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Tonsillectomy, Adenoidectomy, and Uvulopalatopharyngoplasty
Nilesh R. Vasan and K. J. Lee
Tonsillectomy and adenoidectomy are common procedures performed by otolaryngologists. Subsequently, a multitude of surgical methods have been developed that achieve the same goal. One of the most important factors leading to a satisfactory outcome is counseling of the patient or parents regarding the postoperative period, that is, pain management, otalgia, importance of continued hydration and eating, and descriptions of the appearance of the tonsillar fossa during healing. All patients must be questioned regarding bleeding, and any patient with a suspected or confirmed bleeding disorder must be investigated and evaluated by a hematologist prior to surgery.
- Following induction of general anesthesia (GA), the patient is usually intubated using a standard orotracheal tube. The procedure can be performed using a laryngeal mask; however, because of the size of the mask and tubing, the operation can be more cumbersome. Also, as the larynx is not entirely secured, this form of airway would be unwise, especially with cold dissection techniques (i.e., risk of blood aspiration).
- A small towel roll under the shoulder helps achieve the desired position (Rose position). A Boyle-Davis or Crowe-Davis mouth gag is then inserted. The blade length is important because too short a blade can occlude the tube and provide poor visualization. An overly long blade in a child can also cause injury to the epiglottis, risking possible epiglottitis.
- Inserting the mouth gag correctly requires the orotracheal tube to be centered on the tongue. This is best achieved by positioning the tube in the midline at the tongue base. For a right-handed surgeon, using the nondominant hand, the thumb is placed on the tube against the lower incisors. The middle and ring finger retract the upper left molars to open the mouth for gag insertion. In this manner the tube should not move. The gag is inserted in a similar fashion, as one would intubate the patient. Once in place, the gag is opened, ensuring that both the upper and lower lips are not caught in the retractor.
- Excessive retraction of the gag can dislocate the temporomandibular joint, and the surgeon must be cautious of this. Following suspension of the mouth gag, the surgery may proceed. Avoid overextension of the neck, which places the teeth at risk for injury. Extra caution should be exercised in patients with cervical spine problems.
- Some surgeons may inject the tonsillar fossa with local anesthetic (LA) with epinephrine as preemptive analgesia, as well as aiding dissection hydrostatically. A large Yankauer sucker is a prerequisite for this operation.
- A blunt instrument such as a Dennis-Brown or sponge forceps is preferable to retract the tonsil compared with an Allis forceps, which unnecessarily traumatizes the tonsil. This is important in cases where the tonsil is friable (e.g., Epstein-Barr virus tonsillitis) or where accurate pathological assessment is required (e.g., malignancy).
- The key to tonsillectomy, whichever technique is used, is getting into the correct plane. This is the potential space between the tonsillar capsule and constrictor muscle. Failure to dissect in this plane leads to tonsillar remnants as well as a more bloody operation.
- When retracting the tonsil medially, the lateral aspect of the tonsil can be seen submucosally. It is in this area within the upper pole that injection of LA is performed using an aspiration injection technique. Five minutes or so should elapse prior to tonsillectomy. The tonsil is retracted throughout the procedure.
- Using Metzenbaum/tonsillectomy scissors, the mucosa at the upper pole of the tonsil is incised. Using the lower blade of the scissors, the mucosa of the anterior pillar medially over the tonsil is divided. Using the upper blade of the scissors, the posterior pillar mucosa is divided in a similar fashion. This frees the tonsil from its mucosal attachments, which makes dissection easier.
- To obtain entry into the correct plane, the scissors are turned perpendicular to the tonsil plane and inserted just lateral to the lateral tonsillar border. The scissors are then opened, and a relatively bloodless plane should be seen. With the scissors still open within this space, the forceps is repositioned with one blade placed within this newly developed space (i.e., clasping the upper tonsillar pole).
- The tonsil is then retracted toward the lower pole of the contralateral tonsil, and in some cases considerable dissection can be performed with this move alone. When dissecting, the tonsil must be regrasped occasionally to maintain traction.
- A Gwynne-Evans or similar dissector is used to reflect the constrictor muscle off the tonsil. Care should be taken not to penetrate the constrictor muscle with the dissector. Large tears should be reapproximated with chromic suture. Dissection should not be taken into the lingual tonsils; otherwise, troublesome hemorrhage may ensue.
- The lower pole can either be divided with tonsil snare or clamped and then divided with the lower pole being secured using a silk tie or suture. The tonsil fossa is packed, and the contralateral tonsillectomy is performed.
- Hemostasis can be achieved using 1–0 silk tie with the aid of an ear, nose, and throat (ENT) or chest Negus and a knot pusher or with bipolar diathermy. In cases with persistent arterial bleeding not controlled with diathermy, a silk tie or suture is required. Another suture used is a 2–0 plain gut with no. 863 needle. If a suture ligature is used, one must be sure that the needle is strong enough not to break and become embedded in the tonsillar fossa adjacent to the carotid artery.
- The nasopharynx must be suctioned following completion of the procedure to aspirate clot, which is at risk for occluding the airway in a semicomatose patient. The gag must be released and reopened to reexamine the tonsillar fossae for bleeders, which had been temporarily tamponaded by the open gag.
