Tonsillectomy and Adenoidectomy

DefinitionExcision of the faucial (palatine) and nasopharyngeal tonsils (adenoids).

DiscussionT & A is routinely performed to excise chronically infected tonsils and adnoids.The faucial tonsils and the nasopharyngeal tonsils are aggregates of lymphoid tissue in the posterior pharynx and nasopharynx; the tissue hypertrophies secondary to infection (usually). In children, tonsillectomy is relatively simple, whereas in adults, because of chronic infections and the resultant long-standing fibrosis, the procedure is more difficult. The adenoids are usually atrophied by age 15; hence, adenoidectomy in adults is uncommon.Whereas the use of antibiotics has reduced the number of tonsillectomies performed for infection-related indications, T & A are also performed to relieve pediatric snoring and sleep apnea secondary to airway obstruction. Special preoperative teaching and orientation (video) is provided by many facilities for the pediatric patient anticipating T & A; this often results in reduced anxiety and increased cooperation of the pediatric patient. Traditional T & A technique may use a cold knife (scalpel), scissors, or wire snare excision of tonsils, alone or in combination with low-energy monopolar electrosurgery, bipolar diathermy, or laser (CO2, KTP, or Nd:YAG) for the extracapsular tonsillar excision (all tonsillar tissue is excised, including the capsule). When monopolar electrosurgery is employed, the tissue is dessicated to effect cauterization, causing increased postoperative pain.The laser is less injurious to surrounding tissues than electrosurgery, as the size of the area and the amount of energy used can be better controlled. Either of these extracapsular techniques exposes throat muscles, large blood vessels, and nerves to bacterial toxins that increase pain and swelling. Intracapsular T & A uses the microdebrider, radio-frequency (RF) coblation, or the Harmonic Scalpel to excise tissues more precisely. When each of these techniques is employed, the result is decreased pain and morbidity postoperatively; the patient returns to his/her usual activities sooner. The surgeon considers the cost, the amount of postoperative pain, the possibility of complications, and his/her familiarity with the technology and instrumentation. Complications of T & A include swallowing difficulties, vomiting, fever, ear and throat pain, and hemorrhage.

ProcedureTraditional cold knife T & A is described.The operating microscope may be employed.The mouth is retracted and held open with a self-retaining mouth gag.The tongue is depressed with a tongue blade.A soft catheter (e.g., Foley) may be passed via the nose into the nasopharynx and grasped orally to retract the soft palate and enhance exposure. Adenoidectomy is performed with an adenotome, adenoid curette, or punch; a dental-type mirror aids visualization. In tonsillectomy, the tonsil is grasped, and the mucosa is dissected free, preserving the posterior tonsil pillar.The capsule of the tonsil is separated from its bed.A forceps is passed through the loop of the snare, and the tonsil is seized.The snare loop is passed over the free portion of the tonsil, and the tonsil is amputated. During any of the approaches, great care is taken during intraoperative suctioning not to dislodge the endotracheal tube, while preventing blood from being aspirated or from entering the stomach.The tonsillar fossa is usually packed with a tonsil sponge. Bleeding may be controlled with electrosurgery, ties (slip knot), and/or by suture ligature. The procedure is repeated on the contralateral tonsil.

Alternate ApproachesLaser T & A may be performed utilizing a contact CO2 or the Nd:YAG laser, [e.g., SLT Contact Laser™ system (Surgical Laser Technologies)]; tissue is vaporized.The laser may be handheld, or a laser beam or fiber may be directed through a microscope or endoscope. T & A by micro debrider, a powered rotary shaving device [e.g., Straightshot® M4 (Medtronic)]

