Surgical Procedures of the PharynxBy

Dr. Asmatullah AchakzaiMBBS, DLO, MCPS, FCPS

Assistant Professor ENT Department

Bolan Medical College, Quetta

Adenoidectomy

Indications

• Adenoid facies

• Adenoids causing nasal obstruction and mouth breathing

• Septic focus: Otitis media, chronic rhinosinusitis

• Snoring

• Sleep apnea syndrome

Contraindications• Age < 3 years

• Bleeding disorders

• Acute infection

• Cervical spine pathology like unstable spine, Mucopolysaccharidosis, etc.

• Epidemic of poliomyelitis

Technique Types• Conventional: Curettage

• Endoscopic: Transnasal or transoral.

Steps of Adenoidectomy Curettage

• Orotracheal intubation.

• Position: Supine with extention of neck and atlantoaxial joint

• Place the Boyle-Davis mouth gag in position and the bipod stand is not

used

• Palpate the nasopharynx to confirm the size of adenoid with respect to the

choana and the septum.

• St. Clair Thomson's adenoid curette with/ without cage is used.

Steps of Adenoidectomy Curettage

• Insert the curette behind the soft palate till the posterior end of septum

is felt.

• Neck is flexed to avoid cervical lordosis thus preventing injury to the

anterior spinal ligament during curettage.

• Push curette backwards to trap adenoids inside the curette

• Curette with sweeping motion—Downwards and forwards

• Curettage is repeated till choanae one patient on palpation.

Complications

• Hemorrhage: Primary and reactionary. Secondary hemorrhage is very rare.

• Aspiration

• ET orifice injury: Otitis media with effusion, suppurative otitis media

• Injury to soft palate, posterior pharyngeal wall, etc. may occur.

• Injury to anterior longitudinal ligament causing subluxation of the

atlanto-occipital joint which may lead to quadriplegia.

Endoscopic Adenoidectomy

This is the recent development in the surgical management of adenoid hypertrophy. It was first

described by Nayak et al in 1998 for a case of Scheie syndrome (MPS I S) which is associated with

instability of the atlanto-axial joint and a traditional adenoidectomy is contraindicated as it needs proper

positioning of the patient. Comparative study between the conventional versus endoscopic technique

showed less blood loss and better post operative airway improvement as there is direct visualization and

clearance of the airway without injuring the eustachian tube orifice (Nayak et al 2005).

TonsillectomyTypes

• Dissection method

• Cryosurgery

• Monopolar cautery assisted tonsillectomy

• Bipolar cautery assisted tonsillectomy with or without aid of microscope

• Laser assisted tonsillectomy

• Coblation tonsillectomy (Radiofrequency ablation)

• Harmonic scalpel assisted tonsillectomy

• Microdebrider assisted tonsillectomy

• Guillotine tonsillectomy

Absolute Indications

• Respiratory obstruction

• Peritonsillar abscess (4-6 weeks)

• Sleep apnea syndrome

Relative Indications

• Chronic tonsillitis

Not responding to medical treatment

More than 4 to 6 acute tonsillitis per year

Associated with cervical lymphadenopathy

Acting as septic focus for rheumatic heart disease, glomerulonephritis,

arthritis, etc. (13-hemolytic streptococcus)

Failure to thrive due to excessively enlarged tonsil

Relative Indications

• Primary tuberculosis of the tonsil

• Carrier of diphtheria

• Tumors of tonsils

– Benign—Papilloma

– Malignant—Small tumors confined to tonsils

– Suspected lymphoma in unilateral tonsillar enlargement

Relative Indications

• Tonsillar cyst, Tonsillolith, embedded FB in the tonsils, etc.

• Surgical approach

– Elongated styloid process

– Resection of ossified stylohyoid ligament

– Glossopharyngeal neurectomy

– As part of Uvulo-palato-pharyngo-plasty (UPPP).

Contraindications (ABCDEF)• Active infection/Acute exacerbation, Aneurysm of internal carotid artery, Age

below three years, Active menstruation.

• Bleeding and clotting disorders

• Cervical spine pathology

• Diphtheritic tonsillitis. Drugs: Patients under aspirin, oral contraceptives, etc.

• Endemic of polio

• Failure to control systemic diseases like hypertension, diabetes, bronchial asthma, LRTI, etc.

