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Reasons for tonsillectomy

Tonsillectomy may be performed when the patient:

• Experiences frequent bouts of acute tonsillitis. The number requiring tonsillectomy varies
with the severity of the episodes. One case, even severe, is generally not enough for most
surgeons to decide tonsillectomy is necessary.
• Has chronic tonsillitis, consisting of persistent, moderate-to-severe throat pain.
• Has multiple bouts of peritonsillar abscess.
• Has sleep apnea (stopping or obstructing breathing at night due to enlarged tonsils or
adenoids)
• Has difficulty eating or swallowing due to enlarged tonsils (very unusual reason for
tonsillectomy)
• Produces tonsilloliths in the back of their mouth.
• Has abnormally large tonsils with crypts (Craters or impacts in the tonsils)

[edit] Common causes and demographics


Infections requiring tonsillectomy are often a result of Streptococcus ("strep throat"), but some
may be due to other bacteria, such as Staphylococcus, or viruses. However, the etiology of the
condition is largely irrelevant in determining whether tonsillectomy is required [1].

Most tonsillectomies are performed on children, although many are also performed on teenagers
and adults. The number of tonsillectomies in the United States has dropped significantly from
several million in the 1970s to approximately 600,000 in the late 1990s[citation needed]. This has been
due in part to more stringent guidelines for tonsillectomy and adenoidectomy (see tonsillitis and
adenoid). Still, debate about the usefulness of tonsillectomies continues. Not surprisingly, the
otolaryngology literature is usually pro-tonsillectomy, whereas the pediatric literature has the
opposing view[citation needed]. Enlarged tonsils are removed more often among adults and children for
sleep apnea (airway obstruction while sleeping), snoring, and upper airway obstruction. Children
who have sleep apnea can do poorly in school, are tired during the day, and have some links to
ADHD [2] [3].

Tonsillectomy in adults is more painful[citation needed] than in children, although each patient will
have a different experience. Post-operative recovery can take from 10 up to 20 days, during
which narcotic analgesics are typically prescribed. Most surgeons advise eating soft foods after
having your tonsils removed. Patients in the United States and Canada are usually advised not to
eat "crunchy" or "rough" food (toast, biscuits, cookies & crackers) as these will scrape the back
of the throat, increasing the risk of bleeding or infection after the operation, whereas patients in
the United Kingdom are often encouraged to eat rough foods to keep the tonsillar beds clean.
Some believe that dairy products tend to coat the throat causing an increase in possible infection
and therefore discourage their use. Spicy and acidic foods are irritating and should be avoided.
Proper hydration is also very important during this time, since dehydration can increase throat
pain, leading to a vicious cycle of poor fluid intake. At some point, most commonly 7-11 days
after the surgery (but occasionally as long as two weeks (14 days) after), bleeding can occur
when scabs begin sloughing off from the surgical sites. The overall risk of bleeding is
approximately 1-2% higher in adults [4]. Approximately 3% of adult patients develop significant
bleeding at this time. The bleeding might naturally stop quickly, or else mild intervention (e.g.,
gargling cold water) could be needed (but ask the doctor before gargling because it might bruise
the area of the skin that has been cauterized). Otherwise, a surgeon must repair the bleeding
immediately by cauterization, which presents all the risks associated with emergency surgery
(most having to do with the administration of anesthesia on a patient whose stomach is not
empty). Various procedures are available to remove tonsils, each with different advantages and
disadvantages. Children and teenagers sometimes exhibit a noticeable change in voice [5] after the
operation [6].

[edit] Methods of tonsil removal


The first report of tonsillectomy was made by the Roman encyclopedist Celsus in 30 AD. He
described scraping the tonsils and tearing them out or picking them up with a hook and excising
them with a scalpel. Today, the scalpel is still the preferred surgical instrument of many ear, nose,
and throat specialists. However, there are other procedures available – the choice may be dictated
by the extent of the procedure (complete tonsil removal versus partial tonsillectomy) and other
considerations such as pain and post-operative bleeding. A quick review of each procedure
follows:

