5. SUBMUCOUS CLEFT PALATE (COVERT)
โข Abnormal nasal speech,
โข Bifid uvula
โข Thin strip of mucosa in the
middle of roof of mouth
โข Notch at the back of hard
palate.
6. ADENOIDECTOMY - PROCEDURE
โข Anaesthesia โ General
Anaesthesia
โข If combined,
Adenoidectomy before
Tonsillectomy
7. POSITION โ ROSEโS POSITION
Supine with head extended by placing a
pillow or sandbag beneath the
shoulders.
Advantage โ
Larynx lies at a higher level than oral
cavity โ no risk of aspiration.
Excellent exposure
Both hands of surgeon are free.
Hyperextension is avoided
Makes cervical vertebral bodies
prominent-Damage to ligaments or
cartilages of vertebral spine or
bodies -> Griselโs syndrome
8. GRISELโS SYNDROME
โข Non traumatic subluxation of atlanto axial joint
โข Results from any condition that results in hyperaemia and
pathological relaxation of the transverse ligament of the
atlanto-axial joint.
โข Due to infection in the periodontoid vascular plexus that
drains the region->paraspinal ligament laxity.
โข Presents with persistent neck pain and torticollis 1-2 weeks
following surgery.
โข More common in Downโs syndrome patients
โข X-ray and CT of Cervical spine confirms diagnosis.
โข Treatment: Cervical immobilisation , analgesics and
antibiotics. Arthrodesis in intractable cases
9. TECHNIQUE OF ADENOIDECTOMY
โข The surgeon stands behind the patient.
โข Boyle-Davis mouth gag is inserted, opened and
held in place by Draffinโs bipod stand
โข Palate is palpated to exclude a submucous cleft
palate.
โข The soft palate is retracted by a suction catheter
introduced through the nose, and pulled out of
the oral cavity.
โข The adenoid is palpated with a finger.
10. โข St Clair Thomson adenoid curette with
guard is introduced into the nasopharynx
above the upper end of adenoid tissue,
โheld like a daggerโ
โข With a downward and forward sweeping
movement, adenoids are shaved off.
โข A smaller sized curette is used to curette the
adenoids around the choana and the
Eustachian cushions
โข Nasopharynx is packed with gauze packs
for a few minutes for haemostasis.
11. OTHER TECHNIQUES OF ADENOIDECTOMY
โข Suction coagulator/diathermy
โข Endoscopic transnasal or transpalatal adenoidectomy with microdebrider
โข Coblator plasma field device
12. POSTOPERATIVE CARE
โข The patient is kept in lateral position
โข Kept nil orally until fully recovered from GA (4-6 hours).
โข Monitor vitals
โข Watch for bleeding: Earliest sign-โFrequent swallowingโ
โข Oral antibiotics and analgesics
15. TONSILLECTOMY-INDICATIONS
Absolute Indications:
๏ง Obstructive
symptoms and
Obstructive sleep
apnoea
๏ง Malignancy or
suspected
malignancy
๏ง Recurrent
peritonsillar abscess
๏ง Tonsillitis causing
febrile seizures in
children
Relative Indications:
๏ถRecurrent tonsillitis:
๏ฑ >= 7 episodes in 1 year
๏ฑ >=4 episodes per year for 2 consecutive
years
๏ฑ >= 3 episodes per year for 3 consecutive
years
๏ถHalitosis due to chronic tonsillitis
๏ถTonsilloliths
๏ถTonsillar cysts
๏ถDental and orofacial abnormalities
๏ถDipheria carriers
๏ถRheumatic fever and Acute
glomerulonephritis
16. TONSILLECTOMY AS PART OF ANOTHER
PROCEDURE
โข Excision of elongated styloid process (Eagle syndrome) โ Nagging throat pain and a
palpatory finding in the tonsillar fossa. Confirmed by palpation and injection of
anaesthetic.
