Download Tonsillectomy

Common ENT Operations
.Tracheotomy
.Laryngotomy (cricothyroidotomy)
.Tonsillectomy
.Adenoidectomy
Tracheotomy
Definition :
Creation of a surgical opening between the trachea and skin
surface.
 Temporary (tracheotomy): just opening the anterior wall of the
trachea to the skin.
 Permanent ( tracheostomy): opening the anterior wall of trachea
and suturing the mucosa of trachea with the skin, example;
following total laryngectomy.
Tracheostomy timing:
Emergent (also known as slash trach): indicated in emergency
airway distress when impending death of a patient exist.
Urgent (awake): indicated in a patient with respiratory distress and
needs immediate surgical intervention. This is best done in a controlled
environment ( intensive care unit or operating room) while using local
anesthesia on an awake patient .
Elective :mostly done in the intubated patients and in patients
undergoing extensive head and neck procedures to facilitate airway
control during the postoperative recovery period.
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Indications:
-1
Relief of up. airway obstruction : due to the following causes:
a- congenital
bilateral choanal atresia
laryngeal web or cyst
subglottic stenosis
tracheo-esophageal anomalies.
b- traumatic
external: blunt neck trauma as RTA, sport injuries, assault
penetrating neck injuries as missiles, blasts, stabs.
internal: inhalation of steam or irritating fumes
foreign bodies and chemicals
c- infection
acute laryngotracheobrondhitis, acute epiglottitis
diphtheria, ludwig’s angina
d- tumors
benign and malignant tumors of the tongue, pharynx, larynx,
upper trachea and thyroid
gland
.
e- bilateral vocal cord palsy
after thyroidectomy
bulbar palsy
f- allergy : angioneurotic edema
2
-2 Protection of tracheobronchial tree :
aspiration can be done easily in conditions leading to :
-1
inhalation of saliva, food, blood or gastric contents
-2
stagnation of bronchial secretions
These Conditions include :
a- coma: due to any cause ( head injury ,CVA, drug overdose….etc)
b- poliomyelitis
c- tetanus
d- myasthenia gravis
e- burns of the face and neck
f- multiple fractures of the mandible
-3
Treatment of conditions leading to respiratory insufficiency :
Any of the diseases mentioned above in (1) and (2) might cause
respiratory insufficiency. It may also result from :
chronic bronchitis
emphysema
severe chest injury ( flail chest)
-4
Elective
For major operations of the mouth, pharynx and larynx to facilitate
the surgery and the postoperative recovery.
Surgical technique:
Anesthesia :general or local (lidocaine infiltration)
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Position :head extended over a small sandbag under the neck
Incision :midline vertical between the cricoid and suprasternal
notch or horizontal ( in elective cases) 2 cm below the cricoid.
Separation of strap muscles :in the midline by scissor.
Thyroid isthmus :divided and ligated or retracted (upward or
downward(.
Trachea exposed and opened :between 2nd4- th tracheal rings by
taking a circular cut out window from the anterior tracheal wall or
making a superiorly based flap or just making vertical incision without
cartilage removal ( in children .)The first tracheal ring should not be
disturbed.
Insertion of tube :either plastic (portex) or metallic (silver).
Closure of wound :after ligation or electrical cautery of bleeding
points the wound is loosely closed for fear of emphysema or of making
reinsertion of the displaced tube more difficult (if closed tightly).
 Tracheotomy tubes:
-1
metal (silver)
inner and outer tubes
longer half life
more traumatic
without cuff
can be used with laser but not radiotherapy
-2
plastic tube (portex)
Only one tube (usual types)
Shorter half life
4
More comfortable and less traumatic
With or without cuff
Used with radiotherapy but not laser
 Postoperative care:
-1
position: sitting or semi-sitting.
-2
suction : applied regularly passing a sterile catheter into the
trachea.
-3
humidification :humidifier or moisturized gauze to prevent
crustation and tube obstruction.
-4
chart of vital signs
-5
observation of the area: for hematoma or emphysema.
-6
dressing: changed regularly once or twice daily.
-7
changing the tube: better kept as long as possible unless there is
tube obstruction. It is advised to keep it at least 72 hours before the first
change .
 Physiological changes and effects of tracheotomy:
-1
bypass upper airway obstruction.
-2
reduce the dead space area by up to.%50
-3
reduce airway resistance.
-4
allow for clearance and suction of lower respiratory tract
secretions.
-5
allow for assisted ventilation ( mechanical ventilation .)
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Complications of tracheotomy

-1Immediate : during the operation or immediately after:
a -hemorrhage : from the skin, muscles or thyroid gland; controlled
by packing, electrical cautery or by ligation.
b -air embolism :the large veins of the neck( negative pressure
vessels) if opened inadvertently might suck air and result in air
embolism.
c -apnea :due to rapid washout of the Co2 from the blood following
tracheotomy , since the Co2 is the main stimulus for the respiratory
center in the brain, sudden or rapid decline in the Co2 level in the blood
might results in suppression of the respiratory center. This can be
avoided by inhalation of O2 mixed with Co2 ( carbogen).
d -damage to adjacent structures : innominate artery or pleura of
the lung dome ( especially in children).
e -cardiac arrest :due to hyperkalemia from tissue damage or acidbase imbalance.
f -Complications of GA.
