crypts.
Openings of the 12-15 crypts can be seen
on the medial surface.
One of the crypts situated near the upper
part of the tonsil is very large and deep
and is called cryptomagna or
intratonsillar cleft.it represents the
ventral part of 2nd pharyngeal pouch.
 LATERAL SURFACE:
It presents a well defined fibrous capsule.
B/w the capsule and bed of tonsil is the
loose areolar tissue which makes it easy
to dissect the tonsil in the plane during
tonsillectomy.
It is also the site for collection of pus in
peritonsillar abscess
 UPPER POLE:
Extends into soft palate .
Its medial surface is covered by semilunar
fold,extending b/w anterior and posterior pillars and
enclosing a potential space called supratonsillar
fossa.
 LOWER POLE:
Is attached to the tongue.
A triangular fold of mucous mem extends from
anterior pillar to the anteroinferior part of tonsil and
encloses a space called anterior tonsillar space
The tonsil is separated from the tongue by a sulcus
called tonsillolingual sulcus which may be the seat of
carcinoma.
 BED OF THE TONSIL:
It is formed by the superior
constrictor and styloglossus
muscles.
The glossopharyngeal erve and
styloid process,if enlarged
may lie in rlation to the lower
part of the tonsillar fossa.
Outside the superior
constrictor, tonsil is related to
the facial
artery,submandibular salivary
gland,posterior belly of
digastric muscle,medial
pterygoid muscle and the
angle of mandible.
 FUNCTIONS
 Palatine tonsils have a protective role and act as
sentinels at the portal of air and food passage.
 Tonsillar B-cells can mature to produce all the 5
major Ig classess.
 When incubated in vitro with either mytogens or
specific antigens,they produce specific antibodies
against DT, polio virus, strep pneumonia, haem
influenza, staph aureus, lipopolysaccharide of E.coli .
 In addition to humoral immunity ,there is
considerable T-cell response in palatine tonsils.
 The cyrpts in tonsils increase the surface area for
contact with foreign substances.
 BLOOD SUPPLY
 Main artery supplying the tonsil
is tonsillar branch of facial artery.
 It also receives arterial supply
from the
ascending palatine branch of
facial artery
ascending pharyngeal artery from
external carotid
 Dorsal linguae branches of
lingual artery.
 Descending palatine branch of
maxillary artery.
 VENOUS DRAINAGE

 Partonsillar vein
 Pharyngeal plexus.
 Facial vein
These communicate with pterygoid plexus
and eventually into common facial and
internal jugular veins.
LYMPHATIC DRAINAGE

 Tonsillar fossa- drain into upper deep cervical

nodes
 Anterior pillar- upper deep nodes along with
internal jugular vein and into submaxillary gland
and rarely into posterior triangle nodes.
 Posterior pillar- upper deep nodes and
posteriortriangle nodes and nodes around the
spinal accessory.
 INNERVATIONS

 Sensory supply –mainly from tonsillar branch of

glossopharyngeal nerve.
 The upper part of the tonsil near soft palate
supplied by lesser palatine branches of maxillary
division of trigeminal nerve, received by way of
pterygopalatine ganglion.
 Symphathetic fibres from superior cervical
ganglion.
APPLIED ANATOMY
 The sensory branches of glossopharyngeal nerve
have its cell bodies located in the inferior ganglion
of 9th cranial nerve.
 The cell bodies of tympanic nerve are also located
here, which provides general sensation to medial
surface of TM and middle ear mucosa.
 Both oropharyngeal and tympanic nerve project
proximally via trigeminal tract to the ventral
postromedial nucleus of thalamus.
 These common central projections account for the
simultaneous perception of pain in ear and
oropharynx.
 TONSILLITIS

 Tonsillitis is inflammation due to infection of the

tonsils.
 Epidemiology:
It is a very common condition most frequent in
children aged 5-10 years and young adults b/w
15-25 years.
 Types:
Acute
Chronic
 ACUTE TONSILLITIS
 Def:
Acute inflammatory condition of the tonsil, which may involve the
mucosa crypts follicle and tonsillar parenchyma.
 ETIOLOGY:
Initially starts with viral infection which is followed by secondary
bacterial infection. viruses commonly isolated include influenza
para-influenza adenovirus,rhinovirus.
Bacterial: Haemolytic strep is the most commonly infecting organism
Other organisms are haemophilus infleunza, pneumococus, staph,
M.catarrhalis.

