Adenotonsillectomy – Tonsils Operation

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Adenotonsillectomy is an operation performed to remove both the adenoids and tonsils. Tonsillectomy is another operation to remove the tonsils.

These operations are done on patients who suffer from repeated tonsillitis or have an obstructed breathing, pauses between breathing at night, obstructed sleep apnea and abscess. Tonsil operation is one of the most common procedures in children. It takes about 2 weeks for children to recover from the operation.


HISTORY OF TONSIL OPERATION

The first Tonsillectomy was performed by Shushrut in the year 1000 BC. The surgery performed using fingernails.

De Medicina is a medical treatise (book) by Aulus Cornelius Celsus 25 BC- 50 AD, a Roman encyclopaedist. Celsus describes Tonsillectomy as a complete removal of tonsils.

They ought to be disengaged all round by the finger and removed. If they are not separated by this method, it is necessary to take them up with a blunt hook and separate them with a scalpel; then to wash them with vinegar and anoint the wound with a styptic application.


Aetius, a Greek physician advocated partial removal of Tonsils

Only the part of the tonsil which projects and is easily seen should be removed, that is about half of the enlarged gland. Those who extirpate the entire tonsil remove, at the same time, structures which are perfectly healthy, and, in this way, give rise to serious hemorrhage.

American physician, around 1897, switched from Partial to Total Tonsillectomy.


Other events that are happening at this time:

1772 Nitrous Oxide discovered
1840s Ether and Chloroform
1846 First operation under GA
1920 Endotracheal intubation Magill
1928 Penicillin discovered

Lancet – published a series of nine hundred cases.
He described Dissection Tonsillectomy as we practise today
“The operation was performed with the patient lying on his back with the head extended. The tongue was held out of the way with a stitch, and the mouth held open with a gag between the last molar teeth.”
He was against the use of the Guillotine.


TONSILLOTOMY

Alternate names:-

  • Partial Tonsillectomy
  • Sub total Tonsillectomy
  • Intra Capsular Tonsillectomy

In order to minimize or avoid morbidity, a number of otolaryngologists in the United States and Europe have revived a historical procedure, previously known as ‘tonsillotomy’, specifically for those patients with obstructive sleep-disordered breathing (OSDB) due to adenotonsillar hypertrophy.

  • Regrowth occurs in .5 to 6 percent – when a completion tonsillectomy can be done
  • Currently considered ideal for Enlarged Tonsils causing SDB (sleep disordered breathing).
  • Total Tonsillectomy may still be procedure of choice for patients with Recurrent Tonsillitis

 


PROBLEMS WITH TOTAL TONSILLECTOMY

  • Bleeding
  • Pain

Complete removal of the tonsils leaves the pharyngeal musculature to heal by secondary intention, leading to most of the morbidity


PROS AND CONS OF PARTIAL VERSUS TOTAL TONSILLECTOMY

The children who were treated with Partial Tonsillectomy experienced

Benefits

  • Significantly less postoperative pain
  • Fewer days to normal activity and diet
  • Less analgesic use,
  • The frequency of delayed postoperative bleeding appeared lower with partial tonsillectomy (4.7% and 1.7% for standard and partial tonsillectomy, respectively), but this difference was not statistically significant.

Adverse Effects

  • Significantly greater intraoperative blood loss
  • Slightly longer time to perform (an average of 3 minutes longer for experienced surgeons).
  • The microdébrider instrumentation was more expensive

Koltai PJ, Solares CA, Koempel JA, et al. Otolaryngol Head Neck Surg. 2003;129:532–538


INDICATIONS OF ADENOIDECTOMY

Obstruction:
• Chronic nasal obstruction or obligate mouth breathing
• OSA with FTT, cor pulmonale
• Dysphagia
• Speech problems
• Severe orofacial/dental abnormalities

Infection:
• Recurrent/chronic adenoiditis (3 or more episodes/year)
• Recurrent/chronic OME (+/- previous BMT)


tonsil-operation-methods

ADENOTONSILLECTOMY- METHODOLOGY

  • Finger nails
  • Blunt dissection
  • Cold steel dissection/ Guillotine
  • Electro cautery – monopolar/ bipolar
  • Adenotonsillectomy – methodology
  • RadioFrequency
  • Laser
  • Microdebrider
    • ‘’biological dressing’’ limits postop pain and inflammation
  • Coblator
    • Ionized Na+ molecules broken down at 40-70 celcius -
  • HARMONIC SCALPEL
    • Simultaneous cutting and coagulation of  blood vessels
    • Mechanical vibration at 55.5 kHz
    • Ruptures  hydrogen bonds  of the proteins, proteins  denatured , forms a  coagulum and seals vessel
    • Low temperature

    HOT VERSUS COLD STEEL TONSILLECTOMY
    Some controversies laid to rest regarding Post op Haemorrrhage -
    EBM results of most common controversies related to Adenotonsillectomy

    • Hot (Monopolar Electrosurgery) versus cold knife tonsillectomy revealed that postoperative haemorrhage rates were not significantly different
    • Coblation versus Electro cautery – no difference