This chapter serves to review pertinent anatomy, surgical technique, and perioperative considerations for both intracapsular and extracapsular tonsillectomy and for adenoidectomy.
22 Tonsillectomy and Adenoidectomy
Tonsillectomy and adenoidectomy (T&A) is one of the most common procedures performed in pediatric patients. These procedures may be performed alone or in combination. Adenoidectomy may be considered for many different indications including nasal obstruction, recurrent or chronic rhinosinusitis, chronic otitis media with effusion, hyponasal voice, mouth breathing, and to effect change on dentofacial development. T&A was often recommended for infectious reasons (recurrent tonsillopharyngitis and streptococcal tonsillitis) but with increased availability of oral antibiotics in liquid form, the number of children undergoing T&A began to decrease in the 1980s. With the decline in frequency of performing T&A for infectious causes, a new diagnosis began to emerge as a surgical indication, obstructive sleep apnea (OSA). OSA from adenotonsillar hypertrophy was first reported in 1987. Tonsil surgery has undergone change, and the concept of partial tonsillectomy, tonsillotomy, subcapsular tonsillectomy, or intracapsular tonsillectomy has been recommended over the past 20 years.
Advances in technology have provided otolaryngologists with multiple options for instrumentation to perform both techniques of tonsillectomy and adenoidectomy. Adenoidectomy can be performed with curettage, suction electro cautery, a microdebrider, and coblation. Complete tonsillectomy can be performed with cold dissection, electrocautery, coblation, plasma blade, lasers, microbipolar dissection, and other techniques. Partial tonsillectomy has evolved from removing enough tonsil tissue to the level of the tonsil pillars to a more thorough dissection removing most of the tonsil tissue (intracapsular tonsillectomy) and may be performed with a microdebrider, coblator, or laser.
22.2 Preoperative Evaluation and Anesthesia
A preoperative bleeding questionnaire (▶ Fig. 22.1) is used to determine whether blood work is necessary prior to surgery. If the questionnaire is positive, then a complete blood count (CBC) with platelet count and coagulation studies including a partial thromboplastin time (PTT) and prothrombin time (PT) are ordered. If the preoperative questionnaire is negative, then blood work may not be necessary.
When evaluating a child for OSA, the history and physical exam are paramount. If the exam matches the history in an otherwise healthy patient, then a sleep study may not be necessary. Indications for polysomnography include children that are obese, those with craniofacial abnormalities, children with Down syndrome, children under the age of 2, or those in which the examination does not match the history. In addition, there are situations where the parents desire a formal sleep study to confirm the diagnosis prior to contemplating surgery.
In children with Down syndrome, a C-spine X-ray to evaluate the atlanto-occipital area prior to surgery is important to prevent injury.
Communication with the anesthesia team is imperative. Narcotic usage intraoperatively and postoperatively in children with obstructive sleep apnea needs to be considered with extreme caution. Methods to prevent intraoperative airway fires should be implemented with the oxygen percentage throughout the surgical procedure below 29% if electrocautery is used. Dexamethasone (0.5–1.0 mg/kg, up to 10–12 mg/dose) is given once the intravenous has been started. Antibiotics are rarely indicated with exceptions for an acute infection, Quinsy tonsillectomy, or in children with pediatric autoimmune and neuropsychiatric disorders associated with streptococcal infection (PANDAS).
22.3 Surgical Technique
Various techniques are available to perform this surgery; we will discuss suction Bovie ablation here followed by powered microdebrider adenoidectomy.
Patient is placed under general anesthesia and after intubation, the endotracheal tube (ETT) is secured in midline to lower lip when tonsillectomy is also performed (▶ Fig. 22.2).
When adenoidectomy is performed alone or in combination with turbinate surgery, a laryngeal mask airway (LMA) may be used (▶ Fig. 22.3).
Topical oxymetazoline is placed in each nasal cavity to decrease nasal congestion prior to placing the red rubber catheters (▶ Fig. 22.4).
Place the patient in the Rose position with a shoulder roll to extend the neck and a head drape with blue surgical towel to protect the face and eyes (▶ Fig. 22.5).
Visualize adenoid tissue with angled mirror; define limits of adenoid tissue and avoid injury to torus tubarius bilaterally and vomer superiorly (▶ Fig. 22.6).
Bend suction Bovie cautery with gentle ~90 degree curve 2 to 3 cm from distal tip.
Setting between 30 and 35 watts.
Bury tip of suction cautery in tissue and coagulate until tissue turns white and ablates away.
Begin at choana and continue inferiorly.
Alternatively, the microdebrider with the RADenoid 40 blade may be used to remove adenoid tissue. It is set to 1,500 rpm on oscillating mode. Additional exposure is obtained with gentle retraction of the left clamp with your fourth finger further elevating the soft palate (▶ Fig. 22.7). Always be aware of the angle of the nasopharynx when using the debrider (▶ Fig. 22.8). Assure the dissection inferiorly is not too deep, especially in the lateral aspect where there can be excessive bleeding. An advantage of using the microdebrider is to be able to leave an inferior ledge of adenoid tissue to reduce postoperative velopharyngeal incompetence. When removing the microdebider blade from the oral cavity, cover the opening of the blade with the mirror to avoid suction damage to the uvula and soft palate (▶ Fig. 22.9). After microdebriding adenoid tissue, pack the nasopharynx with one to two tonsil sponges soaked in oxymetazoline. Suction cautery on low setting of 20 watts to obtain hemostasis. Here is an example of a nasopharynx a year after microdebrider adenoidectomy (▶ Fig. 22.10).