that uses interchangeable outer cutting tubes, and special blade (e.g., RADenoid®) with continuous suction; better visualization of the operative area is permitted. Harmonic Scalpel T & A utilizes high-frequency ultrasonic vibration (e.g., ultrasound power for oscillating vibration) of the titanium blades to simultaneously cut and coagulate tissue, thereby reducing blood loss. The Harmonic Scalpel offers precise cutting with minimal thermal damage. (RF) coblation T & A uses bipolar radio frequency low-level l energy delivered by probe; the probe is applied to the tonsillar tissue in a saline medium. This method shrinks the tissues in the nasopharynx, improving airway patency. Multiple treatments may be required to achieve the desired results. RF coblation causes shrinking of tonsillar tissue using low-level heat (140_ to 185_F, 60_ to 85_C) from radio- frequency energy.After 8 to 12 weeks, the residual tissue is reabsorbed. As bipolar RF coblation reduces tonsillar tissue size utilizing a lower output of energy; there is no open wound and the patient has less discomfort. This modality is being used with increasing frequency. Transoral or transnasal endoscopic adnoidectomy may be performed in conjunction with electrosurgical, laser, or microdebrider instrumentation. The endoscopic approach is preferred overcold knife adnoidectomy, as it more completely enables elimination of adenoidal tissues that may obstruct the eustachian tubes.Preparation of the PatientThe patient may be a child or an adult; however, children do not receive a local anesthetic. For adults, the position of the patient usually depends on the type of anesthesia administered. Most adults receive local anesthesia while children receive general anesthesia. When local anesthetic is employed, the patient is placed in a semi-Fowler’s (sitting) position for the local injections and may stay in this position or may be placed in supine position for the surgery. For semi-Fowler’s (sitting) position, the patient is supine with knees over the lower break of the table.The head of the table is raised from the middle break.The foot of the table is lowered; a padded footboard supports the feet.The arms may be placed on the patient’s lap on a pillow and secured with softly padded restraints. The safety strap is secured over a blanket above the knees. For the special nursing interventions to consider regarding the child as patient, see Pediatric General Information, p. 978.When general anesthesia with endotracheal intubation is administered (to all children and some adults), the patient is supine, positioned at the top edge of the table; the head may be placed on a padded, foam, or gel headrest. A rolled towel is placed under the shoulders to gently extend the neck. The arms may be restrained using softly padded restraints secured to the table for either the adult or child (depending on the size of the child), or one arm is padded and restrained and the contralateral arm is secured on a padded armboard. A pillow may be placed under the knees to avoid straining low back muscles, or the table may be flexed for comfort (adults). For both positions [i.e., semi-Fowler’s (sitting) and supine] all bony prominences and areas vulnerable to skin and neurovascular trauma or pressure are padded. When monopolar electrosugery is employed an electrosurgical dispersive pad is placed (e.g., under the shoulder).

Skin PreparationT & A is considered a “clean” procedure, and there is no skin prep. The best possible technique is employed to prevent infection.

DrapingA sheet is draped over the patient’s body. Use of a head drape is optional; for head drape, see Draping, Submucous Resection of the Nasal Septum, When the operating fiber-optic microscope is used, it is not draped.

EquipmentPadded, foam, or gel headrest, e.g., donut, optionalPadded upper-extremity restraints and additional padding (e.g.,

foam padded cups on elbows and heels), as necessary to avoidpressure injuryShoulder roll, e.g., rolled towel, optionalPadded footboard and pillow (sitting position, adults)SuctionBlade, (1) #12ESU, monopolar or bipolar (monopolar for electrosurgical suction),optionalDiathermy unit for bipolar bayonet forceps, optionalFiber-optic headlight (may contain camera) and fiber-optic lightsource (e.g., Xenon 300 W)Operating fiber-optic microscope, e.g., Zeiss, optionalLaser, CO2 or SLT Contact Laser system and laser adaptor formicroscope (use all laser safety precautions)Sitting stools (when microscope is used)Fiber-optic light source (e.g., Xenon 300 W) for fiber-optic endoscope,optionalMonitor, optionalCamera console, optionalVCR, optionalCD burner, optionalPrinter, optionalVideo attachment to the microscopeMicrodebrider console with foot pedal, e.g., Medtronic XPS3000, optionalHarmonic Scalpel generator with foot pedal (or hand activation),optionalRF coblation generator, optional

InstrumentationTonsillectomy and Adenoidectomy trayElectrosurgical suction (with side port) and cord (optional), Beckmanadenotomes, Guggenheim forceps, Luc’s forceps, andpilar retractorDiathermy bipolar bayonet forceps and cord, optionalRF coblation probe and cord (radio frequency)834 Chapter 27 Otorhinolaryngological (ENT) Surgery

Alternate technology uses adapted instrumentation similar to thatused in the open procedureLaserAdaptor for endoscope, laser (e.g., Nd:YAG) fiber, cord, and specialinstrumentationMicrodebrider (shaver)Handpiece, oscillating blade set with removable interchangeable 12_and 40_ blades, outer cutting tubes, and an RADenoid blade (4.5-mm blade for adults and 4.0-mm blade for children), Hurd dissector(7 mm), pilar retractor (11 mm), and left and right stabilizersRF CoblationRadio-frequency probe and cordHarmonic Scalpel (Ultrasonic)Cord, handpiece, and open or endoscopic instrumentationEndoscopicVideo coupler and laser adaptor, rigid Hopkins 0_ and 30_ angled,ebonized rhinoscope and cord, and special instrumentationfor that approach

SuppliesMedicine cups (2), paper labels, and indelible marking penLocal anesthetic, e.g., lidocaine/xylocaine 1% with epinephrine1:100,000Control syringes (2) and needles, e.g., 27 gauge _ 11/2′′and spinalneedle, e.g., 27 gaugeBasin setSuction tubingBlade, (1) #12Needle magnetElectrosurgical pencil with extender, cord, holder, and scraperFoley catheter for retractionTonsil spongesPlain suture (usually), 2–0 ties or 2–0 swaged on tonsil needleMicrodebrider dual tubing for irrigation and suction, or polyethyleneIV tubing connected to bag of irrigation solution andsuction tubing