2. History
• Cornelius Celsus (30 A.D. )
– Described tonsillectomy by finger dissection
and used vinegar for hemostasis
• Philip Physick (early 1800s)
– Developed tonsillectomy
• Wilhelm Meyer (1867)
– Reported removal of adenoid through nose
with a ring knife
• George Waugh(1909)
6. Local indications
1. Recurrent tonsillitis meeting Paradise
criteria : ( ≥ 7 episodes in 1 yr or 5 episodes / yr for 2
yrs or 3 episodes / yr for 3 yrs)
2. After second attack of Quinsy
3. Intra tonsillar abscess
4. Malignant or benign tumour or
unilateral tonsillar enlargement of
suspicious cause
5. Tonsil enlargement with stridor or
8. As an approach to other
surgeries
1. Styloid process excision (Eagle’s
syndrome)
2. Glossopharyngeal neurectomy
3. Uvulopalatopharyngoplasty
4. Branchial fistula excision
9. Contraindications
• Age < 3 yr
– Limited space; immunity is lost; blood
loss not tolerated; lingual tonsils
hypertrophy
• Acute infection : More bleeding
• Aneurysm of internal carotid or tonsillar
artery
• Bleeding disorders : Hemophilia
10. Contraindications
• Cervical spondylosis : affects surgical
position
• Diabetes mellitus; hypertension;
tuberculosis
• Epidemic of polio : bulbar poliomyelitis
• Female patient during menstruation
11. Subcapsular vs Intracapsular
Tonsillectomy
• Subcapsular total tonsillectomy
– Removes tonsil tissue completely
• Intracapsular tonsillectomy
– Removes 90% of tonsils leaving behind
a layer of tonsil tissue
– Protects tonsillar bed and reduces
post-op pain and recovery time
– Not appropriate for recurrent tonsillitis
21. Steps of tonsillectomy
• 1. Rose position: patient kept supine
with extension of neck and atlanto-
occiptal joint
• 2. Boyle Davis mouth gag inserted and
fixed with Draffin’s bipod & Mac
Gauren’s plate
• 3. Incision made between tonsil and
anterior pillar
22. Steps of tonsillectomy contd….
5. Lower tonsil pedicle snared with Eve’s
tonsillar snare
6. Tonsil removed and fossa packed with
H2O2 soaked gauze for 5 min
7. Bleeder ligated with silk suture or
cauterized by bipolar cautery
31. Post-operative care
1. Keep the patient in left lateral position with
head low
2. Inform surgeon immediately in case of
– Fever above 100 0
F
– Difficulty in breathing or swallowing
– Excessive bleeding from oral cavity
3. Eat soft foods and ice-cream
4. Encourage swallowing and gum chewing
5. Drink plenty of cold fluids
34. Late Complications (After
24 hrs)
Surgical
• Secondary hemorrhage
• Scarring of soft palate
leading to
velopharyngeal
insufficiency
• Lingual tonsil
hypertrophy
Anesthetic
•Lung
collapse
35. Hemorrhage after
Tonsillectomy
• Primary hemorrhage
– Occurs during surgery, due to injury to
blood vessels
– Normal = 80 ml.
• Reactionary hemorrhage
– Within 24 hr of surgery (commonly
within 8 hr)
• Secondary hemorrhage
36. Causes for reactionary
hemorrhage
• Slippage of ligature
• Displacement of clot
• Re-opening of collapsed blood vessels
– Caused by high B.P. due to cough /
retching and wearing off effect of
hypotensive anesthesia
• Clots in tonsillar fossa
– Prevent contraction of superior
38. • Remove blood clots from tonsillar fossa
• H2O2 gargle (causes thermal cautery and
vasoconstriction by releasing nascent oxygen)
• Pressure gauze packing of fossa for 5 min
• If bleeding continues, shift the patient 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
39. Bleeder
identified
Yes No
Ligation or
bipolar cautery
Adrenaline pack or AgNo3
application or Tincture benzoin
paint
Bleeding still 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 and not
Internal carotid artery)
44. Procedure
• Rose position but atlanto-occipital joint
neutral
• Mouth gag inserted, finger palpation done
– To assess the size of adenoids
– To bring the adenoid mass in midline
– To check the position of Eustachian
tube
• Adenoid curetted keeping head slightly
49. Etiopathogenesis
• Collection of pus between tonsillar
capsule and superior constrictor muscle
• Pathology: Aerobic + anaerobic organisms
– De novo
– Acute tonsillitis → blockage of crypts
→ intra tonsillar abscess →
peritonsillitis → quinsy
– Abscess of Weber's salivary gland in
50. Clinical features
• Symptoms: Young adult with severe
odynophagia, fever, halitosis and muffled
voice
• Signs:
– Peritonsillar area swollen and
congested
– Tonsil hidden behind the anterior
pillar, pushed medially and congested
–
52. Incision and Drainage
• Incision made with # 11 blade or
Thilenius peritonsillar abscess drainage
forceps
• Nick made above and lateral to junction
of 2 imaginary lines, horizontal along
base of uvula and vertical along anterior
54. Surgical treatment
1. Interval tonsillectomy → after 4 – 6 wk.
2. Hot tonsillectomy or abscess
tonsillectomy is avoided as it leads to
– More bleeding
– Septicemia
