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 .

Lined by ciliated columnar epithelium 6. Has crypts 4. Unencapsulated 2. Has no efferent lymphatics Adenoid 1. Lined by squamous epithelium 6. Has furrows 4. Present in oropharynx 5.DIFFERENCES BETWEEN TONSIL AND ADENOID Tonsil 1. Two 3. one 3. Present in nasopharynx 5. Has both afferent and efferent lymphatics . Encapsulated 2.

and Streptococcus pneumoniae . Moraxella catarrhalis.  Overall.  Adenoids can contribute to recurrent sinusitis and chronic persistent or recurrent ear disease because they can harbor a chronic infection. Staphylococcus aureus. group A beta-hemolytic Streptococcus.ADENOIDITIS  Inflammation of the adenoids is known as adenoiditis. The type and amount of pathogenic bacteria seem to vary based on the disease present and the age of the child. the most commonly cultured bacteria have been Haemophilus influenzae.

CLINICAL FEATURES  C/F: Nasal obstruction Hypertrophied gland Post nasal catarrhal discharge Lack of resonance of voice Cervical lymphadenitis Secondary Infections .

and vacant expression. open mouth. shortened upper lip. . high arched palate.closed nose voice  Adenoid facies The features of adenoid facies include elongated face. pinched nostrils.DUE TO HYPERTROPHY:  Feeding problems in children resulting in malnutrition  Noisy respiration  Impaired speech.

DUE TO POST NASAL CATARRHAL DISCHARGE  Nocturnal cough  Nausea and vomiting  Headache .

Epistaxis: When adenoids are acutely inflamed.  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 . Voice change: Voice is toneless and loses nasal quality. epistaxis can occur with nose blowing.DUE TO SECONDARY INFECTIONS  NOSE: Sinusitis Chronic maxillary sinusitis is commonly associated with adenoids.

e Lack of concentration. . General Symptoms Pulmonary hypertension: nasal obstruction due to adenoid hypertrophy can cause pulmonary hypertension and cor pulmonale Aprosexia: i.

SIGNS  POSTERIOR RHINOSCOPY: Lobulated pink mass with lacing of muco pus  EAR: Retracted tympanic membrane .

CLINICAL GRADING OF ADENOID SIZES GRADE Grade I Grade II Grade III Grade IV DESCRIPTION Adenoid tissue filling one third of the vertical portion of choanae Adenoid tissue filling from one third to two-thirds of the choanae From two-thirds to near complete obstruction of choanae. Complete choanal obstruction. .

.  A rigid or a flexible nasopharyngoscope is also useful to see details of the nasopharynx.DIAGNOSIS  Examinations of postnasal space and an adenoid mass can be seen with miror.

 Soft tissues lateral radiograph of nasopharynx.  Detailed nasal examination .

MEDICAL: Nasal Decongestants Anti biotics Anti histaminics SURGICAL: Adenoidectomy .

PALATINE TONSIL .

 Tonsil is extended upwards into the soft palate. The Palatine Tonsil is one of the mucosa associated lymphoid tissues(MALT).downwards into the base of the tongue. which is situated in the lateral wall of oropharynx between anterior and posterior pillars. .  Tonsil is one of the chief immunocompetent tissues in the oropharynx.anteriorly into palatoglossal arch.  It forms part of the waldeyer¶s ring.

through dorsal extension of mesenchyme into the forming soft palate.  Lymphocytes appear near epithelium during 3rd month but organises to nodular form after 6 months  By 5th month. tonsillar capsule is formed from mesenchyme.EMBRYOLOGY  The tonsil pillars are formed from 2nd and 3rd bronchial arches. . The tonsillar crypts develop by 3-6 months as solid ingrowths from surface epithelium.

RELATIONSHIPS OF TONSIL  It has two surfaces-medial and lateral and two poles-upper and lower. .it represents the ventral part of 2nd pharyngeal pouch. One of the crypts situated near the upper part of the tonsil is very large and deep and is called cryptomagna or intratonsillar cleft.  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.

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. LATERAL SURFACE: It presents a well defined fibrous capsule. It is also the site for collection of pus in peritonsillar abscess .

