Tonsillectomy

Tonsillectomy is the name of the surgical procedure performed to remove the tonsils , which are two small glands located in the back of the throat. They make white blood cells to fight infection, but sometimes they can also become infected.

Summary

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• 1 Procedures
  • 1 Dissection tonsillectomy technique
  • 2 Intracapsular technique
  • 3 Other techniques
• 2 Recovery
• 3 Indications
• 4 Contraindications
• 5 Nursing care in tonsillectomy
• 6 Complications
• 7 Sources

Procedures

Tonsillectomy technique

There are several different ways to remove the tonsils. The most common method is called a cold scalpel dissection, which is simply the removal of the tonsils with a scalpel.

Another common method is to burn the tissues using a process called cauterization. Ultrasonic vibration (with sound waves) is also applied in some tonsillectomies. In general, these types of interventions take half an hour and regardless of the surgical method chosen by the doctor, general anesthesia will be administered. You will not be awake during the procedure or feel pain. When you wake up, you will be in the recovery room. Medical personnel will check your blood pressure and heart rate once you are awake. Most people go home the same day as surgery if there are no complications.

Dissection tonsillectomy technique

This excellent technique of Anglo-Saxon origin was modified and introduced with emphasis by the European M.Andrea.

The universally accepted technical procedure is the dissection technique under intubation and with general anesthesia, since it offers the least risk to the patient since it allows regulated haemostasis and complete control of the airway throughout the intervention, avoiding the risk of bleeding and of tracheobronchial aspiration. Today anesthetic protocols, patient position, surgical equipment and technical maneuvers are standardized. This technique is performed in a properly equipped operating room, always performed under general anesthesia.

• Anesthesia: both in children and adults it should be performed under general anesthesia with naso or orotracheal intubation, channeling of a peripheral venous line and monitoring of vital signs. Thus, anesthetic complications are rare and if they occur they can be comfortably and effectively addressed.
• Patient position: supine position; with the head supported by a circular roller that stabilizes it, a discreet cervical hyperextension that is achieved by placing some support under the shoulders, always taking care that the head is resting on the table and the head is flush with the edge of the table to have good accessibility to the surgical field.

The surgeon is positioned sitting behind the patient’s head, working under the light of a photophore. It must be carried out with asepsis, since the fact of existing pathogenic bacterial flora in the pharynx is not an attribute to introduce a new one, coming from outside.

The first surgical time consists of the placement of a Russel-Davis type mouth gag or similar, which rests on the upper incisors and depresses the tongue with a central ranula paddle as large as possible but does not rub against the edges of the lower alveolar arch. When introducing the mouth gag, it is advisable to monitor the condition of the teeth so as not to damage them, and dental protection may be necessary. A gauze can be placed in the hypopharynx to prevent the passage of blood to the digestive tract, otherwise it is necessary to suck it at the end of the intervention.

If an adenotonsillectomy is to be performed, the adenoidectomy is started.

It begins by learning the amygdala with a tonsil pressing forceps (White, Blohmke, Colver, etc.) with which the amygdala is held and is pulled a little towards the median line, as if extracting it from its fossa. With the other hand, a dissecting scissor is taken making an incision 2-3 mm from the edge of the anterior pillar, at the level of the upper pole to enter the tonsillar bed. An extracapsular dissection of the amygdala is performed, executing it gently, attached to the capsule, without producing aponeurotic tears, by blunt dissection, detaching it from its muscle bed without cutting anything. The trumatism on the amigaline bed must be minimal and the pillars must be preserved as much as possible, since in the future it is important to preserve the anatomy of the jaw isthmus as much as possible. Dissected, the amygdala is fixed only by a pedicle in its lower pole, which can be sectioned with a cold handle or with a cross clamp. The dissection is assisted by aspiration and a swab soaked in coagulating fluid is inserted into the tonsillar bed to aid hemostasis.

Once the dissection is completed, hemostasis of the surgical site must be performed, which can be performed using silk or resorbable material ligatures. There are various techniques, all of them equally effective. There are those who suture the bed with three lower, middle and upper points; others suture the anterior to posterior pillar; and other surgeons gauze the surgical field and ligate on demand every visible vessel that bleeds. Other professionals prefer to perform this hemostasis using bipolar forceps. When the removal of the first amygdala has been particularly hemorrhagic, we do not recommend starting with the dissection of the second, until the operative bed of the first amygdala has been drained.

In addition to the classic dissection, multiple technical variants of it have been described, all aimed at better control of bleeding in the surgical act, reduction of post-tonsillectomy bleeding and better control of postoperative pain. Realization with surgical microscope, with bipolar coagulation, etc. There is no valid information available to assess which of these methods is the most appropriate.