Technique• General anesthesia is preferred, though few centers perform tonsillectomy under local

anesthesia in compliant patients

• Nasotracheal /orotracheal intubation with tube fixed in the midline.

• Rose position: Supine with extension of the neck and extension of the head at atlanto-

occipital joint

• Boyle-Davis mouth gag is placed after choosing the correct size tongue blade so as to retract

the base of the tongue and expose both the tonsillar fossae. Specialized tongue blade with

groove for the endotracheal tube (Doughty's tongue blade) may be used in case of

orotracheal intubation which avoids compression of the endotracheal tube.

Technique

• Draffin's bipod stand is used to stabilize the Boyle-Davis mouth gag in position.

• Superior pole of the tonsil is held using Dennis-Browne tonsil holding forceps or

Luc's forceps and the tonsil is gently pulled medially to facilitate retraction of the

tonsil from the anterior pillar and in showing a thin white line between the pillar

and the tonsil (loose areolar tissue plane).

• Incision is given along that line using a 11 number blade and the incision is

converted to a U shaped passing through the upper pole and the pillars.

Symptoms Cont…• Using a Mollison's tonsillar dissector with anterior pillar retractor, the tonsillar capsule is

exposed and the tonsil is dissected along the loose areolar cleavage plane till the inferiorpole of the tonsil is reached.

• Tonsillar scissors may be required to divide tough fibrous band attached to the tonsillarcapsule from the fossa. Fibrous band is divided close to the tonsillar capsule.

• Eve's tonsillar snare is applied with its loop around the inferior pole and the tonsillarattachment is divided.

• Hemostasis is achieved either by bipolar cautery or by catching the bleeder using astraight tonsillar hemostat and then replaced by Negus curved tonsillar artery forcepswhich helps in ligation of the bleeder. The silk knot can be carried to the site using aNegus ligature carrier.

Postoperative Care Lateral position: In the postoperative period the patient is placed in the

lateral position to avoid any aspiration.

Vital signs are monitored frequently. Look for tachycardia, weak and

rapid pulse and increased respiratory rate, blood pressure, fever, etc.

Look for frequent swallow reflex which if present may suggest bleeding

in the tonsillar fossa.

Oral or parenteral antibiotics and analgesics are given.

Cold feeds after 4 hours which helps in vasoconstriction.

Saline or dilute hydrogen peroxide gargles may be advised to keep the

operated site clean.

Maintain good hydration.

Complications (Immediate)

Primary and reactionary hemorrhage

Aspiration of blood/saliva

Injury to structures Teeth, lips, gums, palate, etc.

Injury to posterior pillars may cause change in speech and nasopharyngeal reflux

Pain throat with or without referred otalgia

Dehydration

Fever is not common and is usually related to local infection

Postoperative airway obstruction may occur because of uvular edema, hematoma,

aspirated material

Pulmonary edema

Secondary hemorrhage occurs usually on 5th - 7th day.

Complications (Delayed)

• Lingual tonsillitis (compensatory hypertrophy).

• Nasopharyngeal stenosis

• Velopharyngeal insufficiency

• Residual tonsillitis

Tonsillectomy Hemorrhage• Hemorrhage may be classified into primary, reactionary and secondary.

Primary Haemorrhage.

• This occurs during surgery often from the paratonsillar veins.

• This is often due to

–Poor selection of the case: (patient with acute attack of tonsillitis or

pharyngitis, bleeding disorders, hypertension or if. the patient is on

NSAIDS including aspirin, anticoagulant therapy and oral

contraceptives, etc.).

– Improper technique (dissection not in the proper cleavage plane,

injury to the superior constrictor muscles and paratonsilaar veins,

presence of tonsillar remnants and mucosal tags)

Tonsillectomy Hemorrhage Cont.…

• To stop primary hemorrhage is packed with wet gauze and wait for 5 minutes

till the bleeding and clotting time is over. This will stop the bleeding in most

of the cases.

• If bleeding persists, ligate/ cauterize the bleeding vessel.

Reactionary Hemorrhage

This occurs in the postoperative within 24 hours. Usually it occurs within 6 to

8 hours after the surgery.

This can be due to the following:

Failure to ligate all vessels

Slippage of sutures

Hypotensive anesthesia-BP returns to normal postoperatively

Increased arterial or venous pressure during recovery.

