The lecture has been given on Apr. 18th, 2011 by Dr. Sherko.

1. Lecture 3<br />TONSILLECTOMY <br />Indications of Tonsillectomy<br />The tonsils get infected because of bad oral hygiene, unhygienic eating habits, and constant postnasal discharge, mouth breathing and irritant eatables. Control of these, thus, can prevent infection. However, the following cases do need tonsillectomy:<br />1. Carriers of diphtheria and Strepticoccus hemolyticus as proved by repeated throat swabs, who are a potential source of infection.<br />2. Cases with chronic enlargement if regional lymph nodes in association with sore throat.<br />3. Tonsillectomy is indicated when it is thought that tonsillar infection is producing secondary effects in other organs. Rheumatic fever and acute glomerulonephritis develop as an antigen antibody reaction to streptococcal infections. Though tonsillectomy does not help an established rheumatic heart disease or nephritis, recurrent attacks can be prevented by tonsillectomy. However, in such cases before undertaking tonsillectomy there should be no evidence of active throat infection.<br />4. In cases of recurrent attacks of acute tonsillitis when the source of infections from the nose , paranasal sinuses, etc., has been eliminated and the patient does not respond to specific conservative treatment.<br />5. Rarely tonsillar hypertrophy may cause difficult in swallowing, breathing or speaking and may require removal to restore normal function.<br />Previously, peritonsillar abscess (quinsy) was thought to be an indication but now it has been observed that if the abscess is drained well and proper antibiotic cover given for adequate time, usually there is no recurrence of the abscess, hence tonsillectomy is not required.<br />Indications of Unilateral Tonsillectomy<br />1. As excision biopsy of the tonsil to determine a possible malignancy.<br />2. As an approach to expose the glossopharyngeal nerve or enlarged styloid process in tonsillar bed, in stylalgia or idiopathic glossopharyngeal neuralgia.<br />3. Tonsillolith, tonsillar cyst, and impacted foreign body on the tonsil need tonsillectomy on the affected side. <br />4. In branchial fistula to remove the complete tract, one end of the tract being in posterior faucial pillar.<br />Contradictions of Tonsillectomy <br />1. Tonsillectomy should not be done during an epidemic of poliomyelitis as there is a high risk of contracting bulbar poliomyelitis.<br />2. Blood dyscrasias like purpura, aplastic anaemia, bleeding and coagulation defects.<br />3. Case of uncontrolled systemic disease like diabetes.<br />4. Tonsillectomy should not be done during or immediately after an attack or infection or when the child has recently been exposed to infectious disease like measles.<br />5. Tonsillectomy is not done during menstruation or during pregnancy.<br />Method <br />Surgery is generally done under general anaesthesia, but can be undertaken under local anaesthesia also.<br />The dissection method is the procedure of choice tonsillectomy. <br />The dissection method allows complete removal of the tonsillar tissue under direct vision. Bleeding points are properly ligated. The following are the steps of the operation. <br />Postoperative Care<br />Normal unaided respiration should be established before the patient leaves the operation theatre. The patient is placed in tonsil position. This position allows free respiration and permits any blood and secretion, which may collect, to run out of the nose and mouth.<br />A strict watch should be kept on the pulse and respiration of the patient. A rising pulse rate indicates a haemorrhage. Cold drink and soft diet are prescribed for the initial few days. Analgesics are given for pain. Antiseptic mouth washes help to keep mouth clean.<br />Postoperative Complications<br />Haemorrhage Besides the complications that may, arise because of anaesthia, the main surgical problem is haemorrhage. It could be primary (during operation), reactionary (within the first 24 hours), or secondary (between fifth to tenth postoperative day) haemorrhage.<br />Excessive bleeding at the time of the operation usually arises because of trauma to an aberrant vessel or paratonsillar vein.<br />Reactionary Haemorrhage usually arises as a result of slipping or a ligature or because of the postoperative rise in blood pressure. If a clot has formed in the fossa, it is removed. This allows the muscular contraction and retraction of the blood vessel.<br />A gauze pack may also be held in the fossa for a few minutes to control the bleeding. However, if the bleeding does not stop, the patient is reanaesthetised and the bleeding vessel is ligated. Sometimes, the tonsillar pillars may need to be stitched over a pack to control the bleeding.<br />Secondary haemorrhage is the result of infection. Bleeding is usually mild. Antibiotics, antiseptic mouth washes are given in addition to bed rest.<br />Surgical Trauma During tonsillectomy, trauma may occur to the pillars, soft palate, teeth or uvula.<br />Pulmonary complications Pulmonary complications may result because of inhalation of blood or tonsillar tissue, with the result collapse, pneumonia or lung abscess may occur.