Indications of unilateral tonsillectomy :

1. Unilateral tonsillar enlargement suspected of malignancy.
2. Suspected malignant ulcer of the tonsil.
3. Benign tumours from the tonsil.
4. In glossopharyngeal neuralgia for nerve section.
5. Removal of styloid process.

Procedure of tonsillectomy :

Instruments :

1. Endotracheal tube.
2. Revolving tool.
3. Draffin’s Bipod.
4. Boyle Davis mouth gag
5. Tonsillar snare.
6. Tonsil replacement forceps.
7. Artery forceps.
8. Blade.

Positions of the patients : (Rose’s Position/Tonsillectomy position)

• Supine position.
• Head extended by placing a pillow under the shoulders. A rubber ring is placed under the to stabilize it.

Positions of the surgeon : Head end of the operation table on a revolving tool.

Anaesthesia : General anaesthesia with endotracheal intubation

Steps of operation :

• Sterile draping and cleaning.
• Opening of the mouth by introducing a Boyle.
• Fixation of the mouth gag with the help of Draffin’s Bipod.
• Suction and cleaning of the oral cavity, hypopharynx and a pack is given within the hypopharynx not to allow introducing blood in the stomach (as blood is a highly emetic).
• Holding of tonsils and drawn medially by tonsil holding forceps.
• Incision: On the whitish line (capsule) over the anterior pillar or junction from upper to lower pole.
• Dissection of tonsils-from upper to lower pole.
• Cutting and crushing of the lower pole of tonsils, this is done by tonsillar snare.
• Searching of bleeding points- caught and ligated.
• In the same way the other side, tonsillectomy is done.
• Again suction and cleaning of the oral cavity and hypopharynx and then removal of the pa Never remove the hypopharyngeal pack before suction.

Post-operative order of tonsillectomy operation :

Immediate general care :

• Keep the patient in coma position until fully recovered from anaesthesia.
• Keep a watch on bleeding from the nose and mouth.
• Keep check on vital signs, e.g. pulse, respiration and blood pressure.

Diet :

• When patient is fully recovered he is permitted to take liquids, e.g. cold milk or ice cream.
• Sucking of ice cubes gives relief from pain.
• Diet is gradually built from soft to solid food. a day.

Oral hygiene :

• Patient is given Condy’s or salt water gargles three to four times a day.
• A mouth wash with plain water after every feed helps to keep the mouth clean.

Analgesics for relieve of pain.

Antibiotics : A suitable antibiotic can be given orally.

Patient is usually sent home 24 h after operation unless there is some complication.

Patient can resume his normal duties within 2 weeks.

Complications of tonsillectomy operation :

Immediate : 

1. Primary haemorrhage.
2. Reactionary haemorrhage
3. Injury to the tonsillar pillars, uvula, soft palate, tongue or superior constrictor muscles, teeth.
4. Aspiration of blood.
5. Facial oedema.
6. Surgical emphysema.

Delayed :

1. Secondary haemorrhage.
2. Infection: Parapharyngeal abscess, otitis media.
3. Lung complications.
4. Scarring of soft palate & pillars
5. Tonsillar remnants.
6. Hypertrophy of lingual tonsil.

Types of harmorrhage after tonsillectomy :

Primary haemorrhage : Haemorrhage during the operation.

Reactionary haemorrhage : Bleeding within 24 hours of tonsillectomy operation.

Secondary haemorrhage : Haemorrhage after 24 hours till the wounds heal, usually within 3 to 10% postoperative day.

Primary haemorrhage after tonsillectomy : 

• Primary haemorrhage occurs at the time of operation.
• It can be controlled by : Pressure, ligation, electrocoagulation of the bleeding vesscls.

Management of Reactionary haemorrhage after tonsilliectomy : 

Reactionary haemorrhage : Bleeding within 24 hours of the operation, but commonly within 5-6 hours is called reactionary haemorrhage.

Causes :

1. Failure to ligate the all bleeding points.
2. Slipping of ligature.
3. Collapsed vessels opening up in the post-operative period.
4. Failure of vessels to contract and retract following crushing.
5. Dislodgment of the clot due to raised blood pressure.
6. Relaxation of the stretched faucal tissue.
7. In case of local anaesthesia, as the effect of adrenaline wears off, the vessels dilate

Clinical features :

1. Dribbling of blood.
2. Vomiting of clotted blood.
3. Repeated swallowing
4. Increase pulse rate.
5. Decrease blood pressure
6. Cold and calms extremities
7. Shallow respiration
8. Oral cavity full of blood clot
9. Large colt in the tonsillar fossa.

Treatment:

1. Assessment of the patient-pulse, blood pressure, respiratory rate and temperature.
2. If the patient is in shock-intravenous fluid and blood transfusion.
3. Mouth is opened by tongue depressor and removal of clot by long arterial forceps and gauze pack which is given not more than 10 minutes. If not stopped-

   .If oozing-H2O2, soaked gauze to be applied.

   .If sprouting-Bleeding vessel to be ligated under general anaesthesia.

4. Other treatment : Antibiotic, analgesic, vitamin.

Secondary haemorrhage :

Definition :  Any haemorrhage after 24 hours in the post-operative period is called secondary haemorrhage but the usual time is on the 5th to 10th post-operative days.

Cause :

1. Secondary infection in the tonsillar fossa.
2. Separation of slough.

Clinical features :

1. Bleeding-slight at first, later frank ooze occurs.
2. Blood stained salvia.
3. Fever
4. Pain on swallowing
5. Foetor oris.
6. In the tonsillar fossa-infected colt & unhealthy slough.

Investigation : Throat swab for culture & sensitivity.

Treatment :

1. Remove the infected clot or slough by long arterial forceps.
2. H2O2, gurgle (local treatment only): So all the clots and sloughs will come out clearly.
3. Systemic antibiotics. Should be changed what was given before and give high dose broad spectrum antibiotics.
4. Sedative: Diazepam
5. Analgesics for relieve of pain.
6. Rest in bed.
7. Gauze piece in the fossa soaked with H2O2, if the above procedures are failed (48 hours will remain there) [Gauze pack-in between anterior and posterior pillar and 2-3 stitches (over sewing the pillars) are given under general anaesthesia]
8. Blood transfusion is necessary in severe cases.

Pre-operative investigations :

1. Complete blood count.
2. Serum creatinine.
3. Blood urea.
4. Blood sugar: Fasting/ Random/ Post-prandial..
5. Urine R/M/E.
6. Chest X-ray.
7. ECG.
8. Blood grouping & Rh typing.
9. HBsAg

b) Patient is not fit for tonsillectomy: Please write contraindications of tonsillectomy.

c) Monitoring of a post tonsillectomy patient: Please write from above discussion.