• Dissection and snare method: Removal of the tonsils by use of a forceps and scissors
with a wire loop called a 'snare' is the most common method practiced by
otolaryngologists today. The procedure requires the patient to undergo general anesthesia;
the tonsils are completely removed and the skin is cauterized. The patient will leave with
minimal post-operative bleeding.
• Electrocautery: Electrocautery burns the tonsillar tissue and assists in reducing blood
loss through cauterization. Research has shown that the heat of electrocautery (400°C)
results in thermal injury to surrounding tissue. This may result in more discomfort during
the postoperative period.
• Harmonic scalpel: This medical device uses ultrasonic energy to vibrate its blade at
55kHz. Invisible to the naked eye, the vibration transfers energy to the tissue, providing
simultaneous cutting and coagulation. The temperature of the surrounding tissue reaches
80°C. Proponents of this procedure assert that the end result is precise cutting with
minimal thermal damage.
• Radiofrequency ablation: Monopolar radiofrequency thermal ablation transfers
radiofrequency energy to the tonsil tissue through probes inserted in the tonsil. The
procedure can be performed in an office (outpatient) setting under light sedation or local
anesthesia. After the treatment is performed, scarring occurs within the tonsil causing it to
decrease in size over a period of several weeks. The treatment can be performed several
times. The advantages of this technique are minimal discomfort, ease of operations, and
immediate return to work or school. Tonsillar tissue remains after the procedure but is
less prominent. This procedure is recommended for treating enlarged tonsils and not
chronic or recurrent tonsillitis.
• Thermal Welding: A new technology which uses pure thermal energy to seal and divide
the tissue. The absence of thermal spread means that the temperature of surrounding
tissue is only 2-3 °C higher than normal body temperature. Clinical papers show patients
with minimal post-operative pain (no requirement for narcotic pain-killers), zero edema
(swelling) plus almost no incidence of bleeding. Hospitals in the US are advertising this
procedure as "Painless Tonsillectomy". Also known as Tissue Welding.
• Carbon dioxide laser: Laser tonsil ablation (LTA) finds the otolaryngologist employing
a hand-held CO2 or KTP laser to vaporize and remove tonsil tissue. This technique
reduces tonsil volume and eliminates recesses in the tonsils that collect chronic and
recurrent infections. This procedure is recommended for chronic recurrent tonsillitis,
chronic sore throats, severe halitosis, or airway obstruction caused by enlarged tonsils.

The LTA is performed in 15 to 20 minutes in an office setting under local anesthesia. The patient
leaves the office with minimal discomfort and returns to school or work the next day. Post-
tonsillectomy bleeding may occur in 2-5% of patients. Previous research studies state that laser
technology provides significantly less pain during the post-operative recovery of children,
resulting in less sleep disturbance, decreased morbidity, and less need for medications. On the
other hand, some believe that children are adverse to outpatient procedures without sedation.

• Microdebrider: The microdebrider is a powered rotary shaving device with continuous


suction often used during sinus surgery. It is made up of a cannula or tube, connected to a
hand piece, which in turn is connected to a motor with foot control and a suction device.

The endoscopic microdebrider is used in performing a partial tonsillectomy, by partially shaving


the tonsils. This procedure entails eliminating the obstructive portion of the tonsil while
preserving the tonsillar capsule. A natural biologic dressing is left in place over the pharyngeal
muscles, preventing injury, inflammation, and infection. The procedure results in less post-
operative pain, a more rapid recovery, and perhaps fewer delayed complications. However, the
partial tonsillectomy is suggested for enlarged tonsils – not those that incur repeated infections.

• Bipolar Radiofrequency Ablation (see Coblation tonsillectomy): This procedure


produces an ionized saline layer that disrupts molecular bonds without using heat. As the
energy is transferred to the tissue, ionic dissociation occurs. This mechanism can be used
to remove all or only part of the tonsil. It is done under general anesthesia in the
operating room and can be used for enlarged tonsils and chronic or recurrent infections.
This causes removal of tissue with a thermal effect of 45-85 °C. It has been claimed that
this technique results in less pain, faster healing, and less post operative care [7]. However,
review of 21 studies gives conflicting results about levels of pain, and its comparative
safety has yet to be confirmed [8].

Adenoidectomy
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Intervention:
Adenoidectomy

Location of the adenoid

ICD-10 code:

ICD-9 code: 28

MeSH D000233

Other codes:

Adenoidectomy is the surgical removal of the adenoids. They may be removed for several
reasons, including impaired breathing through the nose and chronic infections or earaches. The
surgery is common. It is most often done on an outpatient basis under general anesthesia. Post-
operative pain is generally minimal and prevented with an abundance of icy or cold foods,
though dairy foods such as ice cream should be avoided, as they coat the back of the throat,
encouraging the body to produce phlegm, which can interfere with healing. The procedure can
sometimes be combined with a tonsillectomy if needed. Recovery time can range from several
hours to two or three days (though as age increases so does recovery time).

Adenoidectomy is often performed on children aged 1-6, as adenoids help the body's immune
system. Adenoids become vestigial organs in adults.

Tonsillectomy
A tonsillectomy is the surgical removal of the tonsils. The adenoids may or may not be removed at the
same time. Adenoidectomy is not discussed in this topic. For more information, see the topic Ear
Infections.
Children whose tonsils are removed for recurrent throat infections may have fewer and less severe strep
throat infections for at least 2 years. However, over time, many children who do not have surgery also
have fewer throat infections.
A general anesthetic is always used to sedate a child having a tonsillectomy. Adults may require only a
local anesthetic to numb the throat.
What To Expect After Surgery
The surgery may be done as outpatient surgery or, occasionally, during an overnight hospital stay.
A very sore throat usually follows a tonsillectomy and may last for several days. This may affect the sound
and volume of the person's voice and his or her ability to eat and drink. The person may also have bad-
smelling breath for a few days after surgery. There is a very small risk of bleeding after surgery.
A child having a tonsillectomy may feel "out of sorts" for a period of a week to 10 days. But if the child is
feeling well enough, there is no need to restrict his or her activity or to keep the child at home after the
first few days.
Why It Is Done
A tonsillectomy may be done in the following cases:1

• A person has recurring episodes of tonsillitis in a single year despite antibiotic treatment.
• Abscesses of the tonsils do not respond to drainage, or an abscess is present in addition to other
indications for a tonsillectomy.
• A persistent foul odor or taste in the mouth is caused by tonsillitis and does not respond to antibiotic
treatment.
• A biopsy is needed to evaluate a suspected tumor of the tonsil.

