Tonsillectomy : Indications/Complications

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Tonsillectomy was 1st performed by a roman surgeon named Celsus 30 AD. Over time, different instruments have been used: snare, guillotine( the Sluder Ballenger).The last 30 years, an explosion of new modalities made the surgery somewhat safer and with less blood loss: -CO2 Laser -Bipolar Scissors -Coblation Technique -Harmonic Knife -Microdebrider(for intracapsular tonsillectomy) Tonsillitis The correct diagnosis is very important, that should include: sore throat, fever, and neck node swelling. ...

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Tonsillectomy : Indications/Complications Tonsillectomy was 1st performed by a roman surgeon named Celsus 30 AD. Over time, different instruments have been used: snare, guillotine( the Sluder Ballenger).The last 30 years, an explosion of new modalities made the surgery somewhat safer and with less blood loss: -CO2 Laser -Bipolar Scissors -Coblation Technique -Harmonic Knife -Microdebrider(for intracapsular tonsillectomy) Tonsillitis
The correct diagnosis is very important, that should include: sore throat, fever, and neck node swelling. A differential diagnosis is in order before treatment or tonsillectomy is recommended: -Infectious mononucleosis -Malignancy: Lymphoma, Leukemia, Carcinoma -Diphteria, Scarlet Fever, Agranulocytosis -Syphilis, Candidiasis The main indications for Tonsillectomy fall into 2 categories : Infections and Hypertrophy with obstruction and occasionally for diagnosis of a primary CA Chronic Tonsillitis : 3 or more episodes per year (treated with antibiotics) 2 or more positive cultures for streptococcus A . Halithosis caused by tonsilloliths (accumulation of sulfur producing bacteria plus debris that are lodged in the tonsils crypts)
Hypertrophy of tonsils and adenoids causing malocclusion or obstructive sleep apnea Indications of Adenoidectomy . Recurrent adenoiditis 3 or more episodes per year . Recurrent serous otitis media on children with previous myringotomies and tubes. . Chronic nasal obstruction, mouth breathing . Speech problems, obstructive sleep apnea . Severe orofacial/dental abnormalities. When performing a Tonsillectomy, usually an Adenoidectomy is included: T+A But an Adenoidectomy could be performed separately if there is no true indication for a tonsillectomy. It should be noted that the Adenoids disappear after the age of 20-21. Chronic recurrent infections of tonsils and adenoids are mostly caused by:
. Streptococcus A . H. influenza . S. aureus . Spreptococcus pneumoniae The 1st line of treatment of chronic tonsillitis: Penicilline for 3-6 weeks will eliminate the need for surgery in 17% of cases. Peritonsillar Abscess This entity deserves a special paragraph, due to the difficult diagnosis (for the family physician) the delay of treatment and the possible life- threatening complications. The clinical picture is usually typical: the patient complains of moderately severe pain on one side of the throat, radiating to the ear and the same side of the head despite of antibiotics and pain medications for a few days.The pain is getting worse, accompanied by trismus and inability to swallow liquids and own saliva. The patient could be febrile or having a low grade fever.
When the oral cavity examination is still feasible, it showed bulging of one tonsillar area, pushing the uvula to the opposite side. The differential diagnosis should include : - Internal Carotid Artery Aneurysm (pulsations of the bulging could be seen or palpated) there will be no displacement of the uvula, no trismus. - Pleomorphic Adenoma (the tonsillar bulging is very vascular, there is no exudate, no trismus) Treatment of peritonsillar abscess: . In adults, if the trismus is not too severe, the abscess can be drained in the office using a 16 g needle then the opening can be enlarged with long forceps. If the decision was made to do the I+D under general anesthesia (especially in children) an IV antibiotics should be started. Some Surgeons opted to do the tonsillectomy on both sides so there will be no more tonsils infections, the rationale was that the tonsil can have another abscess at the lower pole and the opposite tonsil can have small abscesses undetected clinically. The argument against tonsillectomy was that it is the wrong time to subject the patient to a long and bloody procedure while the patient was already weakened and dehydrated the past few days. The majority of
Surgeons would recommend a tonsillectomy 4-6 weeks after drainage of the abscesss or wait untill the patient had another abscess. A peritonsillar Abscess left untreated could rupture and the patient could aspirate pus or the abscess could spread to become a retropharyngeal abscess with airway obstruction, worse yet the abscess can spread down into the chest. Tonsillectomy performed in the same setting with drainage of a peritonsillar abscess is known as “quincy tonsillectomy” or the borrowed french terminology “tonsillectomy à chaud”. Regional Anatomy As in any surgical procedure, the detailed knowledge of the surrounding anatomy is crucial. The vascular system around and behind the tonsils is very intricated. The blood supply is through the external carotid and its branches: - superior pole of tonsils: ascending pharyngeal artery and lesser palatine artery. - inferior pole of tonsils: facial artery branches, dorsal lingual artery, ascending palatine artery. The Adenoids are fed by: the ascendind pharyngeal and sphenopalatine arteries.
