Tonsillectomy

Adenoidectomy
& Quinsy
Dr. Vishal Sharma
 History
Cornelius Celsus first described tonsillectomy by
finger dissection in 30 A.D. Used vinegar for
hemostasis.
Philip Physick developed tonsillotome in early
1800s
In 1867 Wilhelm Meyer reports removal of adenoid
through nose with a ring knife
George Waugh first described complete
tonsillectomy in 1909
Tonsillectomy
 Indications
• Local indications

• Focal indications

• Systemic indications

• As part of other surgery

 Local indications
1. Recurrent tonsillitis:  7 episodes in 1 yr or
5 episodes / yr  2 yr or 3 episodes / yr  3 yr
2. Quinsy (2nd attack)
3. Intra tonsillar abscess
4. Malignant / benign tumour
5. Tonsil enlargement with stridor / dysphagia
6. Tonsillolith / tonsillar cyst with halitosis
7. Impacted foreign body
 Focal indications
Tonsil acts as focus of infection in:

1. Suppurative otitis media

2. Chronic jugulo-digastric node enlargement

3. Chronic tuberculous node enlargement

 Systemic indications
1. Rheumatic fever with arthritis
2. Sub-acute bacterial endocarditis
3. Glomerulonephritis
4. Diphtheria carrier
5. Chronic bronchitis / bronchial asthma
6. Phlyctenular conjunctivitis
7. Urticaria / erythema 8. Failure to thrive
 As part of other surgery

1. Stylalgia (Eagle syndrome)

2. Glossopharyngeal neuralgia

3. Uvulopalatopharyngoplasty in sleep apnea

4. Branchial fistula
 Contraindications
Age < 3 yr  limited space; immunity is lost;

blood loss not tolerated; lingual tonsil ed

Acute infection  bleeds more

Aneurysm of internal carotid or tonsillar artery

Bleeding disorder  hemophilia

Cleft palate  rhinolalia aperta

 Contraindications
Cervical spondylosis  affects surgical position

Diabetes mellitus; hypertension; tuberculosis

Epidemic of polio  bulbar poliomyelitis

Female patient  during menstruation

Granular pharyngitis  infection flares up

Hemoglobin < 10 g / dl
 Types of Tonsillectomy
• Subcapsular total tonsillectomy:

Removes tonsil tissue completely.

• Intracapsular tonsillectomy:

Removes 90% of tonsils leaving behind a layer

of tonsil tissue. It protects tonsillar bed &

reduces post-op pain + recovery time. Not

appropriate for recurrent tonsillitis.

Subcapsular tonsillectomy
Intracapsular tonsillectomy
Methods of tonsillectomy
Cold Hot
Dissection & snare Electro-cautery

Microdebrider Laser

Harmonic scalpel Radiofrequency coblation

Cryosurgery

Cold knife

Guillotine section: obsolete

Tonsillectomy by
Dissection &
Snare Technique
Rose Position & mouth gag
Tonsil holding forceps
Incision
Mollison’s tonsil dissector
+ anterior pillar retractor
Blunt dissection
Cutting of triangular ligament
Eve’s tonsillar snare
Snaring & Haemostasis
Birkett straight artery
forceps
Negus replacement artery
forceps
Negus ligature pusher
 Steps for tonsillectomy
1. Rose position: pt supine with extension of
neck & atlanto-occiptal joint.

2. Boyle Davis mouth gag inserted & fixed with

Draffin’s bipod & Mac Gauren’s plate.

3. Incision made b/w tonsil & anterior pillar.

4. Tonsil dissected from its base, till lower pole

with tonsil dissector.
 Steps for tonsillectomy
5. Lower tonsil pedicle snared with Eve’s

tonsillar snare.

6. Tonsil removed. Tonsil fossa packed with

H2O2 soaked gauze for 5 min.

7. Bleeder ligated with silk suture or cauterized

by bi-polar cautery.
Micro-debrider
Ultrasonic Harmonic scalpel
Ultrasonic Harmonic scalpel
Cryosurgery
Cold knife
Guillotine
Electro-cautery
Laser tonsillectomy
Bipolar radiofrequency
 Post-operative advice
1. Inform surgeon immediately in case of
 fever above 100 degrees F
 difficulty in breathing or swallowing
 excessive bleeding from oral cavity
2. Eat soft foods & ice-cream
3. Encourage swallowing & gum chewing
4. Drink plenty of fluids. Avoid citrus fruit juice.
5. Two white patches will form in tonsil fossa
Early Complications ( 24 hrs)
Surgical Anesthetic

1. Hemorrhage 1. Aspiration
 Primary (operative) 2. Cardiac arrest
 Reactionary ( < 24 hr)
2. Injury to lip / teeth / uvula / pillars
3. Surgical emphysema
4. Tonsil remnant
Late Complications (> 24 hrs)
Surgical Anesthetic
1. Secondary hemorrhage 1. Lung collapse
2. Scarring of soft palate 
velo pharyngeal insufficiency
3. Lingual tonsil hypertrophy
4. Tonsil fossa infection
5. Granular pharyngitis
Tonsillectomy Hemorrhage
Primary hemorrhage occurs during surgery,

due to injury to blood vessels. Normal = 80 ml.

