Tonsillectomy

Overview

Tonsillectomy is the surgical removal of the tonsils. One of the most popular surgical procedures is tonsillectomy. The tonsils are believed to combat infections. However, in many youngsters, the glands themselves can grow big and inflamed, causing a slew of infections and sick days. When this occurs, your child's doctor may decide that removing them is preferable to combat the infections that swollen tonsils may bring.

 

What is Tonsillectomy?

Tonsillectomy is a surgical operation that removes the tonsil, including its capsule, by dissecting the peritonsillar gap between the tonsil capsule and the muscle wall. It can be performed with or without adenoidectomy.

Tonsils are two masses of tissue in the rear of the mouth, one on each side. Tonsils are an important aspect of our immune system. Our immune system aids in the battle against microorganisms that cause sickness. Tonsils can be thought of as germ processing centers. They assist our bodies in learning to detect various types of germs so that we can fight them more effectively.

There are three types of tonsil:

• Palatine tonsils: These are at the top of the throat
• Adenoids — tonsilla pharyngealis: These sit in the nasal cavity
• Lingual tonsils — tonsilla lingualis: This type is in the throat below the palatine tonsils

A tonsillectomy typically involves removing the palatine tonsils.

 

Anatomy and Physiology

The palatine tonsils are part of Waldeyer's lymphoid tissue ring. Adenoids, tubal tonsils, and lingual tonsils are also included. A fibrous capsule that arises from the pharyngobasilar fascia separates lymphoid tissue from surrounding muscle. The peritonsillar space is the possible space between the capsule and the muscle. The tonsils are located between the anterior and posterior pillars, which are formed by the palatoglossus and palatopharyngeal muscles, respectively. 

The tonsil is lateral to the superior constrictor muscle. The glossopharyngeal nerve is located just underneath these muscles and is vulnerable to damage during tonsillectomy. Temporary swelling around this nerve might result in taste changes and referred otalgia. The tonsils' vasculature is provided by a network of blood arteries.

The lingual, facial, ascending pharyngeal, and internal maxillary arteries all originate from branches of the external carotid artery. The tonsillar branch arises from the lingual artery. A tonsillar and upward palatal branch emerges from the facial artery. The descending palatal artery connects the internal maxillary artery to the tonsil. Anomalies in this architecture are possible.

 

What are the benefits of having a tonsillectomy?

Tonsils are routinely removed when they create complications. Common reasons for tonsil removal include:

• Tonsil infections that occur on a regular basis (tonsillitis). If you have frequent or severe spells of tonsillitis, having your tonsils removed will prevent this from happening. It does not, however, prevent sore throats or other throat infections.
• Recurring abscesses around the tonsil (called quinsy).
• Tonsils (and/or adenoids) obstruct the airway, making it difficult to breathe, sleep, or eat. If you suffer obstructive sleep apnea, for example, removing your tonsils and adenoids may be beneficial.
• Growths on the tonsil that need further investigation.

 

Tonsillectomy Indications

As previously stated, sleep-disordered breathing and recurrent tonsillitis are the two most prevalent reasons for tonsillectomy. Sleep-disordered breathing is the recurring partial or total blockage of the upper airway during sleep, causing disturbance of normal ventilation and sleep patterns. It can be diagnosed based on the patient's history and physical examination. SBD symptoms include hyperactivity, fatigue during the day, and aggressiveness. Heroic snoring, observed apnea, restless sleeping, growth retardation, poor school performance, and nocturnal enuresis are all symptoms of Sleep Disordered Breathing (SBD).

When compared to children without SDB, children with SDB have considerably higher rates of antibiotic use, 40% more hospital visits, and a 215 percent increase in healthcare consumption due to greater upper respiratory infections. The most prevalent cause of SDB is tonsillar and adenoid hypertrophy. Tonsillar size does not necessarily correspond with the severity of SDB, and polysomnography can be used to further examine patients with SDB symptoms but no tonsillar hypertrophy.

In patients with recurrent tonsillitis, it is suggested to utilize careful waiting if they have had less than seven episodes in the previous year, fewer than five episodes yearly in the previous two years, or fewer than three episodes annually in the previous three years. If the frequency of infections reaches certain thresholds, tonsillectomy may be advised as a therapeutic option.