2- Intermediate: during patient stay at the hospital:
a- Dislodgement or displacement of the tube: accidentally or by
coughing, retching or vomiting. This is prevented by suturing the tube to
the skin and use of special tape fixed to the tube and wrapped around
the neck.
b- Obstruction of the tube: due accumulation of crustation of
secretions inside the tube. Prevented by humidification and repeated
sterile suction.
c- Surgical emphysema: due to extensive subcutaneous dissection, large
tracheotomy opening, small tracheotomy tube or tube obstruction.
Usually self-limiting.
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d- Pneumothorax and pneumomediastinum: if there is damage to the
pleura of the lung. More common in children.
e- Infection of the stoma: daily dressing, local antibiotics and tube
replacement reduce the incidence of infection and bacterial biofilm
formation
f- Fistula : between the trachea and innominate artery resulting in
bleeding from the stoma which could be first only minor (sentinel
bleeding) followed by massive bleeding 3 days to 3 weeks later. Or
between the trachea and esophagus (tracheo-esophageal fistula)
resulting in dysphagia and aspiration.

-3Late : when the patient has gone home:
a -stenosis :narrowing due to stenosis at the level of the stoma or in
the subglottis due to granulation tissue formation caused by trauma
from the tube or by local infection.
Treatment by dilatation or surgery.
b -persistent tracheo-cutaneous fistula :closure of the tracheotomy
called weaning or decannulation done by gradual reduction of the tube
size for several days at the hospital and then removal of the tube( if the
patient can tolerate). After tube removal the wound will close
spontaneously by secondary intention without wound suturing in vast
majority of cases. Only rarely the wound will not close after tube
removal resulting in persistent tracheo-cutaneous fistula which should
be closed surgically under GA.
Laryngotomy (cricothyroidotomy)
Opening through the cricothyroid membrane.
 Indications:
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sudden laryngeal obstruction when facilities or experience for
tracheotomy are not available, impaction of a foreign body in the larynx
is the commonest indication.
 Surgical technique:
It is an emergency done without anesthesia using any sharp
instrument as a knife and making a transverse incision through the
cricothyroid membrane , the incision is then deepened followed by
insertion of a tube .
Wide bore cannula can be used instead of the incision and tube
insertion. The membrane is immediately subcutaneous in location with
no overlying large veins, muscles or fascial layers allowing easy access.
Laryngotomy provides relief for only short period of time until the
patient is transferred to the hospital where facilities and experience
are available.
Tonsillectomy and Adenoidectomy
Tonsillectomy is the commonest elective operation performed all
over the world.
Anatomy :
Waldeyer’s ring consists of the nasopharyngeal tonsil, lateral
pharyngeal bands, palatine tonsils and lingual tonsils. It is the palatine
tonsils to which the term tonsils is applied.
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The palatine tonsils (right and left) are invaginated on the medial
surface by crypts (6-20 in number) lined with squamous mucosa.
Epithelial debris collecting in these crypts and mixed with bacteria from
the oral cavity cause chronic inflammation and when the crypts become
obstructed, tonsilloliths might develop which are often malodorous.
The palatine tonsil is lined with a capsule on its deep surface and is
separated by loose areolar tissue from the underlying superior
constrictor muscle.
The blood supply to the palatine tonsils includes branches from:
-1ascending pharyngeal a.
-2ascending palatine a.
-3lingual a.
-4facial a. (main blood supply to the palatine tonsils)
-5descending palatine a.
Venous drainage ultimately into the internal jugular vein.
The palatine tonsils drain mainly into the upper deep jugular lymph
nodes
They are located in a fossa between folds of palatal musculature
known as the anterior and posterior pillars (palatoglossus and
palatopharyngeus muscles respectively).
The palatine tonsil (adenoid) is a single midline structure situated at
the junction of the roof and posterior wall of the nasopharynx. It is lined
by columnar (respiratory) epithelium and there is no capsule on its deep
surface.
The blood supply to the adenoid is primarily from the ascending
pharyngeal artery. Venous drainage ultimately into the internal jugular
vein.
Lymph drains into the deep jugular lymph nodes either directly or
through the retropharyngeal lymph node .
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 Indications of tonsillectomy:
-1
recurrent tonsillitis: 4 or more attacks of genuine tonsillitis per
year for 2-3 years. the decision to perform tonsillectomy may be based
on the amount of time that the patient is non-productive ( school or
work absence)
-2
peritonsillar abscess(quinsy): recurrent quinsy is an absolute
indication while single attack is a relative indication.
-3
respiratory obstruction: hypertrophied tonsils causing sleep
disorders or dental malocclusion
-4
suspicion of malignancy: unilateral tonsillar hypertrophy or
ulceration on the tonsil. The tonsil is removed for biopsy (excisional).
-5
other indications: approach to glossopharyngeal nerve (Eagle’s
syndrome), recurrent otitis media, chronic inflammation causing foul
breath or taste ( no response to medical treatment).