Reactionary hemorrhage occurs within 24 hr of

surgery (commonly within 8 hr).

Secondary hemorrhage occurs after 24 hr

(commonly 6th - 8th day); due to infection.

 Causes for reactionary hge
1. Slipping of ligature.

2. Displacement of clot

3. Re-opening of collapsed blood vessels

(caused by  B.P. due to cough / retching /

wearing off effect of hypotensive anesthesia)

4. Clots in tonsil fossa  prevent contraction of

superior constrictor (required for hemostasis)

Post-op tonsillar bleeding
 Remove blood clots from tonsil fossa

 H2O2 gargle (causes thermal cautery + vaso-

constriction by releasing nascent oxygen)

 Pressure gauze packing of fossa for 5 min

 bleeding continues

Shift to operation theatre

 In operation theatre
 Treat shock; blood transfusion if required.

 Head low; continuous pharynx suction.

 Ryle's tube insertion, remove aspirated blood

 Intubate + inflate cuff + put throat pack

 Remove all blood clots from tonsil fossa to

identify any bleeder

 Bleeder identified?
Yes No

 Ligation or  Adrenaline pack or

 Bipolar cautery  AgNO3 application or

 Tincture benzoin paint

 Bleeding continues

Suture both pillars over gelfoam kept in fossa

 Bleeding still continues
• External carotid artery ligation, distal to

superior thyroid artery (so that retrograde

thrombus / aneurysm involves superior

thyroid artery & not Internal carotid artery)

• Ligation done in neck via incision made along

anterior border of sternomastoid.

Adenoidectomy
 Adenoidectomy
First do adenoidectomy then tonsillectomy
(haemostasis is by blind nasopharynx packing)

Indications: adenoids with

1. Adenoid facies 2. Sleep apnea / snoring
3. Rhinolalia clausa 4. Recurrent sinusitis
5. Refractory O.M.E. 6. C.S.O.M.
 Tonsillectomy &
Adenoidectomy positions
Adenoid curette with guard
Procedure
 Procedure
• Rose position with AO joint in neutral position

• Mouth gag inserted, finger palpation done for:

1. size of adenoid. 2. bring adenoid in midline

3. check position of Eustachian tube.

• Adenoid curetted keeping head slightly flexed to

avoid trauma to atlanto – occipital joint.

• Nasopharyngeal pack put for 5 min.

Adenoidectomy specimen
Microdebrider adenoidectomy
 Complications
1. Hemorrhage  10, R0, 20  post nasal pack
2. Damage to E.T. orifice  scarring  O.M.E.
3. Subluxation of Atlanto-Occipital joint 
torticollis (Griesel disease)
4. Velopharyngeal insufficiency  nasal twang +
regurgitation from nose
5. Nasopharyngeal scarring & stenosis
6. Adenoid remnant
 Contraindications

• Acute infection

• Bleeding disorders

• Cleft palate: adenoidectomy will make

symptoms worse
 Peritonsillar
abscess or Quinsy
 Etiopathogenesis
Pus present between tonsillar capsule &

superior constrictor muscle.

Pathology: aerobic + anaerobic organisms
1. Acute tonsillitis  blockage of crypts  intra
tonsillar abscess  peritonsillitis  quinsy
2. Abscess of Weber's salivary gland in supra
tonsillar fossa  quinsy
 Clinical features
Symptoms: Young adult with severe odyno-

phagia, fever, halitosis & muffled voice

Signs: 1. Para-tonsil area swollen & congested

2. U/L tonsil ed, pushed medially, congested

3. Jugulo-digastric lymph node tender, ed

4. Trismus

5. Torticollis
Peri-tonsillitis & Quinsy
 Management
Diagnosis:
Needle aspiration  reveals pus
Medical treatment:
1. Urgent admission, I.V. fluids
2. I.V. Cefotaxime + Metronidazole
3. Antihistamine - decongestant + analgesic
4. Betadine gargle
Needle aspiration
Incision
Incision line & quinsy forceps
Alternate incision site at
maximum bulge
Abscess drainage
 Incision drainage
• Incision made with # 11 blade or Thilenius
peritonsillar abscess drainage forceps.

• Nick made above & lateral to junction of 2

imaginary lines. Horizontal along base of uvula,
vertical along anterior tonsillar pillar.

• Incision widened with sinus forceps & pus

drained. No anesthesia is required.
 Surgical treatment
1. Interval tonsillectomy  after 4 – 6 wk.

2. Hot tonsillectomy or abscess tonsillectomy is

avoided as it leads to:

 more bleeding

 septicemia
Complications of quinsy
1. Parapharyngeal abscess

2. Retropharyngeal abscess

3. Laryngitis & laryngeal oedema

4. Lung abscess

5. Internal jugular vein thrombosis

6. Septicemia
Thank You