 RISK FACTORS:
Immuno deficiency
Familyhistory or atopy
CLINICO-PATHOLOGICAL
TYPES
Depending of the progress of the disease
This can be classified into
1. CATARRHAL TONSILLITIS:
Occurs due to viral infection of the
URT involving the mucosa of the tonsil.
2.CRYPTIC TONSILLITIS:
Following viral infection secondary
bacterial infection supervenes and gets
entrapped within the crypts leading to a
localized form of infection.The mucosa
within the crypts gets swollen and is
associated with inflammatory exudate
which occupies the crypts
3.3. ACUTE FOLLICULAR
TONSILLITIS:
In severe from infection of the tonsils
caused by virulent organisms, it causes
spread of inflammation from tonsillar
crypts to the surronding tonsillar
follicles. The follicles become
inflammed and swollen.The surfae of
the tonsil appear irregular with crypts
filled yellowish white exudate which
may coalesce to form a coating which
gives an appearance of a flase membrane
4.ACUTE PARENCHYMAL
TONSILLITIS:
Here tonsil substance is affected.Tonsil
is uniformly enlarged and red
 Symptoms:
Pain in the throat is sometimes severe
may last more than 48 hrs,along with
pain during swallowing,
Fever which is always highgrade,
Generalised malaise and body aches ,
Dry cough,
Head ache,
Pain may be reffered to the ears,
Classical streptococcal tonsillitis has an
acute onset,headache,abdominal pain
and dysphagia.
 Signs
Congested and edematous tonsils,
Tonsils may be difusely swollen in
parenchymatus tonsillitis,
Crypts can be seen filled with pus with
swollen follicles in fillicular tonsillitis,
Enlarged and tender jugulo diagastric
LN,
Often the breath is foetid and tongue is
coated,
Hyperaemia of pillars, soft palate
,uvula.
 INVESTIGATIONS

 Throat swab for cs

 Peripheral smear to rule out haemopoeitic disorders
like leukamia and agranulocytosis
 Paul bunnel test to rule out IM
 X Ray nasopharynx to rule out adenoid hypertrophy
 X Ray PNS to rule out naso sinus septic focus
 TREATMENT
 Encourage to take plenty of fluids
 Analgesics to relieve pain
 Antimicrobial therapy;
penicillin is the drug of choice especially for streptococcus
Betalactmase producing haemolytic strep should be treated
with amoxy+clav combination.
Erythromycin should be preferred in patients sensitive to
penicillin group of drugs.
Injectable penicillin like crystalline penicillin and amoxyclave
should be given in sever cases.
 Antiseptic gargles and throat lozenges may be given.
 Mandl’s throat paint may alleviate pain.
 COMPLICATIONS