Clot in the fossa-Prevents contraction and retraction of the vessels and can

precipitate bleeding

Injured muscle may cause diffuse ooze after recovery from anesthesia.

Mismatched blood transfusion

Management

• Remove the clot and apply pressure with a small pack held in an artery forceps.

Usually the bleeding stops. Hydrogen peroxide gargle is helpful in removing the

clot postoperatively and is also a mild cauterizing agent. Vital signs should be

maintained. Treat hypovolemia and blood loss. If bleeding persists, shift patient to

operation theater and ligate/ cauterize the bleeding vessels.

Secondary Hemorrhage

• This is due to sepsis of the tonsillar fossa and usually occurs on 5th to 7th

postoperative day. Premature separation of the slough may precipitate this bleeding.

• Management - Start parenteral broad spectrum antibiotics including tinidazole or

metronidazole.

• Cold liquid diet

• General management is as for reactionary hemorrhage.

• In case of persistent bleeding, shift patient to operation theater and inter-pillar suturing may be

required in extreme cases.

Peritonsillitis and Peritonsillar Abscess (Quincy)

Definition

• Peritonsillitis is defined as an acute inflammatory process associated with

cellulitis involving the loose areolar tissue in the peritonsillar space which lies

between superior constrictor muscle and the tonsillar capsule. The resultant

spread of infection involving looser areolar tissue causing collection of pus

within the space is called quincy or peritonsillar abscess.

Etiology

1. Recurrent attacks of acute tonsillitis

2. Penetrating trauma or foreign body

3. Common in adults in the 2nd and 3rd decade and is rare in infants and

young children.

4. Dental infection like periodontitis

Etiology

5. Tonsillolith or cyst

6. Infectious mononucleosis

7. Leukemia and other causes of immunocompromised state.

8. Inflammation of accessory salivary tissue called Weber gland that is situated just

above the superior pole in the soft palate, has been recently implicated for.

Pathogenesis

Recurrent attacks of acute tonsillitis may cause crypta magna to be obstructed

leading to intratonsillar abscess and subsequent spread of infection to the peritonsillar

space. Though this has been well accepted in the past, recent studies shows that the

supratonsillar space of the soft palate, immediately above the superior pole of the

tonsil and the surrounding muscles, especially the internal pterygoids can be site of

initial infection. Group A beta-hemolytic streptococcus is frequently isolated.

Clinical Features Symptoms

• General: Fever, chills and rigor, malaise bodyache and toxic features are often present.

Local

1. Acute severe unilateral odynophagia

2. Referred otalgia

3. Neck pain

4. Trismus due to pterygoid muscle spasm

5. Muffled speech (hot-potato speech)

6. Dribbling of saliva

Signs

• Anterior pillar cannot be distinguished easily from the rest of the tonsils due to

edema and swelling of the overlying mucosa

• Tonsil is pushed medially and downward due to involvement of supratonsillar

space.

• Involved tonsil is often congested and follicles/ membrane may be present at

the crypts

Signs• Uvula is congested, edematous and deviated to the opposite side

• Mucosa is edematous.

• Trismus causes difficulty in further examination.

• Tender, enlarged, discrete cervical lymphadenitis may be seen.

• If untreated, the abscess may rupture causing purnilent fetid discharge.

Differential Diagnosis

• Peritonsillar cellulitis (Peritonsillitis)

• Parapharyngeal abscess

• Parapharyngeal neoplasm

• Severe tonsillitis

Investigations

• Throat swab for culture and sensitivity

• Complete blood picture

• Rule out diabetes mellitus

• CT imaging if there is suspicion of a parapharyngeal abscess

Treatment• IV antibiotics and analgesics and analgesics.

• If dysphagia is severe: Hospitalization IV fluids

• Wide bore needle aspiration

• Incision and drainage: This is done using quinsy knife or an ordinary Hard -Park

knife with only about a centimeter of the t! of the knife exposed and the rest

covered by a plaster to prevent deep penetration of the knife.

TreatmentA stab incision is given at one of the following points:

1. Imaginary horizontal line drawn at the base of the uvula which, intersects at a

vertical line drawn along the anterior pillar. Incision is given at the point of

intersection of these two lines.

2. At the point of maximum bulge in the supra-tonsillar area.

• Hot (abscess) tonsillectomy: Some people advocate tonsillectomy during the

active abscess stage. tonsillectomy after 6 weeks.

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