history The tonsils arelymphoid organs strategicallylocated at the entrance of the digestive and respiratory systems**4 Firstknown tonsillectomy was performed by Cornellus Celsus almost 2000 yearsago.15**** Modern tonsillectomy began in early years of this centurywith development of Dissection tonsillectomy in Baltimore by Worthington(1907) & in London by Waugh (1909) & Guillotine tonsillectomyin New Castle by whillis and Pybus (1910).Ligation of bleeding vessels withintonsillar fossa was considered extremely difficult and was first employed on a regularbasis by Cohen (1909). 1 Throughout the world,tonsillectomy is one of the most frequently performed otorhinolaryngological procedures2****** Tonsillectomy was initiallyperformed by general surgeons, but at the end of 19th century it became an ENTdoctor´s care, due to the best techniques of illumination that they knew.Important steps in the progress of the tonsillectomy were taken using mouth-gagand tongue-depressors, besides the positioning of patient with leaning andsuspended head.
This position was first described by Killian in 1920, but onlyadopted after improvements on anesthesia techniques (4).It is estimated that in the United States 1,400,000tonsil surgeries were performed in 1959, around 500,000 in 1979 and 250,000ones per year in the last decade 4 .Datashow that in during the 40´s and 50´s many illnesses, of which the etiology orphysiopathology were not known, were associated to tonsils as possibleinfectious focus. This resulted in thousand of surgeries 4 .As time went by, due to lack of convincing results andexcess of indications, this procedure lost its reputation, and as a consequenceit was not recommended even for caseswhentherewassuchneed.4Therapeutical advance on medicine, especiallywith the use of antibiotics and improvement on work conditions on public healthservices and on group medicine also contributed for a reduction on tonsilremoval surgery.
(4)The laser of carbon dioxide, introduced in medicine in 1960,proved to better reduce and control bleedings than ruby laser, introduced soonafter the World War II. The first report of laser of carbon dioxide use intonsillectomies was in 1973. The advance on technology of intensity andfrequency control of the laser allowed it to be used in such a way as a scalpelas much as coagulator4Otorhinolaryngologywas the first surgical specialty in which laser features of carbon dioxide wererecognized and applied successfully in clinical situations in great amount 4In1968, Remington-Hobbs described the use of monopolar diathermy for removal of tonsils14 Further, Andrea defined the first microsurgical bipolar cautery technique in1993 ******15AnatomyThecircular band of lymphoid tissue within the pharynx consisting of the adenoids,thepalatinetonsils (Figure 1), and lingual tonsils is known as Waldeyer’s ring. Thepalatinetonsilsare lymphoid tissue with prominent germinal centers and the palatine tonsils,incontrastto the lingual tonsils and adenoids, have a distinct capsule1which separatesthetonsilsfrom the lateral pharyngeal walls.
The tonsil lies within a bed of threemuscles thatmakeup the tonsillar fossa. Forming the anterior pillar is the palatoglossus muscleand theposteriorpillar is the palatopharyngeus muscle, while the superior constrictor musclemakes up the bed of the fossa. Medially, the tonsil crypts lay exposed to theoropharynx with specialize stratified squamous epithelium.*****16Bloodsupply of the tonsils: blood supply tothe palatine tonsils is variable, butin general, they are supplied by several branches of theexternal carotid artery: · ascendingpharyngeal, · ascending palatine,· and branches of thelingual and facial arteries. The blood supply enters from the lower portion of the palatine tonsil pole. The internalcarotid artery (ICA) lies approximately 2 to 2.
5 cm deep and posterolateral to the palatine tonsil; howevr case reports (14) exist of aberrant ICA courses which come within 1 cm ofthe inferior pole. The ICA may have a tortuous and convoluted course of which the surgeon must be cognizant. Venous drainage is by way of a peritonsillar venous plexus, which surrounds the capsule and drains into thelingual and pharyngeal veins (12). BB p 1432——10Thenerve supply of the tonsils arise from the ninthcranialnerve and descending branches from the lesser palatine nerves and the tympanicbranchof CN IX is thought to account for the referred ear pain found in some cases oftonsillitis.