Its medial surface is covered by semilunar fold.  LOWER POLE: Is attached to the tongue. UPPER POLE: Extends into soft palate . 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. .extending b/w anterior and posterior pillars and enclosing a potential space called supratonsillar fossa.

tonsil is related to the facial artery.medial pterygoid muscle and the angle of mandible. The glossopharyngeal erve and styloid process.posterior belly of digastric muscle. BED OF THE TONSIL: It is formed by the superior constrictor and styloglossus muscles.submandibular salivary gland. . Outside the superior constrictor.if enlarged may lie in rlation to the lower part of the tonsillar fossa.

The cyrpts in tonsils increase the surface area for contact with foreign substances.there is considerable T-cell response in palatine tonsils.they produce specific antibodies against DT.coli . When incubated in vitro with either mytogens or specific antigens. staph aureus. Tonsillar B-cells can mature to produce all the 5 major Ig classess. In addition to humoral immunity . . lipopolysaccharide of E. polio virus. haem influenza.FUNCTIONS  Palatine tonsils have a protective role and act as     sentinels at the portal of air and food passage. strep pneumonia.

 Descending palatine branch of maxillary artery.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.

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

upper deep nodes and posteriortriangle nodes and nodes around the spinal accessory. .LYMPHATIC DRAINAGE  Tonsillar fossa.upper deep nodes along with internal jugular vein and into submaxillary gland and rarely into posterior triangle nodes.drain into upper deep cervical nodes  Anterior pillar.  Posterior pillar.

INNERVATIONS  Sensory supply mainly from tonsillar branch of glossopharyngeal nerve. received by way of pterygopalatine ganglion.  The upper part of the tonsil near soft palate supplied by lesser palatine branches of maxillary division of trigeminal nerve. .  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.  These common central projections account for the simultaneous perception of pain in ear and oropharynx. .  Both oropharyngeal and tympanic nerve project proximally via trigeminal tract to the ventral postromedial nucleus of thalamus.

 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 .TONSILLITIS  Tonsillitis is inflammation due to infection of the tonsils.

pneumococus.  RISK FACTORS: Immuno deficiency Familyhistory or atopy .ACUTE TONSILLITIS  Def: Acute inflammatory condition of the tonsil.rhinovirus.  ETIOLOGY: Initially starts with viral infection which is followed by secondary bacterial infection. staph.catarrhalis. Bacterial: Haemolytic strep is the most commonly infecting organism Other organisms are haemophilus infleunza. M. viruses commonly isolated include influenza para-influenza adenovirus. which may involve the mucosa crypts follicle and tonsillar parenchyma.

CATARRHAL TONSILLITIS: Occurs due to viral infection of the URT involving the mucosa of the tonsil.CLINICO-PATHOLOGICAL TYPES Depending of the progress of the disease This can be classified into 1.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 . 2.

3.3. The follicles become inflammed and swollen.ACUTE PARENCHYMAL TONSILLITIS: Here tonsil substance is affected. it causes spread of inflammation from tonsillar crypts to the surronding tonsillar follicles.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.Tonsil is uniformly enlarged and red . ACUTE FOLLICULAR TONSILLITIS: In severe from infection of the tonsils caused by virulent organisms.

Fever which is always highgrade. . Dry cough. Generalised malaise and body aches . Pain may be reffered to the ears.headache.abdominal pain and dysphagia. Head ache.along with pain during swallowing. Symptoms: Pain in the throat is sometimes severe may last more than 48 hrs. Classical streptococcal tonsillitis has an acute onset.

Hyperaemia of pillars. Signs Congested and edematous tonsils. Crypts can be seen filled with pus with swollen follicles in fillicular tonsillitis. Often the breath is foetid and tongue is coated. Tonsils may be difusely swollen in parenchymatus tonsillitis. Enlarged and tender jugulo diagastric LN.uvula. soft palate . .

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 .

