History amont(1).Remington-Hobbs described the use of monopolar

History

the tonsils are organs
of lymphoid tissues located at the entrance of the respiratory & digestive
system(1).The first tonsillectomy known was operated by Cornellus Celsus,2000
years ago(2).Recent tonsillectomy started at the beginning of this century by
the apearance of tonsillectomy dissection in Balitmore by  Worthington(1907) & in London by
Waugh(1909) & Guillotine tonsillectomy in New Castle by whillis and
Pybus (1910).Vessls ligation in the tonsillar fossa was extremely difficult
& first done by Cohen in 1909(3)

We Will Write a Custom Essay Specifically
For You For Only $13.90/page!


order now

In
1960,the laser of CO2 introduced in medicine & the first use of it in
tonsillectomy was in 1973.Otolaryngology was the first surgical branch in which
the laser used succissfully in great amont(1).Remington-Hobbs described the use
of monopolar diathermyin tonsillectomy in 1968(5) , Andrea defined the first
microsurgical bipolar cautery technique in 1993 (6)

universally
,tonsillectomy is the most frequinly performed otorhinolaryngological    procedures(4).At the bigining tonsillectomy
was performed by ageneral sureons,but later became the operation of
otolaryngologist .The progress of tonsillectomy occured by the apearance of
mouth-gag & tongue depressor in addition to the
positioning of patient with leaning and suspended head .this position was
described first by Killian in 1920(1).In the USA,it is estimated that 1,400,000
tonsillectomy operation done  in
1959,around 500,000 in 1979 & 250,000 onse/ year in the last decade,so at
the initial period tonsillectomy was done frequinly because many diseases
faulty attributed to to tonsils as a focus of infection.but later due to
abscence of convincing results,this procedure lost its influince & No. of
oprations decreased gradually.Also advancement in the use of antibiotic
contributed on this reduction of tonsil removal(1)

Anatomy

platine tonsils
are one of the component of Waldeyer’s ring which form acircular band of
lymphoid tissues in the pharynx in addition to the adenoids & lingual
tonsils.the palatine tonsils have germinal center & distinct capsule in
contrast to to adenoid & lingual tonsil which separat it from the
pharyngial wall.the tonsilar fossa consist of three muscles ,the anterior
pillar is the palatoglossus muscle and the posterior pillar is the
palatopharyngeus muscle & the bed of the fossa formed by the superior
constrictor muscle .in the tonsils there is  crypts exposed to the oropharynx ,covered by  stratified squamous epithelium(7).

. Blood
supply of the tonsils: the palatine tonsils blood supply is variable, they are
supplied by several branches of the external carotid
artery:

·       
ascending
pharyngeal,

·       
ascending palatine,

·       
and branches of the
lingual and facial arteries.

The blood supply enters from the lower pole of the palatine tonsil. The internal carotid
artery (ICA) lies approximately 2 to 2.5 cm deep and posterolateral to the palatine tonsil; howevr case reports  exist of
aberrant ICA courses which come within 1 cm of
the inferior pole. The ICA may have a tortuous and convoluted course of which the surgeon must be cognizant.

Venous drainage is by way of a peritonsillar venous plexus, which surrounds the capsule and drains into the
lingual and pharyngeal veins (8)

the
nerve supply of the tonsil arise from the glossopharyngial nerve & branches
from the lessr palatine nerves.the tympanic branch of the glossopharyngial
nerve cause the rffered ear pain found in tonsilitis

in
the tonsil there is no afferent lymphatic vesselesbut the efferent vesseles
drain  to the upper cirvical lymph
nodesthrough the jugulodigastric group.Tonsils & adenoid are immunologicaly
active between the age of 4-10 years & involute after puberty(9)

indication:

    Absolute

1.
Obstructive sleep apnea

2.
Suspected malignancy

3. Hemorrhagic tonsillitis

4.
Cardiopulmonary complications secondary to airway obstruction (e.g., cor
pulmonale,

5.
Tonsillitis causing febrile seizures

    Relative

1.
Recurrent acute tonsillitis according to  the following criteria:

? Seven episodes in 1 year

? Five episodes/year for 2 consecutive
years

? Three episodes/year for 3 consecutive
years

? Two weeks of missed school or work in 1
year

2.
Chronic tonsillitis refractory to antimicrobial therapy

? Peritonsillar abscess

3.
Tonsillolithiasis with associated halitosis and pain, unresponsive to
conservative measures

? Dysphagia due to tonsillar hypertrophy(10)

Contraindications


leukemia, hemophilia, agranulocytosis, uncontrolled systemic disease

(diabetes,
TB)


Relative Contraindications: cleft palate, acute infection(11)

Types of Tonsillectomy Procedures:

The
techniques of Tonsillectomy can be divided into 2 categories:

extracapsular
(total tonsillectomy, subcapsular) and intracapsular (subtotal,partial
tonsillectomy),or called tonsillotomy is some litritures  Extracapsular tonsillectomy involves
dissecting the tonsil in the plane between the tonsillar capsule and the
pharyngeal musculature, and the tonsil is removed as a single unit. Partial tonsillectomy,involves
removing  of most of the tonsil, but preserving
a rim of lymphoid tissue and tonsillar capsule

Preservation
of this rim of lymphoid tissue, as a “biologic dressing,” may promote recovery,
with lower hemorrhage rates and better recovery of diet and activity compared
with traditional monopolar tonsillectomy techniques.The commonest  extracapsular techniques are  “cold” knife, monopolar electrocautery,
bipolar cautery & harmonic scalpel,while the commonest intracapsular
technique are bipolar radiofrequency ablation (also can remove the entire
tonsil),microdebrider & carbon dioxide laser(12)

According
to the latest survey of members of the American Academy of Otolaryngology and
the American Society of Pediatric Otolaryngology, electrocautery is the
preferred method for tonsillectomy by roughly 55% of Otolaryngologists.
Coblation tonsillectomy is estimated to be the preferred method by 20%–25%, cold
steel techniques by 10% and other techniques including microdebrider partial
tonsillectomy by the remaining 10%. Although popular, the electrocautery
technique has its drawbacks as it has been shown to be a more painful surgery
than cold techniques, due to the additional thermal injury inflicted upon the exposed
musculature. Recently, there has been increasing interest in performing a
partial tonsillectomy, or tonsillotomy, to maintain the tonsillar capsule and
reduce postoperative pain and bleeding. As with every surgical technique,
intracapsular tonsillectomy also has its drawbacks. Large case series have
shown that tonsillar regrowth occurs in about 0.5%–6% of patients with a
smaller percentage requiring completion tonsillectomy. The operation takes
several minutes longer than electrocautery tonsillectomy, which adds to the
surgical costs. Intraoperative blood loss is greater but appears to not be
clinically significant. The role of intracapsular techniques for managing
children with recurrent tonsillitis is still unproven though initial studies are
encouraging for this indication.(13)

 The conventional
techniques are commonly used in most hospitals worldwide because they do not
require any expensive machines(25)

Cold
steel  tonsillectomy

The
most common method of ‘cold steel’ tonsillectomy is the dissection technique (Figure
96.2). In this, the tonsil is retracted medially, the mucosa overlying the
tonsil capsule incised and the plane of loose areolar tissue between the tonsil
and the pharyngeal musculature dissected with steel dissectors, gauze or cotton
wool until the tonsil is fully mobilized (Figure 96.3). Blood vessels traversing
the plane of dissection are dealt with either by ligature or diathermy as
required. (14)

After
removal of tonsils  tonsil,the  bleeding  from the from the lower pole is controled
either by mechanical methods (sanare or ligation) (15)An
alternative method of ‘cold steel’ tonsillectomy
is the guillotine technique, whereby the tonsil
is amputated using a specially designed guillotine
device and haemostasis, secured as necessary by one
of the above methods. Of these two techniques, traditional
dissection remains the most frequently used. (14)