 Indications of adenoidectomy:
-1
airway obstruction: hypertrophied nasopharyngeal tonsil causing
sleep disorders
-2
recurrent suppurative otitis media (no response to medical
treatment)
-3
otitis media with effusion ( no response to medical treatment)
 Contraindications of adenotonsillectomy :relative
contraindications
-1
bleeding disorders: as hemophilia, thrombocytopenia. Should
be corrected first.
-2
recent infection of the tonsil or adenoid: the surgery should be
postponed for 2 weeks because of increased risk of bleeding.
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-3
cleft palate: is a contraindication of adenoidectomy because it
might results in velo-pharyngeal incompetence and hypernasal speech.
-4
general contraindications to GA: as anemia , uncontrolled DM or
hypertension.
 Preparation for surgery and Investigations:
History :full including; number of genuine attacks per year, school
or work absence due to the infection history of bleeding disorders.
Examination :local and general
Investigations:
-1
full blood count
-2
bleeding profile :
bleeding time
clotting time
prothrombine time (PT)
partial thromboplastine time (PTT)
international normalization ratio (INR)
-3
general urine examination
-4
chest x-ray
 Surgical technique:
Tonsillectomy:
-1
Cold dissection technique :using sharp dissection by special
instrument (dissector).
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-2
Diathermy :use of electrical cautery to dissect the tonsils. Might
cause thermal damage to the surrounding structures and associated
with increased risks of pain and infection postop .
-3
Laser : diod, argon, co2 and Nd-YAG. (similar effect postop. to
diathermy). Useful in patients with bleeding tendency.
-4
Coblation :use of bipolar current to create a plasma field which
can results in dissociation of organic molecules .Creation of this field
occurs at low temperature (60-70 c) which is less than that of electrical
diathermy or radiofrequency. The decreased temperature will diminish
surrounding tissue edema with less pain and rapid return to regular diet
and normal activity post-operatively
-5
harmonic scalpel :ultrasonic technology is used to cut and
coagulate tissue also at low temperature similar to coblation.
-6
Radiofrequency :heating the target tissue by placing an
electrode submucosally. This electrode generates radiofrequency which
cause tissue heating, thus shrinkage tissue volume while leaving intact
overlying mucous membrane.
Adenoidectomy:
Done by curation using special curette passed through the oral
cavity into the nasopharynx under GA.
Alternatively the adenoid is removed by suction electrocautery or
the use of powered instrument (micro-debrider).
Post-operative care :
-1 position: lateral position with the head down
-2 chart of vital signs
-3 diet: in the 1st 24 hours soft cold diet as ice cream, cold milk and
juice. After 24 hour encourage normal diet.
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-4 analgesia : paracetamol or narcotics .Non-steroidals (NSAIDs)
should be used with caution.
-5 antibiotics: postoperative antibiotic use is controversial.
Prophylactic perioperative antibiotics should be used in patients with
cardiac abnormality .
-6 Discharge: time of discharge from the hospital is controversial, in
general patients who develop complications postoperatively, or younger
than 2 years or those with obstructive sleep apnea should be kept at the
hospital overnight otherwise patients can be discharged the same day.
Complications of Adenotonsillectomy
-1
Per-operative (during the operation)
A- Hemorrhage:
primary hemorrhage occurs at the time of the operation up to 1
hour postoperatively .Careful gentle dissection and adequate
homeostasis by silk ligature or electric cautery should overcome this
complication . Recent infection ,previous quinsy and severe scarring are
the factors which increase the rate and severity of hemorrhage.
B- Trauma to the adjacent structures:
teeth , gums, tongue and palate might happen.
C- Anesthesia complications :
respiratory or cardiovascular.
-2
Post-operative:
Early:
A -Hemorrhage : postoperative hemorrhage is of 2 types
Reactionary and Secondary.
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Reactionary h. occurs from 1st to 24 hours postoperatively; it is due to
slipped ligature or dislodgement of blood clot from excessive venous
pressure induced by cough or retching.
Secondary h. occurs any time after 24 hours postoperatively,
classically at 8-6 days. It is usually due to infection and mild in severity .
Management of postoperative hemorrhage :hospital admission
with close observation . prepare cross matched blood and blood
transfusion as necessary As a rule all children with hemorrhage even if
it is minor should be returned back to operating theater to stop the
bleeding under GA by silk ligature electric cautery.
In adults if it is minor bleeding : conservative treatment
If bleeding continues or severe : return back to the operating
theater and control hemorrhage under GA.
So there are 3 types of hemorrhage following tonsillectomy or
adenoidectomy :primary ,reactionary and secondary.
B- Infection : results in pain, fever and secondary hemorrhage.
Usually it is mild and treated conservatively with antibiotics .
C -Pulmonary complications: as atelactasis, pneumonia.
D -Subacute bacterial endocarditis (SBE):
Tonsillectomy leads to transient bacteremia and if the patient has
abnormal heart valves , SBE may complicate the operation.
E- other complications : as pain, nausea and vomiting.
Late :
A- scarring: of the pharyngeal mucosa and palate which could affect
the voice.
B- remnant : incomplete removal of the tonsil or adenoid will leave
a remnant which might re-grow again .
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