 Antiseptic gargles and throat lozenges may be given.TREATMENT  Encourage to take plenty of fluids  Analgesics to relieve pain  Antimicrobial therapy. Injectable penicillin like crystalline penicillin and amoxyclave should be given in sever cases.  Mandl¶s throat paint may alleviate pain. Erythromycin should be preferred in patients sensitive to penicillin group of drugs. penicillin is the drug of choice especially for streptococcus Betalactmase producing haemolytic strep should be treated with amoxy+clav combination. .

COMPLICATIONS  Chronic tonsillitis with        recurrent acute attacks. Parapharyngeal abscess. Acute otitis media Rheumatic fever. Acute glomerulonephritis (rare). . Subacute bacterial endocarditis. Cervical abscess. Peritonsillar abscess.

which may be very painful. DIFFERENTIAL DIAGNOSIS If the sore throat is due to viral infection the symptoms are usually milder and often related to common cold. The blisters erupt in a few days and are followed by a scab. small blisters develop on the tonsils and roof of the mouth . Infectious mononucleosis(glandular fever) affects teenagers most often. They may be quite unwell with very large and purulent tonsils and a long-lasting lethargy. If due to infection with the coxsackie virus. .

The most common presentations are cervical lymphadenopathy. It is not uncommon for HIV infection to present with ENT symptoms. Unilateral enlargement of tonsils. foul smelling breath and may feel quite ill. Especially in children.In streptococcal infection the tonsils often swell and become coated and the throat is sore. orooesophageal candidiasis and otitis media . The patient has a temperature. especially in the elderly may indicate malignancy.

The membrane in diphtheria extends beyond the tonsils on to the soft palate and dirty gay in color .DIFFERENTIAL DIAGNOSIS OF MEMBRANE OVER THE TONSIL  Membranous tonsillitis: It occurs due to pyogenic organisms. .It is adherent and its removal leaves a bleeding surface. A membrane forms over the medial surface along with features of acute tonsillitis.  Diphtheria: slower in onset.

Membrane which usually forms over one tonsils.  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 . Vincent¶s angina: Insidious onset witless fever and less discomfort in throat. can be easily removed revealing an irregular ulcer on the tonsil.

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.

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. Clinico-pathological types 1.CHRONIC-PARENCHYMATOUS Following repeated attacks of AT the lymphoid follicles of tonsillar parenchyma undergo hyperplasia leading to uniform enlargement of the tonsils.CHRONIC-FOLLICULAR TONSILLITIS: Tonsillar crypts are full of infected cheesy material that shows on the surface as yellowish spots 2. .

. Acute exacerbations produce symptoms similar to AT. Cough. Symptoms: Recurrent sore throat. Thick speech. Difficulty in swallowing. Halitosis. Bad taste in the mouth due to pus. Sleep apnoeic episodes.

Ervin-moore sign:Positive tonsillar squeeze. Cardinal signs: Persistent congestion of anterior pillars. 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 .

AGN. .COMPLICATIONS  Peritonsillar abscess.  Tonsilar cyst.  Parapharyngeal abscess.  Intratonsillar abscess.  Tonsilloliths  RF.

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

Treatment of acute exacerbations as in AT.sinuses.diet and treatment of coexisting infection of tooth.TREATMENT  Conservative General health.nose.  Surgical Tonsillectomy .

ADENOTONSILLECTOMY .

Sleep apnoea 3.ADENOIDECTOMY INDICATIONS INFECTIONS: 1. Adenoid hypertrophy associated with CSOM with effusion 3. CSOM with perforation OBSTRUCTION: 1. Excessive snoring 2. Adenoid hypertrophy associated with Corpulmonale Failure to thrive Dysphagia Speech abnormalities OTHERS: Adenoid hypertrophy associated with chronic sinusitis . Purulent adenoiditis 2. Recurrent acute otitis media 4.

. Removal of adenoids causes velopharyngeal insufficiency in such cases.Acute infections of upper respiratory tract. 2.Haemorrhagic diathesis.Cleft palate or submucous palate. Contraindications 1. 3.

supine with head extended by placing a pillow under the shoulders.Anesthesia Performed under general anesthesia with oral intubation  Position Patient is placed in Rose`s positions. . Overextension should be avoided.

