Adenoidectomy

Tonsillectomy
Case

▪ 8 y/o child brought w/c/o difficulty staying asleep, snoring, on-

and-off inattentiveness in class, constantly open mouth, B/L.
recurrent episodic profuse ear discharge
▪ O/E flattened nose, long face, open mouth; cold spatula test:
minimal fogging B/L. dull opaque retracted tympanic membrane
▪ Tuning fork:
▪ Rinne B/L –ve @256Hz, -ve @512Hz, +ve @1024Hz
▪ Weber not lateralised
▪ ABC: B/L same as examiner
▪ On posterior rhinoscopy: large soft tissue mass seen
When do we remove adenoids?

Indications Contraindications
▪ Adenoid hypertrophy causing: ▪ ARI/AURTI
▪ Snoring, sleep apnoea, sleep
disturbances ▪ Acute polio
▪ Speech abnormalities (hyponasality) ▪ Cleft palate (velopharyngeal
▪ Rhinosinusitis (abolishes recurrence) insufficiency)
▪ Tubal occlusion (OME, COM)
▪ Dental malocclusion (preventative) ▪ General surgical
contraindications
▪ CVS disorders (electrocard. issues)
▪ Haem. disorders (↓ in clotting, Hgb,
RBCs, WBCs)
▪ Systemic disease, poorly controlled
What kind of adenoidectomy should we perform?
Curettage (conventional)
▪ Increased operative time
▪ Increased blood loss
▪ No op. field visualisation
▪ Eustachian tube damage likelier
▪ Mild hearing loss, otitis media
▪ ?Complete removal
▪ ?Regrowth  ?relapse
Endoscope-assisted (novel)
▪ Think: DNE at time of intervention
▪ Drawback: expense
▪ Reduced operative time & bleeding
▪ Good op. field visualisation
▪ Eustachian tube damage preventable
▪ Complete removal can be assured
►No regrowth!
Why perform adenoidectomy with tonsillectomy?
When do we remove palatine tonsils?
Indications
▪ Absolute:
▪ Recurrent throat infxns (7-5-3 rule, or 2
lost weeks of school/work)
▪ Peritonsillar abscess
▪ Tonsil hypertrophy, incl. tonsillitis
(chronic/halitosis/acute tx’ed w/ abx)
▪ ?Malignancy
▪ Relative
▪ Refractory diphtheria
▪ Strep throat + valv. heart dz!
▪ + other procedures
▪ CNIXectomy, UPPP, styloidectomy
Contraindications
▪ AURTI
▪ Acute tonsillitis w/ active infxn
▪ Acute polio
▪ <3 years age
▪ Cleft palate (velopharyngeal
insufficiency)
▪ General surgical contraindications
▪ CVS disorders (electrocard. Issues)
▪ Haem. disorders (↓ in clotting, Hgb, RBCs,
WBCs)
▪ Systemic disease, poorly controlled
Surgical Procedure
Instruments
Preparing the patient

▪ Place patient in Rose

position
Supinate
Position
Extend Cushion
Stabilise
head w/
patient neck neck rubber
ring

▪ Prepare for general Anaesthesia

anaesthesia
General anaesthesia
Adenoidectomy
CONVENTIONAL CURETTAGE
1. Palpate the
adenoids
Retracting the soft palate with curved end
of tongue depressor; digitally assess the
size of adenoids; push lateral adenoids
towards the midline
2. Insert Boyle–
Davis mouth gag
Hold it in place with Draffin’s bipod stand,
supported by Magauran’s plate.
3. Introduce SCT
adenoid curette
with guard
Decide the size of the curette; introduce
the curette into the nasopharynx until its
free edge touches posterior border of nasal
septum; press backwards to engage the
adenoids
4. Shave the
adenoids off the
nasophrynx
Use a gentle, sweeping motion; make sure
to remove remaining tissue with punch
forceps
5. Pack the nose
Anterior packing → electrocoagulation →
24-hour posterior packing
Tonsillectomy
DISSECTION–SNARE METHOD
1. Retract tonsil
medially and separate
the mucous
membrane
Use the blunt end of Denis-Browne tonsil-
holding forceps; incise the mucous
membrane where it reflects from the tonsil
to anterior pillar; separate upper pole if
necessary
2. Separate the
tonsil from
peritonsillar tissue
Hold tonsil at its upper pole and apply
traction downwards and medially; continue
to dissect with Waugh’s tonsil dissection
forceps until lower pole is reached
3. Snare and
remove the tonsil
Thread wire loop of Eve’s tonsillar snare
over the pedicle of tonsil, tighten it until it
cuts the tonsil away and remove the tonsil
4. Arrest bleeding
Place gauze sponge in fossa and apply
pressure for a few minutes; consider tying
bleeding vessels with silk.
5. Repeat
On other side!
Post-Operative Care

▪ Immediate:
▪ Control any bleeding
▪ Keep in position until fully recovered from anaesthesia
▪ Continue to monitor vitals carefully
Post-Operative Care

▪ Oral hygiene:
▪ Salt water gargle 3-4x daily
▪ Mouthwash w/ drinking water

▪ Diet:
▪ Cold foods: ice, ice cream, milk
▪ → soft food: bread soaked in milk, porridge
▪ → regular diet, within 2-3 weeks (tonsils healed in 10–14
days)
Post-Operative Care

▪ Analgesia:
▪ Severe throat pain w/ referred otalgia for 3-10 days
▪ NSAIDs cause bleeding, avoid!
▪ Opt for paracetamol instead; escalate to opioids only
for severe pain
▪ Antibiotics:
▪ Can be given PO or parenterally
▪ Adenotonsillectomy typically daycare procedure: full
activity in 2 weeks
Complications

Immediate Delayed
▪ Intra-op: ▪ 2° haemorrhage (focal sepsis,
▪ 1° haemorrhage premature membrane separation, etc.)
▪ Infection
▪ Physical injury (to pillars, teeth, soft
palate, tongue, etc.) ▪ Aspiration (blood, tissue, etc.)
▪ Aspiration (blood, tissue, etc.) ▪ Tonsillar remnants + regrowth +
relapse
▪ Post-op ▪ ?Hypertrophic lingual tonsils
▪ Reactionary haemorrhage (clot + ▪ Nasopharyngeal stenosis
↓sup. constrictor fn) ▪ Grisel syndrome
▪ Facial oedema ▪ Velopharyngeal insufficiency
▪ ▼Surgical emphysema
Reactionary haemorrhage is feared!

▪ Causes:
▪ Thrombus/embolus
▪ Vasodilation
▪ Post-op HTN
▪ Coughing/vomiting associated venous HTN
▪ Ligature failure (slipping!)
▪ Dangerous!
▪ Missable d/t residual effects of anaesthesia (occurs within 24 hrs)
▪ Aspiration
▪ Large bleed = electrocoag./ligation under GA… again, in short interval!
▪ Tx: clot removal, topical styptics (1:1000 adrenaline)/systemic
haemostatics, electrocoag., pillar approx., transfusion
Other methods?

▪ Adenoids: endoscopy-assisted is an option

▪ Tonsils:
▪ ‘Hot’ methods
▪ Electrocautery
▪ CO2 or KTP laser
▪ Coblation
▪ Radiofrequency
▪ ‘Cold’ methods
▪ Intracapsular debridement
▪ Harmonic scalpel/ultrasound
▪ Cryosurgery
▪ Guillotine (historical)
~Thank you~