Documentation of each infection should include a sore throat and one or more of the following: 

• Temperature > 38.3 degrees Celsius, 
• Cervical adenopathy, 
• Tonsillar exudates, or 
• A positive GABHS. 

Antibiotic allergy/intolerance, PFAPA (periodic fever, aphthous stomatitis, pharyngitis, and adenitis), or peritonsillar abscess may merit early surgical intervention in individuals with recurrent tonsillitis.

Tonsillectomy is also performed in cases with tonsillar asymmetry (to rule out malignancy) and malignancy. Squamous cell carcinoma and lymphoma are the most frequent palatine tonsil cancers. The majority of malignant neoplasms in children are lymphomas.

 

Contraindications

There are no proven absolute contraindications to tonsillectomy. The most serious consequences of tonsillectomy include bleeding and anesthesia danger. As a result, patients having adenotonsillectomy should have any risk factors for these problems recognized and handled preoperatively with relevant precautions (e.g., bleeding disorders, familial history of malignant hyperthermia).

 

What happens before the operation?

Before the procedure, the hospital will offer you (or your kid) with information. Different hospitals follow somewhat different protocols; nonetheless, you should be informed of what will occur and given a brochure to read. Make sure you have asked all of the necessary questions before signing the permission form to agree to the procedure for you (or your child). You should be aware of the dangers and advantages, as well as what will occur during and after the procedure. 

The anesthetist will examine you and explain the procedure. The anesthetist will examine you (or your kid), do an examination, and, in certain situations, arrange for further testing. This is to ensure that you (or your kid) are fit for anaesthesia and that the procedure can proceed safely.

Before the procedure, you (or your kid) will be unable to eat or drink. Your hospital will tell you precisely when you should 'starve'; nevertheless, it is usually around six hours before the procedure. Water can normally be consumed up to two hours before the procedure.

If your kid is undergoing a tonsillectomy, you will typically be able to accompany them to the anesthesia room if you so choose. You'll see them again after the procedure, either in the recovery room when they wake up or on the ward.

 

Technique

Extracapsular or intracapsular tonsillectomy might be performed. In the United States, the "hot" extracapsular method using monopolar cautery is the most commonly used. The Allis clamp is used to grip the superior pole of the tonsil and medialize it. Submucosally, the lateral margin of the tonsil is detected. If a conventional tip is used, the superior pole is incised with roughly 20W of power. The avascular plane that connects the tonsil to the muscles is recognized. Typically, the complete palatine tonsil is removed from superior to inferior pole. Packing, suction cautery, or ties are used to preserve hemostasis. 

Sharp dissection is used in "cold" tonsillectomy. The tonsil is gripped and medialized with the Allis clamp. The lateral portion of the tonsil is identified and incised once again using a number 12 scalpel. The avascular plane is then identified using Metzenbaum scissors. Once within the plane, a Fisher tonsil dissector separates the tonsil from the fossa until just the inferior pole of the tonsil attachment remains. The tonsil is then separated from its inferior pole using a Tyding snare. Hemostasis is maintained via tonsil sponge pressure, suction cautery, or ties.

Coblation, a procedure similar to monopolar cautery, can be used to remove the tonsil. Coblation employs saline irrigation, which results in an ionized plasma layer and a molecular disintegration of tissue. There is little heat generated, and this is a frequent method for partial tonsillectomies. To accomplish a partial tonsillectomy, a micro-debrider can also be employed.

The merits of one strategy over the other are still being debated. Overall, the advantage of one procedure is determined by the cost, reduced complication rates (i.e., bleeding rates), operating room time, and post-operative discomfort. Some studies demonstrate that "cold" tonsillectomy leads in reduced post-operative discomfort, but "hot" tonsillectomy resulted in less intraoperative blood loss and surgical time. The procedure used is determined on the surgeon's experience and degree of comfort.

 

Complications

One of the most prevalent and dreaded consequences following tonsillectomy with or without adenoidectomy is bleeding. A research including over 100,000 children from 2009 to 2013 found that 2.8 percent of children had unexpected revisits for bleeding after tonsillectomy, 1.6 percent of patients went to the emergency room, and 0.8 percent required surgery.