The adenoid can also be palpated by a finger  St Clair Thomson adenoid curette is introduced into the nasopharynx.with a downward and forward sweeping motion the adenoids are curetted .opened and held in place by Draffin`s bipod stand  A laryngeal mirror is used to inspect the nasopharynx.TECHNIQUE  Boyle Davis mouth gag is introduced.preferably while holding the laryngeal mirror in the other hand.above the superior extent of the adenoid tissue.

Care is taken not to injure them.  If bleeding persists after the procedure it should be cauterized with bipolar diathermy or suction diathermy.before the patient is extubated.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. A smaller-sized adenoid curette is used to curette the adenoid around the choana and around the eustachian cushions.which if present should be removed. .The pack is removed at the end of the operation.  Nasopharynx is packed with a gauze pack for a few minutes.

Earliest sign of bleeding may be frequent swallowing by the patient. .POSTOPERATIVE CARE  Nil per orally till full recovery from anesthesia  Close monitoring of vital signs  Watch for bleeding.  Oral antibiotics and analgesics.

 Surgical trauma 1. 2. Injury to the cervical spine:dislocation of the atlantoaxial joint.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. Trauma to the soft palate and uvula. . Injury to the eustachain cushions resulting in stenosis 3.

 Speech Defects hyper nasal speech.  Griesel syndrome Patient complains of neck pain and develops torticollis. . but can be due to atlantoaxial dislocation requiring cervical collar and even traction.short soft palate or submucous cleft palate.Mostly it is due to spasm of paraspinal muscles.

 Recurrence . Postoperative Scarring 1. 2.Care should be taken when operating patients of Down`s syndrome as 10-20% of them have atlanto-axial instability. Stenosis may impair eustachian tube opening resulting in middle ear problems. Fibrous bands or adhesions in nasopharynx.  Acute otitis media  Injury to pharyngeal musculature and vertebrate This is due to hyperextension of neck and undue pressure of currette.

 Postoperative scarring.CAUSES OF PERSISTENCE OF SYMPTOMS  Adenoid remnant left in the nasopharnyx especially around the choana. .

OTHER TECHNIQUES OF ADENOIDECTOMY  Endoscopic transnasal or transpalatal adenoidectomy using microdebrider.  By suction diathermy  Coablation .

TONSILLECTOMY .

An excisional biopsy is done . 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.INDICATIONS  Absolute  Recurrent infections of the throat.  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. This is the most common indication.

who do not respond to      antibiotics. Chronic Tonsillitis with bad taste Recurrent streptococcal tonsillitis in a patient with valvular heart disease Tonsilloliths Tonsillar Cysts . Streptococcal carriers . Relative  Diphtheria carriers .who may be the source of infection to others.

Cranio facial growth abnormalities 6. Dysphagia 4. Occlusal abnormalities . Obstruction: 1. and failure to thrive 3. Sleep apnoea 2. Adenotonsillar enlargement associated with core pulmonale. Speech abnormalities (Rhinolalia clausa) 5.

 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. Children under 3 years of age. even acute tonsillitis. They are poor surgical risks Overt or submucous cleft palate. Bleeding is more in the presence of acute infection. Uncontrolled systemic disease.cardiac disease.Purpura.haemophilia At the time of epidemic of polio. Bleeding disorders eg:Leukaemia. hypertension or asthma Tonsillectomy is avoided during the period of menses .eg:diabetes.aplastic anaemia.

Both hands of the surgeon are free. 2.  Advantages of Rose position: 1. There is virtually no aspiration of blood or secretions into the airway.supine with head extended by placing a pillow under the shoulders. Overextension should be avoided. Anesthesia Performed under general anesthesia with oral intubation  Position Patient is placed in Rose`s positions. This position helps in proper application of the Boyles Davis mouth gag. The surgeon can be comfortably seated at the head end of the patient . 3.

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 .

