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    Adenotonsillectomy

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    EB
    The document describes a case of an 8-year-old child presenting with symptoms of difficulty sleeping, snoring, inattentiveness, and ear discharge. On examination, the child has enlarged adenoids and tonsils. The document then discusses indications and contraindications for adenoidectomy and tonsillectomy. It provides details on surgical techniques for performing adenoidectomy using curettage or an endoscopic approach, as well as tonsillectomy using dissection and snare methods. Post-operative care and potential complications are also outlined.

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    Adenotonsillectomy

    Uploaded by

    EB
    55 views29 pages
    The document describes a case of an 8-year-old child presenting with symptoms of difficulty sleeping, snoring, inattentiveness, and ear discharge. On examination, the child has enlarged adenoids and tonsils. The document then discusses indications and contraindications for adenoidectomy and tonsillectomy. It provides details on surgical techniques for performing adenoidectomy using curettage or an endoscopic approach, as well as tonsillectomy using dissection and snare methods. Post-operative care and potential complications are also outlined.

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    The document describes a case of an 8-year-old child presenting with symptoms of difficulty sleeping, snoring, inattentiveness, and ear discharge. On examination, the child has enlarged adenoids and tonsils. The document then discusses indications and contraindications for adenoidectomy and tonsillectomy. It provides details on surgical techniques for performing adenoidectomy using curettage or an endoscopic approach, as well as tonsillectomy using dissection and snare methods. Post-operative care and potential complications are also outlined.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    55 views29 pages

    Adenotonsillectomy

    Uploaded by

    EB
    The document describes a case of an 8-year-old child presenting with symptoms of difficulty sleeping, snoring, inattentiveness, and ear discharge. On examination, the child has enlarged adenoids and tonsils. The document then discusses indications and contraindications for adenoidectomy and tonsillectomy. It provides details on surgical techniques for performing adenoidectomy using curettage or an endoscopic approach, as well as tonsillectomy using dissection and snare methods. Post-operative care and potential complications are also outlined.

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    Adenoidectomy

    Tonsillectomy
    Case

    ▪ 8 y/o child brought w/c/o difficulty staying asleep, snoring, on-


    and-off inattentiveness in class, constantly open mouth, B/L.
    recurrent episodic profuse ear discharge
    ▪ O/E flattened nose, long face, open mouth; cold spatula test:
    minimal fogging B/L. dull opaque retracted tympanic membrane
    ▪ Tuning fork:
    ▪ Rinne B/L –ve @256Hz, -ve @512Hz, +ve @1024Hz
    ▪ Weber not lateralised
    ▪ ABC: B/L same as examiner
    ▪ On posterior rhinoscopy: large soft tissue mass seen
    When do we remove adenoids?

    Indications Contraindications
    ▪ Adenoid hypertrophy causing: ▪ ARI/AURTI
    ▪ Snoring, sleep apnoea, sleep
    disturbances ▪ Acute polio
    ▪ Speech abnormalities (hyponasality) ▪ Cleft palate (velopharyngeal
    ▪ Rhinosinusitis (abolishes recurrence) insufficiency)
    ▪ Tubal occlusion (OME, COM)
    ▪ Dental malocclusion (preventative) ▪ General surgical
    contraindications
    ▪ CVS disorders (electrocard. issues)
    ▪ Haem. disorders (↓ in clotting, Hgb,
    RBCs, WBCs)
    ▪ Systemic disease, poorly controlled
    What kind of adenoidectomy should we perform?

    Curettage (conventional) Endoscope-assisted (novel)


    ▪ Increased operative time ▪ Think: DNE at time of intervention
    ▪ Drawback: expense
    ▪ Increased blood loss
    ▪ Reduced operative time & bleeding
    ▪ No op. field visualisation
    ▪ Good op. field visualisation
    ▪ Eustachian tube damage likelier ▪ Eustachian tube damage preventable
    ▪ Mild hearing loss, otitis media
    ▪ Complete removal can be assured
    ▪ ?Complete removal ►No regrowth!
    ▪ ?Regrowth  ?relapse
    Why perform adenoidectomy with tonsillectomy?
    When do we remove palatine tonsils?

    Indications Contraindications
    ▪ Absolute: ▪ AURTI
    ▪ Recurrent throat infxns (7-5-3 rule, or 2
    ▪ Acute tonsillitis w/ active infxn
    lost weeks of school/work)
    ▪ Peritonsillar abscess ▪ Acute polio
    ▪ Tonsil hypertrophy, incl. tonsillitis
    (chronic/halitosis/acute tx’ed w/ abx) ▪ <3 years age
    ▪ ?Malignancy ▪ Cleft palate (velopharyngeal
    insufficiency)
    ▪ Relative
    ▪ Refractory diphtheria ▪ General surgical contraindications
    ▪ Strep throat + valv. heart dz! ▪ CVS disorders (electrocard. Issues)
    ▪ Haem. disorders (↓ in clotting, Hgb, RBCs,
    ▪ + other procedures WBCs)
    ▪ CNIXectomy, UPPP, styloidectomy ▪ Systemic disease, poorly controlled
    Surgical Procedure
    Instruments
    Preparing the patient

