**1.1 Anatomy**

160 Otolaryngology

Wittmann, T. and C. M. Waterman-Storer (2001). "Cell motility: can Rho GTPases and

The circular band of lymphoid tissue within the pharynx consisting of the adenoids, the palatine tonsils (Figure 1), and lingual tonsils is known as Waldeyer's ring. The palatine tonsils are lymphoid tissue with prominent germinal centers and the palatine tonsils, in contrast to the lingual tonsils and adenoids, have a distinct capsule1which separates the tonsils from the lateral pharyngeal walls. The tonsil lies within a bed of three muscles that make up the tonsillar fossa. Forming the anterior pillar is the palatoglossus muscle and the posterior pillar is the palatopharyngeus muscle, while the superior constrictor muscle makes up the bed of the fossa. Medially, the tonsil crypts lay exposed to the oropharynx with specialize stratified squamous epithelium.

The tonsils are well vascularized with the majority of the blood supply arising from the tonsillar branch of the facial artery.1The nerve supply of the tonsils arise from the ninth cranial nerve and descending branches from the lesser palatine nerves and the tympanic branch of CN IX is thought to account for the referred ear pain found in some cases of tonsillitis. The tonsils have no afferent lymphatic vessels. Their efferent lymph drainage is through the upper cervical nodes, especially to the jugulodigastric group. Tonsils and adenoids are immunologically most active between the ages of 4 and 10 years, and tend to involutes after puberty.2

Fig. 1. Orophaynx with Palatine Tonsils.

A Review of Tonsillectomy Techniques and Technologies 163

However, the difficulties encountered by surgeons, especially in controlling the perioperative bleeding, were a major drawback .It was only 1909,when Cohen adopted suture ligation of bleeding vessels to control the hemorrhage, that tonsillectomy became a common

Sixty years later Haase and Noguera8, introduced the use of diathermy and the concept of electro-dissection was first described by Goycolea6 in 1982 using monopolar diathermy.10 years later Pang9 reported the first electro-dissection tonsillectomy using the bipolar forceps

Adequate history and physical examination are essential in the preoperative diagnosis and evaluation of the patient being worked up for tonsillectomy. History alone is the most common method for diagnosing obstructive sleep apnea.10 When the diagnosis is at all in question, the child is younger than 2 years, or there is concern about the severity of the sleep apnea, a polysomnogram should be recommended.11Preoperative electrocardiogram and chest x-ray are not necessary unless there is a history of heart disease.12 Other preoperative evaluation needs to be decided based on the medical conditions of each individual patient. For example, a child with von Willebrand disease should have the input of a hematologist regarding the use of desmopressin to minimize the risk of bleeding during the intra-

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).

practice in hospitals 7.

**3. Preoperative evaluation** 

operative and post-operative periods.

**4. General technique** 

**4.1 Exposure** 

technique.

## **1.2 Indications for tonsillectomy**

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