 Chronic tonsillitis with recurrent

acute attacks.
 Peritonsillar abscess.
 Parapharyngeal abscess.
 Cervical abscess.
 Acute otitis media
 Rheumatic fever.
 Acute glomerulonephritis (rare).
 Subacute bacterial endocarditis.
 DIFFERENTIAL DIAGNOSIS
If the sore throat is due to viral infection the symptoms are
usually milder and often related to common cold.
If due to infection with the coxsackie virus, small blisters
develop on the tonsils and roof of the mouth . The blisters erupt
in a few days and are followed by a scab, which may be very
painful.
Infectious mononucleosis(glandular fever) affects teenagers
most often. They may be quite unwell with very large and
purulent tonsils and a long-lasting lethargy.
In streptococcal infection the tonsils often
swell and become coated and the throat is
sore. The patient has a temperature, foul
smelling breath and may feel quite ill.
Unilateral enlargement of tonsils, especially
in the elderly may indicate malignancy.
It is not uncommon for HIV infection to
present with ENT symptoms, Especially in
children. The most common presentations
are cervical lymphadenopathy, oro-
oesophageal candidiasis and otitis media
 DIFFERENTIAL DIAGNOSIS OF
MEMBRANE OVER THE TONSIL
 Membranous tonsillitis:
It occurs due to pyogenic
organisms. A membrane
forms over the medial
surface along with
features of acute
tonsillitis.
 Diphtheria: slower in
onset, The membrane in
diphtheria extends
beyond the tonsils on to
the soft palate and dirty
gay in color ,It is
adherent and its removal
leaves a bleeding
surface.
 Vincent’s angina: Insidious onset witless
fever and less discomfort in throat.
Membrane which usually forms over one
tonsils, can be easily removed revealing an
irregular ulcer on the tonsil.
 Traumatic ulcer: Any injury to oropharynx
heals by formation of a membrane appear
within 24 hrs.
 Agrnulocytosis : It presents with ulcerative
necrotic lesions not only on the tonsils but
elsewhere In the oropharynx
 CHRONIC TONSILLITIS
 DEF:
It is the chronic inflammation of the palatine tonsils
which occurs as a result of
repeated attacks of acute tonsillitis or due to
inadequately resolved AT
 ETIOPATHOGENESIS
Most frequent etiological agent is b-hemolytic
streptococcus
It follows as a complication of acute tonsillitis.
Pathologically micro abscesses walled of by fibrous
tissue have been seen in lymphoid follicles of tonsils
It may be subclinical infection of tonsils without an
acute attack.
Mostly affects children and young adults.
Pre disposing factor may be chronic infection in
sinuses and teeth.
 Clinico-pathological types
1.CHRONIC-FOLLICULAR TONSILLITIS:
Tonsillar crypts are full of infected cheesy
material that shows on the surface as yellowish
spots
2.CHRONIC-PARENCHYMATOUS
Following repeated attacks of AT the lymphoid
follicles of tonsillar parenchyma undergo
hyperplasia leading to uniform enlargement of
the tonsils.
The tonsils may be grossly enlarged causing
obstruction to fo and air passages
3.CHRONIC-FIBROTIC TONSILLITIS
Here the tonsils are small due to atrophy but
the remnants may get infected leading to
recurrent attacks.
 Symptoms:
Recurrent sore throat,
Cough,
Halitosis,
Thick speech,
Bad taste in the mouth due to pus,
Difficulty in swallowing,
Sleep apnoeic episodes,
Acute exacerbations produce symptoms
similar to AT.
 Cardinal signs:
Persistent congestion of anterior
pillars.
Ervin-moore sign:Positive tonsillar
squeeze.
Enlarged and nontender JD LN.
 GRADES
 Grade1
Tonsils are congested but are
located with in the tonsillar fossa
 Grade2
Tonsils hypertrophies till the brim
of the tonsillar fossa
 Grade3
Tonsillar hypertrphy extends
beyond the pillars but does not
touch each other
 Grade4:kissing tonsils
The tonsils are in contact with
each other causing respiratory and
deglutition problems
 COMPLICATIONS

 Peritonsillar abscess.
 Parapharyngeal
abscess.
 Intratonsillar abscess.
 Tonsilar cyst.
 Tonsilloliths
 RF,AGN.
 INVESTIGATIONS

 CBP.
 CT,BT,PT,APTT.
 Blood group.
 ASO titer.
 Throat swab for CS.
 Evaluation of renal and cardiac
functions if rheumatic ds is suspected.
 TREATMENT

 Conservative
General health,diet and treatment of co-
existing infection of tooth,nose,sinuses.
Treatment of acute exacerbations as in
AT.
 Surgical
Tonsillectomy
ADENOTONSILLECTOMY
 Adenoidectomy
INDICATIONS

INFECTIONS:
1. Purulent adenoiditis
2. Adenoid hypertrophy associated with
    CSOM with effusion
3.  Recurrent acute otitis media
   4. CSOM with perforation