    ▪ Place patient in Rose


    position
    Supinate
    Position
    Extend Cushion
    Stabilise
    head w/
    patient neck neck rubber
    ring

    ▪ Prepare for general Anaesthesia


    anaesthesia
    General anaesthesia
    Adenoidectomy
    CONVENTIONAL CURETTAGE
    1. Palpate the
    adenoids
    Retracting the soft palate with curved end
    of tongue depressor; digitally assess the
    size of adenoids; push lateral adenoids
    towards the midline
    2. Insert Boyle–
    Davis mouth gag
    Hold it in place with Draffin’s bipod stand,
    supported by Magauran’s plate.
    3. Introduce SCT
    adenoid curette
    with guard
    Decide the size of the curette; introduce
    the curette into the nasopharynx until its
    free edge touches posterior border of nasal
    septum; press backwards to engage the
    adenoids
    4. Shave the
    adenoids off the
    nasophrynx
    Use a gentle, sweeping motion; make sure
    to remove remaining tissue with punch
    forceps
    5. Pack the nose
    Anterior packing → electrocoagulation →
    24-hour posterior packing
    Tonsillectomy
    DISSECTION–SNARE METHOD
    1. Retract tonsil
    medially and separate
    the mucous
    membrane
    Use the blunt end of Denis-Browne tonsil-
    holding forceps; incise the mucous
    membrane where it reflects from the tonsil
    to anterior pillar; separate upper pole if
    necessary
    2. Separate the
    tonsil from
    peritonsillar tissue
    Hold tonsil at its upper pole and apply
    traction downwards and medially; continue
    to dissect with Waugh’s tonsil dissection
    forceps until lower pole is reached
    3. Snare and
    remove the tonsil
    Thread wire loop of Eve’s tonsillar snare
    over the pedicle of tonsil, tighten it until it
    cuts the tonsil away and remove the tonsil
    4. Arrest bleeding
    Place gauze sponge in fossa and apply
    pressure for a few minutes; consider tying
    bleeding vessels with silk.
    5. Repeat
    On other side!
    Post-Operative Care

    ▪ Immediate:
    ▪ Control any bleeding
    ▪ Keep in position until fully recovered from anaesthesia
    ▪ Continue to monitor vitals carefully
    Post-Operative Care

    ▪ Oral hygiene:
    ▪ Salt water gargle 3-4x daily
    ▪ Mouthwash w/ drinking water

    ▪ Diet:
    ▪ Cold foods: ice, ice cream, milk
    ▪ → soft food: bread soaked in milk, porridge
    ▪ → regular diet, within 2-3 weeks (tonsils healed in 10–14
    days)
    Post-Operative Care

    ▪ Analgesia:
    ▪ Severe throat pain w/ referred otalgia for 3-10 days
    ▪ NSAIDs cause bleeding, avoid!
    ▪ Opt for paracetamol instead; escalate to opioids only
    for severe pain
    ▪ Antibiotics:
    ▪ Can be given PO or parenterally
    ▪ Adenotonsillectomy typically daycare procedure: full
    activity in 2 weeks
    Complications

    Immediate Delayed
    ▪ Intra-op: ▪ 2° haemorrhage (focal sepsis,
    ▪ 1° haemorrhage premature membrane separation, etc.)
    ▪ Infection
    ▪ Physical injury (to pillars, teeth, soft
    palate, tongue, etc.) ▪ Aspiration (blood, tissue, etc.)
    ▪ Aspiration (blood, tissue, etc.) ▪ Tonsillar remnants + regrowth +
    relapse
    ▪ Post-op ▪ ?Hypertrophic lingual tonsils
    ▪ Reactionary haemorrhage (clot + ▪ Nasopharyngeal stenosis
    ↓sup. constrictor fn) ▪ Grisel syndrome
    ▪ Facial oedema ▪ Velopharyngeal insufficiency
    ▪ ▼Surgical emphysema
    Reactionary haemorrhage is feared!

    ▪ Causes:
    ▪ Thrombus/embolus
    ▪ Vasodilation
    ▪ Post-op HTN
    ▪ Coughing/vomiting associated venous HTN
    ▪ Ligature failure (slipping!)
    ▪ Dangerous!
    ▪ Missable d/t residual effects of anaesthesia (occurs within 24 hrs)
    ▪ Aspiration
    ▪ Large bleed = electrocoag./ligation under GA… again, in short interval!
    ▪ Tx: clot removal, topical styptics (1:1000 adrenaline)/systemic
    haemostatics, electrocoag., pillar approx., transfusion
    Other methods?

    ▪ Adenoids: endoscopy-assisted is an option


    ▪ Tonsils:
    ▪ ‘Hot’ methods
    ▪ Electrocautery
    ▪ CO2 or KTP laser
    ▪ Coblation
    ▪ Radiofrequency
    ▪ ‘Cold’ methods
    ▪ Intracapsular debridement
    ▪ Harmonic scalpel/ultrasound
    ▪ Cryosurgery
    ▪ Guillotine (historical)
    ~Thank you~

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