5 Submucous cleft palate (Covert) Abnormal nasal speech,Bifid uvulaThin strip of mucosa in the middle of roof of mouthNotch at the back of hard palate.
6 Adenoidectomy - Procedure Anaesthesia – General AnaesthesiaIf combined, Adenoidectomy before Tonsillectomy
7 Position – Rose’s position Supine with head extended by placing a pillow or sandbag beneath the shoulders.Advantage –Larynx lies at a higher level than oral cavity – no risk of aspiration.Excellent exposureBoth hands of surgeon are free.Hyperextension is avoidedMakes cervical vertebral bodies prominent-Damage to ligaments or cartilages of vertebral spine or bodies -> Grisel’s syndrome
8 Grisel’s syndrome Non traumatic subluxation of atlanto axial joint Results from any condition that results in hyperaemia and pathological relaxation of the transverse ligament of the atlanto-axial joint.Due to infection in the periodontoid vascular plexus that drains the region->paraspinal ligament laxity.Presents with persistent neck pain and torticollis 1-2 weeks following surgery.More common in Down’s syndrome patientsX-ray and CT of Cervical spine confirms diagnosis.Treatment: Cervical immobilisation , analgesics and antibiotics. Arthrodesis in intractable cases
9 Technique of Adenoidectomy The surgeon stands behind the patient.Boyle-Davis mouth gag is inserted, opened and held in place by Draffin’s bipod standPalate is palpated to exclude a submucous cleft palate.The soft palate is retracted by a suction catheter introduced through the nose, and pulled out of the oral cavity.The adenoid is palpated with a finger.
10 St Clair Thomson adenoid curette with guard is introduced into the nasopharynx above the upper end of adenoid tissue, “held like a dagger”With a downward and forward sweeping movement, adenoids are shaved off.A smaller sized curette is used to curette the adenoids around the choana and the Eustachian cushionsNasopharynx is packed with gauze packs for a few minutes for haemostasis.
11 Other techniques of Adenoidectomy Suction coagulator/diathermyEndoscopic transnasal or transpalatal adenoidectomy with microdebriderCoblator plasma field device
12 Postoperative care The patient is kept in lateral position Kept nil orally until fully recovered from GA (4-6 hours).Monitor vitalsWatch for bleeding: Earliest sign-”Frequent swallowing”Oral antibiotics and analgesics
15 Tonsillectomy-Indications Absolute Indications:Obstructive symptoms and Obstructive sleep apnoeaMalignancy or suspected malignancyRecurrent peritonsillar abscessTonsillitis causing febrile seizures in childrenRelative Indications:Recurrent tonsillitis:>= 7 episodes in 1 year>=4 episodes per year for 2 consecutive years>= 3 episodes per year for 3 consecutive yearsHalitosis due to chronic tonsillitisTonsillolithsTonsillar cystsDental and orofacial abnormalitiesDipheria carriersRheumatic fever and Acute glomerulonephritis
16 Tonsillectomy as part of another procedure Excision of elongated styloid process (Eagle syndrome) – Nagging throat pain and a palpatory finding in the tonsillar fossa. Confirmed by palpation and injection of anaesthetic.Glossopharyngeal neuralgiaUPPP (Uvulopalatopharyngoplasty)or LAUP (Laser-assisted uvulopalatoplasty) or CAUP (Coblation assisted uvulopalatoplasty)
17 Contraindications Bleeding disorders Cleft palate or submucous cleft palateVelopharyngeal insufficiencyAcute infectionUncontrolled systemic diseaseAnaemiaExtremes of age
18 Procedure Anaesthesia: General anaesthesia Position-Rose’s position-supine with head extended by placing a pillow or sandbag under the shoulderOperative techniquesDISSECTION AND SNARING -> ClassicalDiathermyCoblation tonsillectomyUltrasonic dissectionLaser tonsillectomyCapsulotomy techniquesGuillotine method (Ancient)
19 DISSECTION AND SNARE METHOD Boyle Davis mouth gag is inserted, opened and held in position with Draffin’s bipod standUpper pole of tonsil is held with tonsil holding forceps and pulled mediallyMucosa is incised with blunt scissors, knife, forceps or diathermy at the point where it reflects from tonsil to anterior pillar. Incision is continued inferiorly towards base of tongue.The tonsil is separated from its bed by blunt dissection, upto the lower poleThe plane of dissection is the loose areolar tissue separating tonsil from its bed.
20 Once lower pole is reached, a tonsillar snare is passed over the tonsil holding forceps, placed over the tonsil, threaded down to the lower pole, tightened to crush the pedicle, and the tonsil is removedGauze packs are kept in the tonsillar fossaBleeding points are looked for, and bleeding arrested with non absorbable sutures
22 Postoperative care Patient is nursed in the lateral position Kept nil orally until fully recovered from GA (4-6 hours).Monitor vitalsWatch for bleeding: Earliest sign-”Frequent swallowing”Ice cold fluids and ice cream given on the first dayOral antibiotics and analgesics
23 Complications of Tonsillectomy HEMORRHAGEPrimaryDuring the surgeryControlled by pressure packing, ligation, cauterisation
24 Formation of a blood clot or Dislodgement of blood clot from lumen ReactionaryWithin 24 hours of surgeryCAUSES OF REACTIONARY HEMORRHAGE (VIVA):Formation of a blood clot or Dislodgement of blood clot from lumenVasodilation of blood vesselPostoperative rise in blood pressureIncreased venous pressure by coughing or retchingSlipping of ligature
25 Management of Reactionary haemorrhage: Blood is cross matchedTonsillar fossa is inspected and clot removedPressure with a swab soaked in 1:1000 AdrenalineAdministration of hemostatic agents (Ethamsylate, Tranexamic acid)May require taking to the operation theatre and ligation under General Anaesthesia.
26 Most dangerous form of haemorrhage because: It may be missed (Patient may still be under the effect of GA)It may cause fatal aspirationLarge hemorrhages may require ligation or electrocoagulation under GA. Two GAs at a short interval is dangerous.Secondary haemorrhage (>24 hours – 2 weeks)Cause: Infection of the granulating tonsillar bedTreated with Antibiotics
27 OTHER COMPLICATIONS OF TONSILLECTOMY: Injury to:Temporo-mandibular jointLips and commisures of mouthTongue, uvula, soft palateVery rarely Glossopharyngeal nerve, pharyngeal venous plexus, carotid sheathGrisel syndrome (Non traumatic atlanto axial dislocation)Aspiration of blood-> Pneumonia, collapse of lung, or lung abscess
28 Hematoma and oedema of uvula Referred earacheVelopharyngeal insufficiencyTonsillar remnants