Tonsillectomy
Indications
A. Absolute Indications
- 1. Recurrent Throat Infections (Most Common):
Paradise Criteria:
(a) ≥ 7 episodes in 1 year
(b) 5 episodes/year for 2 years
(c) 3 episodes/year for 3 years
(d) ≥ 2 weeks lost school/work in 1 year - 2. Peritonsillar Abscess (Quinsy):
- Children: Done 4-6 weeks after abscess treatment.
- Adults: Done if there is a second attack.
- 3. Tonsillitis causing Febrile Seizures.
- 4. Hypertrophy Causing: Sleep Apnoea, Dysphagia, or Speech interference.
- 5. Suspicion of Malignancy: Unilaterally enlarged tonsil (Lymphoma/Epidermoid Ca). Excisional biopsy required.
B. Relative Indications
- Diphtheria carriers (unresponsive to antibiotics).
- Streptococcal carriers (source of infection).
- Chronic tonsillitis with bad taste/halitosis.
- Recurrent streptococcal tonsillitis in valvular heart disease.
C. Part of Another Operation
- Palatopharyngoplasty (Sleep apnoea).
- Glossopharyngeal neurectomy (Tonsil removed to access IX nerve).
- Removal of Styloid Process.
Contraindications
- Haemoglobin < 10 g%.
- Acute upper respiratory infection (Bleeding risk ↑).
- Children < 3 years (Poor surgical risk).
- Overt or Submucous Cleft Palate.
- Bleeding disorders (e.g., von Willebrand, Leukaemia, Haemophilia).
- During Polio epidemic.
- Uncontrolled systemic disease (Diabetes, HTN, Asthma).
- Menses (Avoided during period).
Pre-Op Details
- Anaesthesia: General (Endotracheal intubation). Local possible in adults.
- Position: Rose’s Position.
- Supine with head extended (pillow under shoulders).
- Rubber ring under head. Avoid hyperextension.
Steps: Dissection & Snare Method
1. Mouth Gag (Boyle-Davis) held by Draffin’s Bipods
↓
2. Tonsil grasped & pulled medially
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3. Incision at reflection (Tonsil/Anterior Pillar)
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4. Upper Pole Dissected (Blunt scissors)
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5. Traction + Dissection down to Lower Pole
↓
6. Snare threaded → Pedicle cut → Removed
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7. Haemostasis (Pressure/Ligation with silk)
Important: Plica Triangularis (near lower pole) should be removed. If left, it may hypertrophy later (Recurrence).
Postoperative Care
- Immediate: Coma position. Watch for bleeding/vitals.
- Diet: Cold liquids (Milk, Ice cream) → Soft diet (Custard, Jelly) → Solids.
- Oral Hygiene: Condy’s/Salt water gargles.
- Analgesics: Paracetamol. Avoid Aspirin/Ibuprofen (platelet risk).
- Antibiotics: For 1 week.
- Recovery: Home after 24h. Normal duties in 2 weeks.
Complications
Mortality Rate: 1:35,000
A. Immediate
| Type | Description & Management |
|---|---|
| Primary Haemorrhage | During operation. Rx: Ligation/Diathermy. |
| Reactionary Haemorrhage | Within 24 hours. Clot prevents muscle retraction. Rx: Remove clot, Vasoconstrictor. If fails: Ligation under GA. |
| Injuries | Pillars, uvula, palate, teeth, nerves, facial oedema. |
B. Delayed
- Secondary Haemorrhage: 5th–10th day (Sepsis).
- Infection (Parapharyngeal abscess, Otitis media).
- Lung complications (Aspiration).
- Hypertrophy of Lingual Tonsil (Compensatory).
Other Methods
| Method | Key Details |
|---|---|
| Laser Tonsillectomy | KTP-512 preferred over CO2. Indicated for coagulation disorders. |
| Laser Tonsillotomy | Indication: Patients unable to tolerate General Anaesthesia. Reduces size only. |
| Cryosurgery | Freezing. 2 applications (3-4 min each). |
| Intracapsular | Debrider used. Capsule preserved (Less pain). |
| Harmonic Scalpel | Ultrasound. Cold method. |
| Coblation | Plasma-mediated. Cold method. |
📚 Ref: Dhingra ENT | Chapter 94
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