OBSTRUCTION:
1. Excessive snoring
2. Sleep apnoea
3. Adenoid hypertrophy associated with
    Corpulmonale
    Failure to thrive
   Dysphagia
   Speech abnormalities
OTHERS:
Adenoid hypertrophy associated with chronic sinusitis
 Contraindications
1.Cleft palate or submucous palate.
Removal of adenoids causes
velopharyngeal insufficiency in such
cases.
2.Haemorrhagic diathesis.
3.Acute infections of upper respiratory
tract.
Anesthesia
Performed under general
anesthesia with oral
intubation
 Position
Patient is placed in Rose`s
positions; supine with head
extended by placing a
pillow under the shoulders.
Overextension should be
avoided.
 Technique
 Boyle Davis mouth gag is
introduced,opened and held in place by
Draffin`s bipod stand
 A laryngeal mirror is used to inspect
the nasopharynx.The adenoid can also
be palpated by a finger
 St Clair Thomson adenoid curette is
introduced into the nasopharynx,above
the superior extent of the adenoid
tissue,preferably while holding the
laryngeal mirror in the other hand;with
a downward and forward sweeping
motion the adenoids are curetted
 A smaller-sized adenoid curette is
used to curette the adenoid around
the choana and around the
eustachian cushions.Care is taken
not to injure them.Injury to the
eustachian cushions can lead to
middle ear disease.
 Nasopharynx is re-examined with
mirror to confirm that no tags of
adenoid tissues are left
behind,which if present should be
removed.
 Nasopharynx is packed with a gauze
pack for a few minutes.The pack is
removed at the end of the operation.
 If bleeding persists after the
procedure it should be cauterized
with bipolar diathermy or suction
diathermy,before the patient is
 Postoperative Care

 Nil per orally till full recovery from

anesthesia
 Close monitoring of vital signs
 Watch for bleeding.Earliest sign of
bleeding may be frequent swallowing
by the patient.
 Oral antibiotics and analgesics.
 Complications

 Hemorrhage
should be controlled before the patient is shifted out
of the operation theater. Sometimes posterior nasal
pack may be needed for uncontrolled post
adenoidectomy bleeding.
 Surgical trauma
1. Trauma to the soft palate and uvula.
2. Injury to the eustachain cushions resulting in stenosis
3. Injury to the cervical spine:dislocation of the
atlantoaxial joint.
 Speech Defects
hyper nasal speech,short soft palate or
submucous cleft palate.
 Griesel syndrome
Patient complains of neck pain and develops
torticollis.Mostly it is due to spasm of
paraspinal muscles, but can be due to atlanto-
axial dislocation requiring cervical collar and
even traction.
 Postoperative Scarring
1. Fibrous bands or adhesions in nasopharynx.
2. Stenosis may impair eustachian tube opening resulting
in middle ear problems.
 Acute otitis media
 Injury to pharyngeal musculature and vertebrate
This is due to hyperextension of neck and undue
pressure of currette.Care should be taken when
operating patients of Down`s syndrome as 10-20% of
them have atlanto-axial instability.
 Recurrence
 Causes of Persistence of Symptoms

 Adenoid remnant left in the

nasopharnyx especially
around the choana.
 Postoperative scarring.
 Other Techniques of Adenoidectomy