The tonsils have no afferent lymphatic vessels. Their efferent lymph drainageisthroughthe upper cervical nodes, especially to the jugulodigastric group. Tonsils andadenoidsare immunologically most active between the ages of 4 and 10 years, and tend toinvolutesafter puberty*******17indication: Absolute1.Obstructive sleep apnea2.
Cardiopulmonary complications secondary to airway obstruction (e.g., corpulmonale,alveolarhypoventilation)3.Suspected malignancy4.
Hemorrhagic tonsillitis5.Tonsillitis causing febrile seizures1.2.2Relative1.Recurrent acute tonsillitis meeting one or more of the following criteria:? Seven episodes in 1 year? Five episodes/year for 2 consecutiveyears? Three episodes/year for 3 consecutiveyears? Two weeks of missed school or work in 1year2.Chronic tonsillitis refractory to antimicrobial therapy3.Tonsillolithiasis with associated halitosis and pain, unresponsive toconservativemeasures? Peritonsillar abscess? Dysphagia due to tonsillar hypertrophy****************5Contraindications•leukemia, hemophilia, agranulocytosis, uncontrolled systemic disease(diabetes,TB)•Relative Contraindications: cleft palate, acute infection*********18techniqueAccordingto the latest survey of members of the American Academy of Otolaryngology andthe American Society of Pediatric Otolaryngology, electrocautery is thepreferred method for tonsillectomy by roughly 55% of Otolaryngologists.21Coblation tonsillectomy is estimated to be the preferred method by 20%–25%, coldsteel techniques by 10% and other techniques including microdebrider partialtonsillectomy by the remaining 10%.
Although popular, the electrocauterytechnique has its drawbacks as it has been shown to be a more painful surgerythan cold techniques, due to the additional thermal injury inflicted upon the exposedmusculature. Recently, there has been increasing interest in performing apartial tonsillectomy, or tonsillotomy, to maintain the tonsillar capsule andreduce postoperative pain and bleeding. As with every surgical technique,intracapsular tonsillectomy also has its drawbacks.
Large case series haveshown that tonsillar regrowth occurs in about 0.5%–6% of patients with asmaller percentage requiring completion tonsillectomy. The operation takesseveral minutes longer than electrocautery tonsillectomy, which adds to thesurgical costs.
Intraoperative blood loss is greater but appears to not beclinically significant. The role of intracapsular techniques for managingchildren with recurrent tonsillitis is still unproven though initial studies areencouraging for this indication.(22) this 22 of book not serch *********19Types of Tonsillectomy Procedures:Techniquesand technologiesThetechniques of Tonsillectomy can be broadly divided into 2 major categories:extracapsular(total tonsillectomy, subcapsular) and intracapsular (partial tonsillectomy).Intracapsularis also known as “subtotal,” and this procedure is referred to as tonsillotomyinsome literatures. Extracapsular tonsillectomy involves dissecting lateral tothe tonsil intheplane between the tonsillar capsule and the pharyngeal musculature, and thetonsil isgenerallyremoved as a single unit.
Partial tonsillectomy, or tonsillotomy, involvesremoval of most of the tonsil, while preserving a rim of lymphoid tissue andtonsillar capsule in the most recent iteration of this older technique.16Preservation of this margin of tissue, this “biologic dressing,” may promote aneasier recovery, with lower hemorrhage rates and better recovery of diet andactivity reported in comparison with traditional monopolar tonsillectomytechniques.The most common extracapsular techniques use a “cold” knife (sharpdissection), monopolar electrocautery, bipolar cautery (or bipolar scissors),orharmonic scalpel. Intracapsular techniques may use the microdebrider, bipolar radiofrequencyablation (which can also be used to remove the entire tonsil), and carbon dioxidelaser ********************20 Coidsteel tonsillectomyThemost common method of ‘cold steel’ tonsillectomy is the dissection technique (Figure96.2). In this, the tonsil is retracted medially, the mucosa overlying thetonsil capsule incised and the plane of loose areolar tissue between the tonsiland the pharyngeal musculature dissected with steel dissectors, gauze or cottonwool until the tonsil is fully mobilized (Figure 96.