Intracapsular technique

This technique has been designed by ALFRED I, who has designed it in order to cause less bleeding and less postoperative pain than with traditional tonsillectomy.

The technique involves the removal of at least 90% of the tonsil tissue, but leaves the tonsil capsule intact. Traditional tonsillectomy cuts and removes all tissue, that is, it is extracapsular.

Other techniques

Tonsillectomy

• Cryosurgical techniques with freon and liquid nitrogen.
• Electrocoagulation: basically the operative times are the same; when taking off, it is cauterized with bipolar forceps: diathermic coagulation.
• CO2 laser removal.

The CO2 laser can be used to perform a tonsillectomy as well as the cut electric scalpel without offering many more advantages, but also in recent years the so-called LAST treatment: laser-assisted tonsillectomy has been proposed as an alternative treatment to conventional tonsillectomy.

Using the LAST technique, partial vaporization of the tonsillar crypts is carried out, producing a macroscopic reduction of the tonsillar tissue, which is achieved by applying repeated laser pulses at a power of about 7 watts, making several passes, until the desired tissue is removed while smoke is inhaled. For this technique the discontinuous super-pulsed laser is used since it allows a better response of the treated tissue, producing less carbonization and thermal relaxation of the tissue, with less inflammatory reaction. In adults it can be done under local anesthesia. In children and in the treatment of the lingual tonsil, general anesthesia is necessary. There may be transient postoperative odynophagia.

Regarding its indications, this technique is of particular interest in situations of hypertrophy of the lymphoid tissue such as tonsillar hypertrophy, tonsillar remains, or hypertrophy of the lingual tonsil, although it can also be performed in tonsillar infectious disease.

• Argon plasma: This diathermy technique originally devised for digestive system techniques was adapted to ENT with a tonsil dissection terminal similar to the conventional tonsil dissector, but with two outlets for argon plasma. There is no bleeding but the dissection is less selective than in bipolar coagulation and we do not yet have enough experience to analyze this technique.
• Radiofrequency scalpel: until now it has not shown significant advantages when compared to the traditional dissection system.

Recovery

Patients feel a little pain during recovery. Sore throat is the main post-surgical symptom. Perhaps there is also pain in the jaw, ears, or neck. Rest is necessary, especially during the first two or three days after surgery.

Pain relievers can be helpful in the recovery stage. Most people who have a tonsillectomy have fewer throat infections thereafter.

Indications

There is discussion among specialists about when it should be done, or if it should be done or not. In general, it has been agreed to do it when there are:

• Recurrent angina.
• Rheumaticor renal complications .
• Flemings.
• Prolonged cervical ganglioninfections .

Contraindications

• Absolute: coagulationproblems (hemophilia), evolutionary tuberculosis , diabetes and hypertension .
• Temporary: Recent primal infection, convalescence, current or skininfection and recent angina .
• Discussed: Menstrual period, allergies(danger of worsening).

Nursing care in tonsillectomy

Before tonsillectomy:

• During the 5 to 7 days before the intervention, perform nasaland pharyngeal disinfection . Some specialists indicate antibiotics .
• Look for hemostasisproblems (bleeding time, clotting , platelet count ).
• Perform blood group and Rh factor.
• Verify analysis and preventive treatment.
• Explain what the treatment consists of and prepare the psychological sphere of the patient.
• Administer pre-anesthetics.
• Monitor that the patient performs a strict fast.

During tonsillectomy:

• Regularly this procedure is carried out with local anesthesiaand sedation in the adult. The technique is very fast, frequently using the Sluder’s guillotine or tonsillotome .
• The nurse should observe the bleeding.

After tonsillectomy:

• Frequently the patient arrives awake and can use pillows.
• Due to advances in science, it is sometimes possible to discharge the same day, if complications do not occur and the treatment is carried out on an outpatient basis.
• Strict monitoring of bleeding for possible bleeding.
• Monitor road signs, pain, and antibiotic therapy.
• Apply an ice collar or ice cream to the neck to reduce pain and avoid inflammation.
• Food according to the specialist’s instructions, cold liquids after 4 hours in the first 24 hours, and soft and semi-solid for 4 or 5 days. Some specialists prefer to administer them at the request of the patient and start the soft and semi-solid diet as soon as possible, and discharge the patient as soon as he manages to swallow the food, if there is no bleeding.

Complications

The greatest is hemorrhage, sometimes: drowsiness , agitation , extreme paleness and cold tremors (symptoms of shock or shock) occur, in this case the surgeon should be notified immediately and prepare for the transfusion.