 Tonsil is grasped with tonsilholding forceps and pulled medially.  A blunt curved scissor may be used dissect the tonsil from the peritonsillar tissue and separate its upper pole. It is held in the place by draffin`s bipods or a string over a pulley.  Incision is made in the mucous membrane where it reflects from the tonsil to anterior pillar.DISSECTION AND SNARE METHOD  Boyle-Davis mouth gag is introduced and opened. . It may be extended along the upper pole to mucous membrane between the tonsil and posterior pillar.

 A gauze sponge is placed in the fossa and pressure applied for a few minutes.  Bleeding points are tied with silk. . Dissection is continued with tonsillar dissector or scissors until lower pole is reached. Now the tonsil is held at its upper pole and traction applied downwards and medially.and the pedicle cut and the tonsil removed.  Now wire loop of tonsillar snare is threaded over the tonsil on to its pedicle.tightened.

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. 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. For tying a ligature around the bleeder for controlling bleeding.

.

. Plenty of fluid should be encouraged.Sucking of ice cubes gives relief from pain.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.jelly.soft boiled eggs or slice of bread soaked in milk on the second day.eg:cold milk or icecream. They may take custard.  Keep check on vital pressure  Diet when patient is fully recovered he is permitted to take liquids.

 Oral hygiene Patient is given condy`s or salt water gargles 3-4 times a day.  Analgesics Pain. An analgesic can be given half n hour before meals  Antibiotics A suitable antibiotic can be given orally or by injection for a week. can be relieved by analgesics like paracetamol. .locally in the throat and referred to ear. A mouth wash with plain water after every feed helps to keep the mouth clean.

 Next is troublesome intra operative bleeding. Complications of tonsillectomy:  Complications can be classified in to immediate. hot tonsillectomy (i. quinsy tonsillectomy). This is common in poorly prepared tonsillectomies (i. staying in the correct plane (i. intermediate and delayed. ligation of bleeders. .e. sub capsular plane) during dissection. The most common of them being the complications of general anaesthesia.  Immediate complications:  Mostly encountered on the table during surgery.e.e. patients who have been taken up for surgery without a pre op course of antibiotics). Bleeding can be controlled by proper dissection. using bipolar cautery to coagulate the bleeding vessels.

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. Trauma to the anterior and posterior pillars. Rhinolalia aperta. Any loose tooth. The size of the blade can be measured by placing it between the mentum and the angle of the mandible . dentures must be removed before intubation because the loose teeth can easily be dislodged and be aspirated.  Teeth must be taken care when mouth gag is being applied.  Trauma to the lips and gums: can be avoided by using the right sized tongue blade.e.

This is caused due to 1. This is done by suturing both the anterior and posterior pillars after placing a gauze or gelfoam in the tonsillar fossa. If bleeding is diffuse and uncontrollable pillar suturing can be resorted to. silk is used to suture the pillars and these sutures must be removed after 48 hours and the gauze is removed. Slipping of ligature These patients must be taken to the operation theatre. 2. If gauze is used to pack the tonsillar fossa. Wearing off of the hypotensive effect of the anaesthesia during the immediate post op period. reanaesthetised and the bleeders must be ligated or cauterised. Haemorrhage during immediate post       op period is also known as reactionary haemorrhage. . 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. Intermediate complications:  Are mostly haemorrhage.

Scarring in soft palate and pillars. These commonly occur     a week after the surgery. Tonsillar remnants Hypertrophy of lingual tonsils. Lung complication: Aspiration of blood. mucus or tissue fragments may cause atelectasis or lung abscess. . Delayed complications:  Are mostly due to infections. Bleeding during this period is known as secondary haemorrhage. Antibiotics are used to control infections.

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 duration of surgery

 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.

. or ionised sodium molecules. to ablate tissues. much lower than that of electro cautery. The major advantage of this procedure is reduced bleeding and reduced post operative pain.80 degrees centigrade. Laser tonsillectomy: Tonsillectomy can be performed using laser. Laser seals all bleeders effeciently.  Coblation tonsillectomy: It is also other wise known as cold abalation. Major advantage of laser surgery is reduced bleeding. The flip side being increased operating time and the cost of laser equipment. The heat generated varies from 40 . A carbondioxide laser or a KTP laser can be used. This technique utilises a field of plasma.

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