Large tonsils are not a reason to have a tonsillectomy unless they are causing one of the above problems
or they are blocking the upper airway, which may cause sleep apnea or problems with eating.
How Well It Works
Children whose tonsils are removed for recurrent throat infections may have fewer and less severe strep
throat infections for at least 2 years. However, over time, children who do not have their tonsils removed
may also have fewer infections.
Risks
Normal or expected risks of tonsillectomy include some bleeding after surgery. This is common, especially
when the healed scab over the cut area falls off.
Less common or rare risks include:

• More serious bleeding.


• Anesthetic complications.
• Death after surgery (very rare).

What To Think About


When you are trying to decide whether to have the tonsils removed, you might want to think about:

• How much time a child is missing from school because of throat infections.
• How much stress and inconvenience the illness has on the family.
The risks of surgery must also be weighed against the risks of leaving the tonsils in. In some cases of
persistent strep throat infections, especially if there are other complications, surgery may be the best
choice.
Liver Biopsy

The digestive system

In a liver biopsy (BYE-op-see), the physician examines a small piece of tissue from
your liver for signs of damage or disease. A special needle is used to remove the tissue
from the liver. The physician decides to do a liver biopsy after tests suggest that the
liver does not work properly. For example, a blood test might show that your blood
contains higher than normal levels of liver enzymes or too much iron or copper. An x
ray could suggest that the liver is swollen. Looking at liver tissue itself is the best way
to determine whether the liver is healthy or what is causing it to be damaged.

Preparation

Before scheduling your biopsy, the physician will take blood samples to make sure
your blood clots properly. Be sure to mention any medications you take, especially
those that affect blood clotting, like blood thinners. One week before the procedure,
you will have to stop taking aspirin, ibuprofen, and anticoagulants.

You must not eat or drink anything for 8 hours before the biopsy, and you should plan
to arrive at the hospital about an hour before the scheduled time of the procedure. Your
physician will tell you whether to take your regular medications during the fasting
period and may give you other special instructions.

[Top]
Liver Biopsy Overview
A liver biopsy is a procedure whereby small pieces of liver tissue are removed in order to be sent to a laboratory for
examination. It is very helpful in the diagnosis of diseases that affect the liver.

There are several potential approaches to procuring tissue for a liver biopsy. These are discussed below.

Percutaneous Liver Biopsy

In a percutaneous liver biopsy procedure, local anesthesia is used to numb the skin where a small incision is made. A
needle the diameter of a pen refill is then passed through the skin and into the liver, where a specimen is obtained.
Multiple biopsies may be taken. In these circumstances, the physician establishes where the liver lies by percussing
or tapping on the skin overlying the liver and listening to the sound to find an area of dullness, under which the liver
lies. Patient cooperation is critical during the procedure.

Percutaneous Image-Guided Liver Biopsy

A percutaneous image-guided liver biopsy is similar to the one described above except that the needle is guided by
CT scan or ultrasound images. This is often helpful when the disease process is localized to discrete spots in the
liver.

Laparoscopic Liver Biopsy

A laparoscopic liver biopsy may be done solely for the purpose of obtaining the biopsy specimen or may be part of
another operative procedure. Small incisions are made in the abdomen and instruments are introduced through
trocars to obtain the biopsy specimens. The laparoscope is a telescope that magnifies the objects it sees and allows
excellent visualization of the liver surface. Ultrasound can be used as part of this procedure.

Open Surgical Liver Biopsy

Open liver biopsies are rarely performed today unless they are part of another operative procedure. When an open
biopsy is done, the surgeon may choose to use a biopsy needle or may surgically excise a small wedge of liver
tissue.

There are two main reasons why your doctor may request that you undergo a liver biopsy. (Some of the more
common diagnoses for which a liver biopsy is ordered are listed in the next section.)

• Diagnosis: A liver biopsy is a very important and helpful test in the diagnosis of numerous diseases that
affect the liver and bile ducts. A small piece or pieces of tissue are removed from your liver and sent for
examination. In most cases, this allows establishment of a very specific diagnosis.

• Monitoring: A liver biopsy can help your doctor monitor the effectiveness of therapy that you are receiving for
a disease that affects the liver. Likewise, it can provide a warning if certain therapies you are receiving are
damaging the liver.