Advantages
and disadvantages of the techniques

there is argument 
regarding the benifit of different tonsillectomeis technique.some
studeis assume that the intracapsular technique result in less post operative
pain in addition low risk of tonsil regrowth.for the extra capsular
technique,cold knife technique associated with less posoperative pain compared
with an electrocautery which is faster & has less  loss of intraoperative blood.it is unkown
which technique has the lowest post operative bleeding rate the available data
suggest that  there is no variation in
the bleeding rates between different techniques(12)

Post-tonsillectomy bleeding :

tonsillectomy
is one of the most common surgical procedure performed in the world, various
techniques have evoled over the years but the percentage of PTB is still almost
the same & concedered as the most significant complication(16) The risk of bleeding is present even when the operation
is done by the best surgeons in spite of using the most meticulous haemostasis
techniques(17) Haemorrhage’
was defined as a bleed that prolonged the patient’s hospital stay, required
blood transfusion,
a return to the operating theatre, or in the case of ‘secondary’ haemorrhage readmission to hospital(18)

 

Post-tonsillectomy bleeding  is divided into two types: primary bleeding  occurring within 24 hr  and secondary bleeding  occurring at any point more than 24?h after
tonsillectomy . The overall bleeding  rate is around 4.5% , with reported rates
of 0.2–2.2% for primary and  0.1–3.5% for
secondary bleeding. (19) . The mortality has been reported to be between 1 per 1100 and 1
per 16000 (20)primary bleeding is
more serious than the secondary one because  it usually occur when the pateint
responsiveness & protective air way reflexes are attenuated  by post anesthetic or narcotic effect,further
more ,the 1ry bleeding  is uasually more
brisk & profuse than secondary one(21) primary
bleeding is usually related to operative technique,(22)

 inadequate hemostasis
during the surgery(19)early loss of spasm of the blood vessels in the tonsillar
fossa, & insuficient blood clotting(22) Secondary bleeding  is associated with detachment of the crust
from the site of the removed tonsils.(19) &
avoiding  advice on postonsillectomy deit (22) risk factors generally associated with PTB
include  age sex, previous hx of
preitonsillar abscess,smooking,HT, use of NSAID ,& season when the op is
performed(22)

Risk factors for postoperative bleeding

Age
The age of patients  is usually consedered a major risk factor for
the occurrence of bleeding, the older patients being at higher risk   (19)

Sex
There is a discrepancy concerning sex as a risk
factor for postoperative bleeding. Some authors found a positive correlation
for male patients being at higher risk  and others did not   (19)

Operationtechniques
operative techniques have been investigated in more detail,
finding a statistically significantly higher or lower postoperative bleeding
rates for different operative techniques ? for example, bipolar diathermy
technique shows higher bleeding rates in comparison with cold steel dissection technique(19)

 Preoperative hemoglobin level and anemia

There were no significant statistical difference regarding the
preoperative hemoglobin level in the occurrence of post-tonsillectomy bleeding.

Postoperative infection of tonsillar fossa

A study from 2007 showed that postoperative infection of the
tonsillar fossa is not a risk factor for secondary bleeding ,but  another study foud a positive relationship
between preoperative bacterial colonization of the tonsillar fossa and
postoperative bleeding, recommending use of
antibiotics . However, prescribed antibiotics did not reduce the risk for
post-tonsillectomy bleeding in general(19)

Mechanism of hemostasis

There are two main components of hemostasis. Primary
hemostasis refers to platelet aggregation and platelet plug formation.
Platelets are activated when they  are exposed to subendothelial matrix, and as a result they adhere to the site of injury and to
each other, plugging the injury. Secondary hemostasis refers to the deposition
of insoluble fibrin, which is generated by the proteolytic coagulation cascade.
This insoluble fibrin forms a mesh that is incorporated into and around the
platelet plug. This mesh serves to strengthen and stabilize the blood clot.
These two processes happen simultaneously (23).
hemostasis  by suture ligation is
thought  to  be initiated after tonsillectomy by 1ry
hemostasis,on the other hand  hemostasis
by snare technique is thought to be initiated after tonsillectomy by crushing
(2ndry hemostasis) (24)