<br />PERITONSILLAR ABCESS<br />(QUINSY, PARATONSILLAR ABCESS)<br />Peritonsillar abscess is a complication of acute or chronic tonsillitis. The pathogenesis of peritonsillar abscess is described in textbook as being a direct communication and progression of acute exudative tonsillitis. Little study has been done on the true aetiology and pathogenesis of peritonsillar abscess. A group of salivary glands (Wever's glands) proven to be located in the supratonsillar space have been shown to be implicated in its pathogenesis . A review of peritonsillar abscess is not necessarily an extension of an acute exudative tonsillitis, but an abscess formation of Weber's salivary glands in the supratonsillar fossa.<br />There occurs accumulation of pus between the tonsil capsule and the tonsil bed. In most of the cases, pus collection occurs anterosuperior to tonsil but may sometimes occur laterally or posteriorly. A mixed bacterial flora of streptococci, staphylococci and pneumococci grows on culture of the pus.<br />Clinical Features<br />The condition usually affects adolescents and is mostly unilateral. The patient complains of unilateral throat pain after a few days of sore throat. The pain gradually becomes severe and may radiate to the ear. Swallowing is markedly painful so the patient even allows the saliva to dribble out. The patient feels extremely ill.<br />Examination shows a toxic patient, with the head inclined to towards the side of the abscess. There is trismus because of spasm of the pterygoid muscles. There is a unilateral swelling of the palate and pillars on the side of the abscess. The tonsil is displaced downwards and medially. The oedematous uvula is pushed towards the opposite side of the lesion. Cervical lymph nodes on the affected side are enlarged and markedly tender. <br />Treatment<br />When pus is suspected, it should be drained. The following are the sites of drainage.<br />1. The most important part of the swelling should be selected and drainage done.<br />2. Alternatively, the intersection of an imaginary line drawn from the base of the uvula and another imaginary line drawn along the anterior faucial pillar is the site of drainage.<br />3. Sometimes drainage is done through the supratonsillar crypt.<br />The peritonsillar abscess draining forceps is introduced and opened up to drain the abscess. The tip of a guarded sharp scalpel can be used to make an incision and the abscess drain by sinus forceps. Anaesthesia is not needed as the pain is already intense and a sharp a sharp stab for the drainage does not add to it. Besides drainage, heavy doses of antibiotics, usually crystalline penicillin 10 lac units IM, 6 hourly prescribed in addition to antiseptic mouth washes and analgesics.<br />Interval Tonsillectomy In view of painful nature of this condition and the possible serious complications that may arise, tonsillectomy is advocated after 6 to 8 weeks, when the inflammation has subsided. Now it it not thought necessary in all cases.<br />Abscess Tonsillectomy (Quinsy tonsillectomy) This procedure of draining the peritonsillar abscess by removing the tonsil has been advocated by some surgeons. It is done on the assumption that since the tonsil forms the medial wall of the abscess, therefore, tonsillectomy will give drainage to the abscess as well as save the patient from interval tonsillectomy. However, this procedure is not favored as the abscess may rupture during anaesthesia with consequent problems of aspiration. Besides, as the tissues are acutely inflamed, there appears severe bleeding and chances of systemic dissemination of infection are more.<br />Complications of Peritonsillar Abscess<br />The abscess may rupture spontaneously and cause aspiration and asphyxia. Spread of infection to parapharyngeal space can cause parapharyngeal abscess.<br />Thrombosis of the internal jugular vein or even carotid artery rupture can occur because of extension of this abscess to the parapharyngeal space.<br />Extensions to the inflammatory process from the peritonsillar space can lead to laryngeal oedema with resultant asphyxia. Systemic infection with the development of septicaemia and multiple abscesses may occur.<br />Peritonsillitis <br />It is a stage in the development of peritonsillar abscess before the pus formation. The clinical features are those of severe tonsillitis with trismus. The peritonsillar tissues are severely inflamed, but there is no displacement of the tonsil. Heavy doses of antibiotics cure the condition and prevent abscess formation.<br />Adenoids<br />Hypertrophied nasopharyngeal tonsils (adenoids) are usually the seat of infections in children between 3 to 6 years of age. As the child grows the size of the nasopharyngeal tonsils diminishes and they disappear by puberty.<br />Clinical Features<br />Hypertrophied nasopharyngeal tonsils may produce symptoms because of their size. The symptoms may be nasal or aural. <br />The common nasal symptoms include recurrent attacks of earache. Deafness and ear discharge. The other important symptoms include headache possibly due to infected materials in the nasopharynx and nocturnal cough because of postnasal discharge. Lack of appetite and mental dullness have also been attributed to adenoids.<br />Examination reveals mucoid or mucopurulent discharge in the nose.<br />Throat examination reveals postnasal discharge and in a cooperative child, posterior rhinoscopy allow enlarged mass of adenoids on the posterosuperior wall of the nasopharynx.<br />Palpation of nasopharynx, though troublesome, may sometimes be needed to arrive the diagnosis. Adenoids have a feel like bag of worms.<br />In a long standing case, the child presents with a typical appearance called quot;