โข Glossopharyngeal neuralgia
โข UPPP (Uvulopalatopharyngoplasty)or LAUP (Laser-assisted uvulopalatoplasty) or
CAUP (Coblation assisted uvulopalatoplasty)
17. CONTRAINDICATIONS
โข Bleeding disorders
โข Cleft palate or submucous cleft palate
โข Velopharyngeal insufficiency
โข Acute infection
โข Uncontrolled systemic disease
โข Anaemia
โข Extremes of age
18. PROCEDURE
โข Anaesthesia: General anaesthesia
โข Position-Roseโs position-supine with head extended by placing a pillow or sandbag
under the shoulder
โข Operative techniques
โข DISSECTION AND SNARING -> Classical
โข Diathermy
โข Coblation tonsillectomy
โข Ultrasonic dissection
โข Laser tonsillectomy
โข Capsulotomy techniques
โข Guillotine method (Ancient)
19. DISSECTION AND SNARE METHOD
โข Boyle Davis mouth gag is inserted, opened and held in position
with Draffinโs bipod stand
โข Upper pole of tonsil is held with tonsil holding forceps and pulled
medially
โข Mucosa is incised with blunt scissors, knife, forceps or diathermy
at the point where it reflects from tonsil to anterior pillar. Incision
is continued inferiorly towards base of tongue.
โข The tonsil is separated from its bed by blunt dissection, upto the
lower pole
โข The plane of dissection is the loose areolar tissue separating
tonsil from its bed.
20. โข Once lower pole is reached, a tonsillar snare is passed over the tonsil holding
forceps, placed over the tonsil, threaded down to the lower pole, tightened to crush
the pedicle, and the tonsil is removed
โข Gauze packs are kept in the tonsillar fossa
โข Bleeding points are looked for, and bleeding arrested with non absorbable sutures
21.
22. POSTOPERATIVE CARE
โข Patient is nursed in the lateral position
โข Kept nil orally until fully recovered from GA (4-6 hours).
โข Monitor vitals
โข Watch for bleeding: Earliest sign-โFrequent swallowingโ
โข Ice cold fluids and ice cream given on the first day
โข Oral antibiotics and analgesics
23. COMPLICATIONS OF TONSILLECTOMY
โข HEMORRHAGE
โข Primary
โข During the surgery
โข Controlled by pressure packing, ligation, cauterisation
24. โข Reactionary
โข Within 24 hours of surgery
โข CAUSES OF REACTIONARY HEMORRHAGE (VIVA):
1. Formation of a blood clot or Dislodgement of blood clot from lumen
2. Vasodilation of blood vessel
3. Postoperative rise in blood pressure
4. Increased venous pressure by coughing or retching
5. Slipping of ligature
25. โข Management of Reactionary haemorrhage:
โข Blood is cross matched
โข Tonsillar fossa is inspected and clot removed
โข Pressure with a swab soaked in 1:1000 Adrenaline
โข Administration of hemostatic agents (Ethamsylate,Tranexamic acid)
โข May require taking to the operation theatre and ligation under General Anaesthesia.
26. โข Most dangerous form of haemorrhage because:
โข It may be missed (Patient may still be under the effect of GA)
โข It may cause fatal aspiration
โข Large hemorrhages may require ligation or electrocoagulation under GA. Two GAs at a
short interval is dangerous.
โข Secondary haemorrhage (>24 hours โ 2 weeks)
โข Cause: Infection of the granulating tonsillar bed
โข Treated with Antibiotics
27. โข OTHER COMPLICATIONS OF TONSILLECTOMY:
โข Injury to:
โข Temporo-mandibular joint
โข Lips and commisures of mouth
โข Tongue, uvula, soft palate
โข Very rarely Glossopharyngeal nerve, pharyngeal venous plexus, carotid sheath
โข Grisel syndrome (Non traumatic atlanto axial dislocation)
โข Aspiration of blood-> Pneumonia, collapse of lung, or lung abscess
28. โข Hematoma and oedema of uvula
โข Referred earache
โข Velopharyngeal insufficiency
โข Tonsillar remnants