3). Blood vessels traversingthe plane of dissection are dealt with either by ligature or diathermy asrequired. . ***************6 scott p 1232Afterremoval of tonsils we start to control bleeding for wx tonsil lower polebleeding is controled either by mechanical methods (sanare or ligation)7*******Analternative method of ‘cold steel’ tonsillectomyis the guillotine technique, whereby the tonsilis amputated using a specially designed guillotinedevice and haemostasis, secured as necessary by oneof the above methods.
Of these two techniques, traditionaldissection remains the most frequently used.***************6 scott p 1232Advantagesand disadvantages of the techniquesthere is argument regarding the benifit of different tonsillectomeis technique.somestudeis assume that the intracapsular technique result in less post operativepain in addition low risk of tonsil regrowth.
for the extra capsulartechnique,cold knife technique associated with less posoperative pain compared withan electrocautery which is faster & has less loss of intraoperative blood.it is unkown whichtechnique has the lowest post operative bleeding rate the available datasuggest that there is no variation inthe bleeding rates between different techniques******20 Post-tonsillectomy hemorrhage : Post-tonsillectomyhemorrhage is divided into two types: primary hemorrhages occurring within 24 hr and secondary hemorrhages occurring at anypoint more than 24?h after tonsillectomy . The overallhemorrhage rate is around 4.5% , with reported rates of 0.
5% for primary and secondary hemorrhages, respectively . Primaryhemorrhage is generally acknowledged to be caused by inadequate hemostasisduring the surgery. Secondary hemorrhage is associated with detachment of thecrust from the site of the removed tonsils . 11 Risk factors for postoperative hemorrhagePatients’ageThe age of patients has consistently beendescribed as being a major risk factor for the occurrence of hemorrhage, witholder patients being at higher risk 11Patients’sexThere is a discrepancy concerning sex as a riskfactor for postoperative hemorrhage. Some authors found a positive correlationfor male patients being at higher risk and others did not 11OperationtechniquesIn recent years, operation techniques have beeninvestigated in more detail, showing in the literature a statisticallysignificantly higher or lower postoperative hemorrhage rates for certainoperation techniques ? for example, bipolar diathermy for tonsillectomy showshigher hemorrhage rates compared with cold steel dissection tonsillectomy 11 Preoperativehemoglobin level and anemia There were no significant statistical difference asregards the preoperative hemoglobin level in the occurrence ofpost-tonsillectomy hemorrhage. Postoperativeinfection of tonsillar fossa A study from2007 showed that postoperative infection of the tonsillar fossa is no riskfactor for secondary hemorrhage , whereas another study described apositive relationship between preoperative bacterial colonization of thetonsillar fossa and postoperative hemorrhage, recommendingantibiotics . However, prescribed antibiotics did not reduce the risk forpost-tonsillectomy hemorrhage in general 11 .hemostasis by suture ligation is thought to be initiated aftertonsillectomy by 1ry hemostasis,on the other hand hemostasis by snare technique is thought tobe initiated after tonsillectomy by crushing (2ndry hemostasis) 12 wx 23 in xyadThere are two main components of hemostasis.
Primaryhemostasis refers to platelet aggregation and platelet plug formation.Platelets are activated in a multifaceted process (see below), and as a resultthey adhere to the site of injury and to each other, plugging the injury.Secondary hemostasis refers to the deposition of insoluble fibrin, which isgenerated by the proteolytic coagulation cascade. This insoluble fibrin forms amesh that is incorporated into and around the platelet plug. This mesh servesto strengthen and stabilize the blood clot.
These two processes happensimultaneously and are mechanistically intertwined 13