Anterior to the tonsils: palatoglossus muscle. Posterior to the tonsils: palatopharyngeus muscle. Superior constrictor muscle is deep to the tonsils. In order to minimize complications, mostly bleeding,avoiding all those structures remained the primary goal during surgery. Preoperative Evaluation and Tests - In case of a pulsatile area adjacent to the tonsil is documented a MRA (Magnetic Resonance Arteriography) should be ordered. - Coagulation disorders: historical sceening, sickle cell Anemia, Willebrand’ Disease. - Blood Tests: CBC, PT, PTT, PT, wWF activity. New surgical instrumentations and techniques: Coblation Surgery (invented in United Kingdom) - disposable hand piece or wand connected to a control unit operated by foot controls.
- a radiofrequency bipolar current is conducted across the electrodes at the tip of the wand,this activates normal saline delivered through the wand to create a plasma field of sodium ions at the tip. This plasma field dissolves intracellular bonds at a T of 60-70 C. Disintegrated tissue and saline are aspirated from the operative field by suction built into the wand. Harmonic Scalpel The instrument converts ultrasonic energy into mechanical motion, vibrating at 50.000 cycles/sec. This action cuts tissue with a fraction of the heat and trauma compared to electrical cutting currents.The intense vibration causes the blood in the immediate area to coagulate.There is virtually no blood loss during the operation. This technique creates less trauma to tissue, minimal blood loss, less pain post op, patient can resume normal diet in 24-72 hrs instead of 7-10 days. Activity levels may also be resumed faster. Intracapsular Tonsillectomy with Microdebrider This is a powered tissue removal system,using different sizes handpieces equipped with alternating cutting burrs, the microdebrider can
remove 90% of tonsil tissue leaving intact the tonsil capsule. The post surgery delayed bleeding is cut in half(3-5%). This technique is particularly useful in a child with huge tonsils where a prolonged procedure would add more risks. Post Op Care and Medications Pain Medications:ibuprofen, Tylenol codeine.Promethazine could be used as antiemetic. Diet: plenty of liquid, water, broth, jell, ice cream, apple juice,no orange juice or acid juice (it burns the throat wound, makes the patient cough) most of my cases with post op bleeding resulted from recent consumption of orange juice!. No spicy food, crunchy food (popcorn, pretzel, chips nuts, cold cereal) for 1 week. The patient may complain of ear pain (that is a referred pain from the throat) bad breath (due to formation of false membrane as a normal process of healing). Activity can resume in one week, 2 weeks for contact sports. Complications of Adenoidectomy and Tonsillectomy
- After tonsillectomy the tonsillar fossae are colonized by high number of bacteria(infection with low grade fever) the patient can loose 5-10 lbs the week following a tonsillectomy (sore throat discouraged eating) The weigth gain is possible in 2-3 weeks. A week of antibiotics is usually recommended. - The post op bleeding is every surgeon’s and anesthesiologist’s nigthmare. The bleeding can happen in the recovery room or the following hours or more dangerous is the delayed hemorrhage 3-5 days after surgery. The typical scenario is a child suddenly cried at nigth after vomiting a stomach full of blood, by the time the parents get to the bedroom the child is in shock. It will be at least another hour usually more before the patient can be in the surgery room for treatment. Intubation through A mouth full of blood and clots could be deadly. By the time the surgeon looked at the tonsillar fossae, blood is oozing everywhere,the tissue is very friable, cauterization seemed ineffective. Tonsils sponges with epinephrine, thrombin powder, sutures in tonsillar fossae could help. In the last resort External carotid artery ligation, arteriography with embolization can be attempted (unfortunately