 Endoscopic transnasal or
transpalatal adenoidectomy using
microdebrider.
 By suction diathermy
 Coablation
Tonsillectomy
 Indications
 Absolute
 Recurrent infections of the throat.
This is the most common indication.
Seven or more episodes in one year or
Five episodes per year for 3 years or
Three episodes per year for 3 years or
Two weeks or more of lost school or work in one year.
 Peritonsillar abscess
In children,tonsillectomy is done 4-6 weeks after abscess has
been treated.
 Tonsillitis causing febrile seizures
 Suspicion of malignancy
A unilaterally enlarged tonsil may be a lymphoma in children
and an epidermoid ca in adult.An excisional biopsy is done
 Relative
 Diphtheria carriers ,who do not respond to
antibiotics.
 Streptococcal carriers ,who may be the source of
infection to others.
 Chronic Tonsillitis with bad taste
 Recurrent streptococcal tonsillitis in a patient
with valvular heart disease
 Tonsilloliths
 Tonsillar Cysts
 Obstruction:
1. Sleep apnoea
2. Adenotonsillar enlargement associated
with core pulmonale, and failure to thrive
3. Dysphagia
4. Speech abnormalities (Rhinolalia
clausa)
5. Cranio facial growth abnormalities
6. Occlusal abnormalities
 As a surgical approach to other
structures like
    Styloid process Excision
    Glossopharyngeal neuralgia
    Parapharyngeal space
UPPP
 CONTRAINDICATIONS
 Haemoglobin level is less than 10g%
 Presence of acute infection in upper respiratory track,
even acute tonsillitis. Bleeding is more in the presence of
acute infection.
 Children under 3 years of age. They are poor surgical risks
 Overt or submucous cleft palate.
 Bleeding disorders eg:Leukaemia,Purpura,aplastic
anaemia,haemophilia
 At the time of epidemic of polio.
 Uncontrolled systemic disease,eg:diabetes,cardiac
disease, hypertension or asthma
 Tonsillectomy is avoided during the period of menses
 Anesthesia
Performed under general anesthesia with oral intubation
 Position
Patient is placed in Rose`s positions;supine with head
extended by placing a pillow under the shoulders.
Overextension should be avoided.
 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
 Techniques
Cold methods
 dissection and snare
 Guillotine method
 intracapsular tonsillectomy
 harmonic scalpel
 Plasma-mediated ablation technique
 cryo surgery

Hot methods
 electrocautery
 laser tonsillectomy
 coblation tonsillectomy
 Radio frequency
 Dissection and Snare method
 Boyle-Davis mouth gag is introduced
and opened. It is held in the place by
draffin`s bipods or a string over a
pulley.
 Tonsil is grasped with tonsil-holding
forceps and pulled medially.
 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.
 A blunt curved scissor may be used
dissect the tonsil from the peritonsillar
tissue and separate its upper pole.
 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.
 Now wire loop of tonsillar
snare is threaded over the tonsil
on to its pedicle,tightened,and
the pedicle cut and the tonsil
removed.
 A gauze sponge is placed in the
fossa and pressure applied for a
few minutes.
 Bleeding points are tied with
silk.
 For tying a ligature
around the bleeder for
controlling bleeding, the
bleeding vessel is
clamped with the tip of
a straight artery forceps.
 Then, the curved artery
forceps is placed under
the tip of the straight
artery forceps, which is
then removed and a 1-0
or 2-0 silk tie is placed
and tied around the
curved forceps using a
ligature-pushers or
straight artery forceps.
 Post-operative care