The frequency is higher at night, with 50% of bleeding occurring between 10 p.m. and 1 a.m., and 50% occurring between 6 a.m. and 9 a.m.; this is thought to be due to changes in circadian rhythm, vibratory effects of snoring on the oropharynx, or drying of the oropharyngeal mucosa from mouth breathing. Patients with known coagulopathies may be at a much increased risk of bleeding.

Another common consequence of tonsillectomy is postoperative nausea and vomiting (PONV). It affects up to 70% of individuals who did not get preventive anti-emetics. PONV can increase admission rates, the requirement for intravenous hydration, the need for pain medication, and patient satisfaction. To combat these side effects, a single intraoperative dosage of dexamethasone is recommended during tonsillectomy. Because PONV is most prevalent within the first 24 hours following surgery, some practitioners will regularly give a single dose of ondansetron for outpatient procedures.

The most common cause of morbidity after tonsillectomy is discomfort, which leads to decreased oral intake and dehydration, dysphagia, and weight loss. It is critical that caregivers be capable of detecting indicators of dehydration and consistently encouraging their kid to keep hydrated. Altering planned dosages of acetaminophen and ibuprofen is one way for reducing oropharyngeal discomfort.

Following tonsillectomy and adenoidectomy, velopharyngeal insufficiency may also arise. Hypernasal speech and food regurgitation via the nasal channel during eating might be symptoms. 

 

Recovery

Most individuals experience severe throat discomfort for 1 to 2 weeks or longer. The discomfort may worsen before it improves. The soreness in your throat might also cause pain in your ears.

You will have good and terrible days. Most patients have the most discomfort within the first eight days. You will most likely be weary for 1 to 2 weeks. You may get poor breath for up to two weeks. You should be able to return to work or your normal schedule in 1 to 2 weeks.

Where the tonsils were, there will be a white coating in your throat. The covering resembles a scab. It normally falls off in 5 to 10 days. It normally goes away in 10 to 16 days. As the covering wears away, you may notice some blood in your spit.

You may snore or breathe through your lips at night after surgery. This normally improves one to two weeks following surgery. Mouth breathing can cause dryness and soreness in the mouth and throat. When you sleep, keep a humidifier near your bed. This may make breathing easier for you. Clean the machine according to the instructions.

Your voice may sound different at first. Your voice will most likely return to normal in 2 to 6 weeks. People frequently lose weight after having this operation. This is due to the fact that swallowing food might be painful at first. This is fine as long as you drink enough of fluids. You will most likely regain the weight once you can eat properly again.

This care sheet will give you an estimate of how long it will take you to recuperate. However, everyone recovers at their own speed. Follow the actions outlined below to get better as soon as possible.

 

How should I take care of my child after surgery?

It is critical that you urge your youngster to drink enough of fluids. Keeping the neck wet reduces pain and helps to avoid dehydration (a dangerous condition in which the body does not have enough water.

As directed by your doctor, give your youngster pain medication. Give it before going to bed and first thing in the morning. Your kid should be able to eat and drink more easily approximately 30 minutes after taking the pain medication, so these are the best times to promote drinking and eating.

Do not give your child any pain relievers that have not been prescribed or advised by your doctor. Recent studies, however, have found no evidence of increased bleeding when children take (ibuprofen) following tonsillectomy. If you are unsure about whether medications are safe, please see your doctor.

After a tonsillectomy, antibiotics are no longer regularly administered. If your kid is having difficulty swallowing the pain medication or is vomiting, talk to your doctor about using pain drug suppositories. At night, install a humidifier or cold mist vaporizer next to your child's bed. Keeping your child's breathing wet will help reduce discomfort and avoid dehydration.

Prevent your child from getting into touch with somebody who has a cold, the flu, or an illness.

 

Conclusion 

Tonsillectomy is a popular surgical operation used to treat chronic or recurring tonsillitis, as well as concerns involving larger or atypical tonsils. There are several requirements that a person must satisfy in order to be a good candidate for tonsil removal. If a person satisfies these requirements, the advantages of the treatment will most likely outweigh any dangers associated with any form of tonsillectomy. To perform a safe operation and avoid post-operative problems, the surgeon must grasp the anatomy of the oropharynx.