**4. General technique**

## **4.1 Exposure**

162 Otolaryngology

2. Cardiopulmonary complications secondary to airway obstruction (e.g., cor pulmonale,

3. Tonsillolithiasis with associated halitosis and pain, unresponsive to conservative

The indications for tonsillectomy have dramatically changed and are today more clearly defined. Geographical variations in the incidence of tonsillectomy are recognized and, although most of this variation may only reflect varying attitudes between physicians, there is little doubt that geographical variations in pathology are partly responsible5.In adults, the most common indication is recurrent acute tonsillitis5. However the most common indication in children is obstructive sleep apnea. Patients with a prior history of recurrent tonsillitis and prior peritonsillar abscess may be more likely to develop another peritonsillar

Tonsillectomy has been performed by otolaryngologists, general surgeons, family practitioners and general practitioners. However, in the past 30 years the recognition for the need of standardization of surgical technique resulted in a shift in practice patterns so that it

The first known removal of tonsils dates back to the first century AD, when Cornelius Celsius in Rome used his own finger to perform it6.The earliest description of the procedure was by Paul of Aegina in 625. The early instruments that were used for tonsillectomy were actually first developed for removal of the uvula. Phillip Syng invented what would become the forerunner for the modern tonsillotome.Not until the mid 18th century did Caque of Rheims performs tonsillectomies on a regular basis. Since then several different techniques

3. Suspected malignancy (asymmetric Tonsillar Hypertrophy) 4

 Five episodes/year for 2 consecutive years Three episodes/year for 3 consecutive years Two weeks of missed school or work in 1 year 2. Chronic tonsillitis refractory to antimicrobial therapy

Dysphagia due to tonsillar hypertrophy.

abscess and are candidates for tonsillectomy.

have been used for tonsillectomy.

is almost exclusively performed by the otolaryngologists.

1. Recurrent acute tonsillitis meeting one or more of the following criteria:

**1.2 Indications for tonsillectomy** 

alveolar hypoventilation)

5. Tonsillitis causing febrile seizures

Seven episodes in 1 year

Peritonsillar abscess

1. Obstructive sleep apnea

4. Hemorrhagic tonsillitis

**1.2.1 Absolute<sup>3</sup>**

**1.2.2 Relative<sup>3</sup>**

measures

**2. History** 

For a successful surgery, adequate exposure, of the oro-pharyn must be achieved. Also knowledge of the relevant anatomy and tissue tension is important. With the aid of a mouth gag, e.g, Boyle -Davis (Figure 2), the oropharynx is exposed. Dentition may be protected by a plastic or rubber athletic mouth guard and careful mouth gag placement. Care is taken not to allow the lateral anges of the tongue blade of the gag to scratch dental enamel. Protection of the mucosa from electrical and thermal conductivity is achieved by interposing a gloved nger between the instrument metal and the patient.13

Fig. 2. Open-sided mouth gag (Davis Mouth Gag).

A Review of Tonsillectomy Techniques and Technologies 165

The techniques of Tonsillectomy can be broadly divided into 2 major categories: extracapsular (total tonsillectomy, subcapsular) and intracapsular (partial tonsillectomy). Intracapsular is also known as "subtotal," and this procedure is referred to as tonsillotomy in some literatures. Extracapsular tonsillectomy involves dissecting lateral to the tonsil in the plane between the tonsillar capsule and the pharyngeal musculature, and the tonsil is generally removed as a single unit. Partial tonsillectomy, or tonsillotomy, involves removal of most of the tonsil, while preserving a rim of lymphoid tissue and tonsillar capsule in the most recent iteration of this older technique.16 Preservation of this margin of tissue, this "biologic dressing," may promote an easier recovery, with lower hemorrhage rates and better recovery of diet and activity reported in comparison with traditional monopolar tonsillectomy techniques.17,18The most common extracapsular techniques use a "cold" knife (sharp dissection), monopolar electrocautery, bipolar cautery (or bipolar scissors),or harmonic scalpel. Intracapsular techniques may use the microdebrider, bipolar radiofrequency ablation (which can also be used to remove the entire tonsil), and carbon dioxide laser. Either extracapsular or intracapsular tonsillectomy can be performed for the pediatric patient with obstructive sleep apnea, but only extracapsular techniques should be used for patients undergoing tonsillectomy as a result of tonsillitis or peritonsillar abscess. In addition, tonsils can be ablated using a laser or monopolar radiofrequency (somnoplasty)

A frequently used method for total tonsillectomy is the"cold"or sharp dissection technique. In this technique, the tonsil and capsule are dissected from surrounding tissue using scissors, knife, or t dissector (Figure 4) and the inferior pole is amputated with a

**6. Techniques and technologies** 

in a cooperative adult in a clinic setting.

**7. "Cold" knife** 

tonsil snare.

Fig. 4. Tonsil Dissector.

### **4.2 Surgical procedure**

The method anesthesia induction and patients' positioning is similar for most patients undergoing tonsillectomy, regardless of which technique is used to remove the tonsils. The patient is placed in the supine position and orally intubated.The endotracheal tube is taped to the patient's chin in the midline. Alternatively, some practitioners prefer to use a laryngeal mask airway.14,15The bed is turned 90°-180° so that the surgeon can sit or stand at the head of the bed. The patient is positioned at the edge of the bed, and a small shoulder roll is placed. Either a Crowe-Davis, McIvor, or Dingman mouth gag is inserted and expanded to keep the mouth open for the duration of the procedure.Tissue tension during complete tonsillectomy is achieved by strong medial traction of Allis clamps and torsion of the tonsils medially (Figure 3).

The tonsils are then removed using 1 of the techniques described later.

Fig. 3. Medial Traction on the Tonsil.
