Dr. T. Balasubramanian M.S.
1. Recurrent acute tonsillitis -
more than 6 episodes / year or 3 episodes / year for more than 2
2. Recurrent acute tonsillitis associated with other
conditions like :
associated with recurrent streptococcal
Recurrent febrile seizures.
Chronic tonsillitis that are unresponsive to medical management and
associated with halitosis, persistent sore throat
and cervical adenitis.
4. streptococcal carrier state
unresponsive to medical treatment.
associated with abscessed nodes.
7. Infectious mononucleosis with
severely obstructing tonsils that is unresponsive to medical
1. Sleep apnoea
Adenotonsillar enlargement associated with cor pulmonale, and
failure to thrive
4. Speech abnormalities
5. Cranio facial growth abnormalities
2. Tonsillar cysts
3. As a surgical approach to
other structures like
indications for adenoidectomy:
2. Adenoid hypertrophy associated
CSOM with effusion
Chronic recurrent acute otitis media
1. Excessive snoaring
3. Adenoid hypertrophy associated
Failure to thrive
Adenoid hypertrophy associated with
showing chronic tonsillitis
In children adenoid
and tonsils are removed together in one sitting. Removing the
tonsils leaving the adenoid in situ may lead on to compensatory
adenoid enlargement causing problems at a later date.
is performed under intubational general anaesthesia.
methods are available for removal of tonsils:
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. In medivial
France prisinor's life was taken off by this
Dissection and Snare method: This is the
commonly used method to perform tonsillectomy today. The
tonsil is dissected along with its capsule and lifted out of its
bed. It is ultimately removed using a tonsillar snare which is
also known as the Eve's snare. Snaring the tonsil has a
distinct advantage. Since the tonsil is crushed before it is cut,
bleeding is minimised. At this juncture it must also be pointed that
blood supply to the tonsil reaches it through its lower pole. The
advantage of this method is that the procedure is safe, bleeding is
less and the tonsil can be removed in toto without any
remnants. The patient is put in Rose position. This
position owes its name to a staff nurse by name Rose who suggested
this position to the surgeon. In fact it must be called as Sister
Rose position. In this position both the head and neck are extended.
This is done by keeping a sand bag under the patient's shoulder
showing a patient put in Rose position with a sand bag under the
Advantages of Rose position:
1. There is virtually no aspiration of blood
or secretions into the airway.
2. Both hands of the surgeon are free. This
position helps in proper application of the Boyles Davis mouth gag.
3. The surgeon can be comfortably seated at
the head end of the patient
showing the Boyles Davis mouth gag applied.
Boyles Davis mouth gag has 2
1. The tongue blade - known as the Boyles
2. Mouth gag - Davis mouth gag.
The mouth gag is held in position by a M
shaped stand called as the jack or by a Draffins pod. During surgery
the mouth gag must be frequently released and reapplied. The mouth
gag applies intense pressure to posterior 1/3 of the tongue causing
certain amount of disruption to its blood supply thus leading on to
intense tongue pain post operatively. Thus frequent release of the
mouth gag during surgery reduces to some extent this type of pain.
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
- 196 degrees centigrade by liquid
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
Tonsillectomy can be performed using laser. A
carbondioxide laser of a KTP laser can be used. Major advantage of
laser surgery is reduced bleeding. Laser seals all bleeders
effeciently. The flip side being increased operating time and the
cost of laser equipment.
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 ovar 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
The major disadvantage is the expense of the
equipment and the increased duration of surgery.
It is also other wise known as cold abalation.
This technique utilises a field of plasma, or ionised sodium
molecules, to ablate tissues. The heat generated varies from 40 - 80
degrees centigrade, much lower than that of electro cautery. The
major advantage of this procedure is reduced bleeding and reduced
post operative pain.
Complications of tonsillectomy:
Complications can be classified in to
immediate, intermediate and delayed.
Mostly encountered on the table during
surgery. The most common of them being the complications of general
anaesthesia. Next is troublesome intra operative bleeding. This is
common in poorly prepared tonsillectomies (i.e. patients who have
been taken up for surgery without a pre op course of antibiotics),
hot tonsillectomy (i.e. quinsy tonsillectomy). Bleeding can be
controlled by proper dissection, staying in the correct plane (i.e.
sub capsular plane) during dissection, ligation of bleeders, using
bipolar cautery to coagulate the bleeding
Trauma to the anterior and posterior pillars.
Trauma to posterior pillar causes nasal regrugitatin whenever the
patient attempts to drink fluids after surgery. It may also cause
undesirable changes in the voice i.e. Rhinolalia aperta.
Teeth must be taken care when mouth gag is
bing applied. Any loose tooth, dentures must be removed before
intubation because the loose teeth can easily be dislodged and be
Trauma to the lips and gums: can be avoided by
using the right sized tongue blade. The size of the blade can be
measured by placing it between the mentum and the angle of the
Are mostly haemorrhage. Haemorrhage during
immediate post op period is also known as reactionary haemorrhage.
This is caused due to
1. Wearing off of the hypotensive effect of
the anaesthesia during the immediate post op period.
2. Slipping of ligature
These patients must be taken to the operation
theatre, reanaesthetised and the bleeders must be ligated or
If bleeding is diffuse and uncontrollable
pillar suturing can be resorted to. This is done by suturing both
the anterior and posterior pillars after placing a gauze or gelfoam
in the tonsillar fossa. If gauze is used to pack the tonsillar
fossa, silk is used to suture the pillars and these sutures must be
removed after 48 hours and the gauze is removed. 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
Are mostly due to infections. These commonly
occur a week after the surgery. Bleeding during this period is known
as secondary haemorrhage. Antibiotics are used to control
site contents © Copyright drtbalu 2006, All rights