these procedures are not available in all hospitals). In most of these cases transfusion may be necessary. The Adenoidectomy could cause stenosis of the nasopharynx or velopharyngeal incompetence. One particular complication is less well known but could be deadly: that involved a young child that just had a T+ A for severe airway obstruction due to very large tonsils, few hours after the surgery the patient was discharged, at home the care giver saw the child sleeping quietly, left the child unattended (a patient that had a severe sleep apnea breaths against an obstacle,now that the tonsils were removed, the brain no longer have the need to trigger the breathing center. In this case,the child should be monitored overnight. Case Report During a career of over 40 years doing Tonsillectomy, I remember some stressful instances: - A 17 months child brought in my office by visibly concerned and exhausted parents, the child had severe airway obstruction, stopped breathing and turned blue when put in bed,could only breathe when held
with head elevated.The parents took this child to 5 different Ers the last 5 nights without relief. The throat exam showed huge tonsils touching in the midline (kissing tonsils). With absolutely no airway. I admitted the child and did an emergency Adenotonsillectomy. Soon after the procedure the child breathes without effort, so quietly that the parents sitting next to the bed watching, believed the child did not breathe. - A young man came to my office for an ENT problem, after the visit, the patient told me something that I did not undestand at first,”Doc, if I listened to you, I would still have my daughter”. I forgot that the previous year, I have seen the 4 years old daughter for a possible tonsillectomy. Given the symptoms and the clinical findings, I recommended against surgery, the father took the child to another specialist who performed the tonsillectomy, the child died 3 days post op from severe hemorrhage. - A middle age man experienced severe 0bstructive sleep apnea, his sleep studies showed dangerous numbers, O2 saturation of 50%, a very agitated sleep pattern. In the office,I found him sleeping with loud snoring and apnea in the waiting room and again in the exam room before I came in.
The throat exam showed huge tonsils, long soft palate and large uvula obstructing completely the airway. This case is obviously an emergency, the patient can die anytime during his sleep. As soon as the insurance allowed, I performed a UPPP (uvulopalatopharyngoplasty) .On a return visit, the patient was very happy about the results of surgery (sleeping much better, no more loud snoring, feeling a lot of energy) actually the patient was thrilled to annouce his wedding to a young woman in the coming month. - An 87y old woman had a peritonsillar abscess, I did a quincy tonsillectomy, one week post op, the patient was free of pain and was able to resume her usual diet. On an elderly patient, the tonsillectomy was done in the same time of the I+D of the abscess because another infection or abscess could be lethal. Improvement in Sleep and Behavior (cognitive problems, inattention, hyperactivity, opposition behavior) were still significant over 2 years after surgery. Commentary The indications and the criteria for Tonsillectomy and Adenoidectomy changed considerably over time, a generation ago, it was a fashionable procedure, I had my tonsils removed because a kid on the block just had it
done! A parent could go to a Doctor and request the surgery for a child without medical justification. There was an unsubstantiated belief that a tonsillectomy could boost the growth of the child. We should be reminded that tonsillectomy and adenoidectomy are elective surgeries (with some exceptions). The discussions of the pros and cons of surgery should be complete and alternative treatments explained. These remained risky procedures that may required repeated anesthesia for post op bleeding ,transfusion and death is a distinct possibility. I couldn’t even imagine the grim task of the surgeon who had to face the family and try to explain how he lost a child after surgery. For people who quoted that T+A are” the bread and butter “of an ENT practice, probably never performed the surgery or witnessed the horror of a post op bleeding. The Coblation technique is favored by the majority of surgeons the past 2-3 years. It brought the incidence of post op bleeding from 6-7% to 3% and allowed a speedier recovery and return to normal diet.
Bs Nguyễn Thanh Trà