adenoid faciesquot;
There is a dull look, pinched nostrils, open mouth, narrow maxillary arch, retracted upper lip and protruding teeth.<br />A lateral view X-ray of the nasopharynx may sometimes be done to show an adenoid mass.<br />Complications of Adenoids<br />These include recurrent attacks of otitis media, secretory otitis media, maxillary sinusitis and orthodontic disturbances. Besides, such patients are likely to encounter speech problems, like rhinolalia clausa (closed nose voice). Chronic infection may lead to the development of adenoid cysts.<br />Treatment <br />Conservative management includes decongestants (systemic and locally in the nose), systemic antibiotics to control the infection and antihistaminic preperations.<br />Surgery<br />The operation of adenoidectomy is advocated if the size of the adenoids is interfering with nasal and Eustachian tube function or causing difficulty in speech and feeding. Adenoidectomy may be needed if the adenoids are thought to be the cause of recurrent upper respiratory tract infection or recurrent otitis media.<br />Since the problem of adenoids and tonsils usually coexist, the operation of adenoidectomy is done in the same sitting as the tonsillectomy. The operation is performed under general anaesthesia and oral intubation is preferred.<br />The main complication of surgery is haemorrhage. Primarily haemorrhage usually occurs due to leftover adenoid tags which may need further curettage. In case of severe bleeding the postnasal pack is kept from 24 to 48 hours. Secondary haemorrhage occurs due to infection and is treated by rest and antibiotics. Pulmonary complications like pneumonia, collapse or abscess may arise because of aspiration of blood or adenoid tissue tags.<br />Damage may occur to the Eustachian tube openings and soft palate. Subluxation of the atlantoaxial joint may result because of trauma, infection, decalcification of the vertebra or laxity of the anterior vertebral ligament. <br />Pharyngeal Abscess<br />Besides the peritonsillar abscess, infection from a tonsil can travel to the retropharyngeal or parapharyngeal spaces and lead to development of an abscess.<br />Retropharyngeal Space<br />The retropharyngeal space is bounded anteriorly by the buccopharyngeal fascia and visceral fascia over the oesophagus and posteriorly by the anterior layer of deep fascia over the cervical vertebrae. Inferiorly this space communicates with mediastinum. The space contains lymph nodes or Rouvier which drain the nasopharynx, part of the oropharynx and paranasal sinuses.<br />A retropharyngeal abscess develops because of infections in this space. <br />Parapharyngeal Space<br />It is a lateral pharyngeal space which extends from the base of the skull above to the level of hyoid bone below.<br />It is bounded medially by the fascia over the pharynx and laterally by the fascia over the medial pterygoid muscle and the parotid glands. Posteriorly lies the carotid sheath with its contents. The space communicates with retropharyngeal space and submaxillary space and inferiorly with the mediastinum. It is divided into prestyloid and postyloid portions by the styloid process. <br />ACUTE RETROPHARYNGEAL ABSCESS<br />Aetiology <br />It is an uncommon condition, usually affecting children. It results from suppuration of the retropharyngeal lymph nodes secondary to infection in adenoids, sinuses or tonsils. The abscess may occur in adults after trauma by a foreign body or on endoscopy.<br />Clinical Features <br />The patient complains of fever, malaise and difficulty in swallowing. The abscess in late stages may represent with respiratory difficulty.<br />The patient is ill, febrile, and looks toxic. The posterior pharyngeal wall may appear bulging. X-ray of the soft tissue of the neck, shows a widened retropharyngeal space . There is increased distance between the laryngotracheal air column and anterior border of the cervical vertebra.<br />Treatment <br />Systemic antibiotics are given. The abscess needs drainage. The patient is held supine on the table with the head end lowered to prevent aspiration or pus into the larynx. An incision is given in the posterior pharyngeal wall and the pus sucked out. <br />CHRONIC RETROPHARYNGEAL ABSCESS<br />This occurs due to tuberculosis of the cervical spine. Radiography of the cervical spine shows destruction of the vertebra. Drainage is done through a neck incision in the neck triangle.<br />Antitubercular treatment is given for the required period.<br />PARAPHARYNGEAL ABSCESS<br />The infection may travel to the parapharyngeal space from the tonsils, teeth or other oropharyngeal or parotid lesions, as well as from the submandibular glands.<br />Clinical Features<br />The patient looks ill, toxic and febrile and complains of difficulty in swallowing and may present with trismus. <br />The oropharyngeal examination may reveal a primary focus of infection. Examination of the neck shows a diffuse tender swelling below the angle of the mandible on the affected side.<br />Treatment <br />Antibiotics are given to control the infection, The abscess is drained through a lateral neck incision given anterior to the sternomastoid from the angle of mandible to the hyoid bone.<br />Early drainage is done to prevent serious complications like thrombosis of major vessels and spread of infection to other spaces. <br />