 Immediate general care

 keep the patient in coma position until fully recovered
from anesthesia
 Keep the watch on bleeding from the nose and mouth.
 Keep check on vital pressure
 Diet
when patient is fully recovered he is permitted to take
liquids.eg:cold milk or icecream.Sucking of ice cubes
gives relief from pain. They may take custard,jelly,soft
boiled eggs or slice of bread soaked in milk on the second
day. Plenty of fluid should be encouraged.
 Oral hygiene
Patient is given 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.
 Analgesics
Pain,locally in the throat and referred to ear, can be
relieved by analgesics like paracetamol. An analgesic
can be given half n hour before meals
 Antibiotics
A suitable antibiotic can be given orally or by
injection for a week.
 Complications of tonsillectomy:
 Complications can be classified in to immediate,
intermediate and delayed.
 Immediate complications:
 Mostly encountered on the table during surgery. The most
common of them being the complications of general
anaesthesia.
 Next is troublesome intra operative bleeding. This is
common in poorly prepared tonsillectomies (i.e. patients
who have been taken up for surgery without a pre op
course of antibiotics), hot tonsillectomy (i.e. quinsy
tonsillectomy). Bleeding can be controlled by proper
dissection, staying in the correct plane (i.e. sub capsular
plane) during dissection, ligation of bleeders, using bipolar
cautery to coagulate the bleeding vessels.
 Trauma to the anterior and posterior pillars. Trauma to
posterior pillar causes nasal regurgitation whenever the
patient attempts to drink fluids after surgery. It may also
cause undesirable changes in the voice i.e. Rhinolalia
aperta.
 Teeth must be taken care when mouth gag is being
applied. Any loose tooth, dentures must be removed
before intubation because the loose teeth can easily be
dislodged and be aspirated.
 Trauma to the lips and gums: can be avoided by using
the right sized tongue blade. The size of the blade can be
measured by placing it between the mentum and the
angle of the mandible
 Intermediate complications:
 Are mostly haemorrhage. Haemorrhage during immediate post op
period is also known as reactionary haemorrhage. This is caused due to
 1. Wearing off of the hypotensive effect of the anaesthesia during the
immediate post op period.
 2. Slipping of ligature
 These patients must be taken to the operation theatre, reanaesthetised
and the bleeders must be ligated or cauterised.
 If bleeding is diffuse and uncontrollable pillar suturing can be resorted
to. This is done by suturing both the anterior and posterior pillars after
placing a gauze or gelfoam in the tonsillar fossa.
 If gauze is used to pack the tonsillar fossa, silk is used to suture the
pillars and these sutures must be removed after 48 hours and the gauze
is removed.
 On the other hand if absorbable material like gel foam is used the
pillars can be sutured with chromic cat gut and the sutures need not be
removed.
 Delayed complications:
 Are mostly due to infections. These commonly occur a
week after the surgery. Bleeding during this period is
known as secondary haemorrhage. Antibiotics are used
to control infections.
 Lung complication: Aspiration of blood, mucus or tissue
fragments may cause atelectasis or lung abscess.
 Scarring in soft palate and pillars.
 Tonsillar remnants
 Hypertrophy of lingual tonsils.
 Other techniques of tonsillectomy

 Intracapsular tonsillectomy:
 In this method tonsil is removed from its capsule.
Special instruments are needed for this purpose.
Micro debrider with a 45 degree hand piece is
used for this surgery. The major advantage of this
procedure is that it causes less trauma to the
pillars and mucosa of the oro pharynx uvula and
soft palate.
 Harmonic scalpel tonsillectomy:
 Harmonic scalpel 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 over 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. The
temperature generated by harmonic
scalpel is less than that of electro cautery
hence it is safer (50 - 100 degrees
centigrade as compared to that of 150 -
400 degrees centigrade).
 The major disadvantage is the expense
of the equipment and the increased
 Guillotine method: The tonsils were
removed during olden days using this
method.  This method has been
abandoned because of the risks of
bleeding.  In this method a guillotine is
used to simply chop off the tonsil.  This
term guillotine is derived from the
French which literally means chop off the
head. 
 CryoTonsillectomy:
 Tonsillectomy can also be performed using a cryo probe.
CryoSurgery is a process in which very cold instrument or
substance is applied to tonsil and it is removed by the process
of repeated freezing and thawing. The temperature reached
during cryo is dependent on the medium used :
 - 82 degrees centigrade by carbondioxide
 - 196 degrees centigrade by liquid nitrogen
 Any of the above can be used in tonsil surgery. The major
advantage of this procedure is minimal bleeding. The major
disadvantage of this procedure is the operating time
involved. This procedure is used only in patients with known
bleeding diathesis.
 Laser tonsillectomy:
Tonsillectomy can be performed using laser. A
carbondioxide laser or a KTP laser can be used. Major
advantage of laser surgery is reduced bleeding. Laser seals
all bleeders effeciently. The flip side being increased
operating time and the cost of laser equipment.
 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 40 - 80
degrees centigrade, much lower than that of electro cautery.
The major advantage of this procedure is reduced bleeding
and reduced post operative pain.
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