Disclaimer: The information contained within the Grand Rounds Archive is intended for use by doctors and other health care professionals. These documents were prepared by resident physicians for presentation and discussion at a conference held at Baylor College of Medicine in Houston, Texas. No guarantees are made with respect to accuracy or timeliness of this material. This material should not be used as a basis for treatment decisions, and is not a substitute for professional consultation and/or peer-reviewed medical literature. Tonsillectomy Anatomy of Tonsils: Not to belabor the point but just to review the gross anatomy of the tonsils. The tonsils are in the oropharynx. The anterior pillar is the palatoglossus muscle. The posterior pillar is the palatopharyngeus muscle. The superior constrictor muscle forms the base of the tonsil. If you look closely at Netter's drawing, you can actually see crypts within the tonsil, and this is important. Even though the exact function of the tonsils is still being elucidated, it is believed to be involved in secretory immunity. These crypts serve to entrap and process antigens in these follicular cells, and immunoglobulins can be secreted both locally and regionally. The tonsils are most active from ages 4-10 years old. However, any healthy adult can active tonsil tissue. Interesting enough, people with recurrent tonsillitis seem to have decreased immunoreactivity, and they think it is because this squamous epithelial layer becomes stratified and scarred, making entrapment and transport of antigens more difficult. The blood supply is classically described by Hollingshead with inferior pole and superior pole vessels. The facial artery has the major contribution to the tonsillar fossa. Cranial nerve number nine is located deep to the superior constrictor muscle, and that is important because it can be injured during a dissection as well as it can cause postoperative referred otalgia. I included this slide just to remind everyone that deep to the superior constrictor muscle, the internal carotid artery is located History of Tonsillectomy: The history of tonsillectomy is fascinating. It is one of the oldest surgical procedures known to man. It was first described by Celsus who used a hook to grasp the tonsil then used his finger to incise it. In the 6 th century, physicians began to use a knife to remove the tonsil as well as began to recognize that being in the correct plane was important for successful outcome. In the 17 th century, more physicians began to recognize that exposure was important, and I thought this was interesting. They also recommend having an assistant to hold the patient steady while doing the procedure. That brings up a good point. Tonsillectomy was painful. Patients could not tolerate going through the procedure for a long period of time so you needed to develop an instrument that would remove the tonsil quickly. They became known as the tonsillotome, and it could both grasp and remove the tonsil in one swift move. McKenzie further developed it turned it into the modern day tonsil guillotine. This has been further modified but really McKenzie created the classic guillotine that is even used today. As a result, guillotine dissection of tonsillectomy became the norm. This is a picture of the guillotine tonsil removal taken from the Methodist OR. The major problem with tonsillectomy or using the guillotine to remove the tonsil was incomplete removal. Doctors recognized these facts. Around the same time anesthesia was becoming more readily available and better understood. Physicians began to recommend using a general anesthetic to perform the tonsillectomy and also lying the patient supine, using a shoulder roll, getting adequate exposure and then taking ones time to dissect out the tonsil using scissors. This became the norm and greatly improved the procedure in general. Dr. Pachan also around the same time began to describe electric cautery use for tonsillectomy. This technique did not catch on till the later half of the 20 th century but these two procedures in combination made tonsillectomy safe and effective for treating tonsillar diseases. So much so that by the mid century, there were over two million cases of tonsillectomies performed a year in the United States. As a result of this, there was somewhat of a backlash that occurred in the late 1960's, early 1970's, and many people felt that the indications for tonsillectomies were not well understood and there were too many procedures being performed. As a result, the numbers of tonsillectomies plummeted throughout the 1970's. However, during the 1980's, clinical scientists began to recognize that tonsillar hypertrophy contributed to obstructive sleep apnea syndrome, and as a result you again saw an increase in the rise of tonsillectomies. Also in the last twenty years, we saw newer techniques gain popularity: bipolar electrocautery, use of the microscope, lasers, ultrasonic scalpel, and most recently, high frequency ablation of tonsillar tissue. Currently, there are about 700,000 procedures performed a year. Serious complication rates are about 15 per 1,000 cases and 80% of tonsillectomies are performed as outpatients. This is just a picture of some of the common instruments. I am sure you recognize many of them, the Alice clamp, the tonsil snare, the hurd retractor. I chose these slides - this is from a book published in 1951 on tonsillar disease, and I thought it accurately depicts the steps in the tonsillectomy. No matter what technique you use, these are the most important steps: first and foremost, just exposure and retraction and then getting in the right plane and staying in the right plane. Those are the key steps to the operation, no matter what technique you use. Complications of the operation : Pain is the most common complication of the operation. It often leads to dehydration which results in prolonged hospitalization and added morbidity. Postoperative hemorrhage is perhaps the most feared complication. It is defined in two ways. There is primary hemorrhage, which occurs in the first 24 hours, and there is secondary hemorrhage, which occurs 24 hours thereafter. It is also important to keep in mind that any patient who has upper airway obstruction, if you remove that obstruction, you can have postobstructive pulmonary edema. The pathophysiology is related to CO 2 content and increased oxygenation, and it is beyond the scope of this lecture but that is important to keep in mind. Of course, if you do any procedure on enough people, enough times, you are bound to see some weird things, and tonsillectomy is no different. Grissel’s syndrome is a result of laxity or infection of the transverse ligament of the axial vertebral body, and they think it is a result of improper positioning and infection of the tonsillar bed, etc. Also, keep in mind as I mentioned earlier, the internal carotid artery is just a few millimeters away from the superior constrictor muscle. If your dissection is too deep and there happens to be an aberrant artery, you can have major bleeding as a result. Pulmonary abscess is more of historical significance. When tonsillectomy was performed in a sitting position but it still occurs occasionally. Eagle syndrome occurs when an elongated styloid process is in contact with the tonsillar fossa, and once you remove the tonsil, the postoperative edema and inflammation can cause scarring around this process leading to chronic pain syndrome. Of course, aspiration of a foreign body, anytime you operate in mouth, teeth, sponges, etc., can be aspirated. The real problems with tonsillectomy are patients like this young lady pictured here. When she presents she is happy. She was told that postoperatively she can eat all the ice cream and all the popsicle sticks she wants, and then we “dropped the bomb” on her. Post-op she cannot swallow, she is crying, she is in pain, her ears hurt, and her parents are now calling you in the middle of the night wondering what is wrong. The pain is multifactorial. This illustration is of a simple concept map, and what I tried to depict here is the different ways that tonsillectomy can lead to postoperative pain. Nociceptive input involves hypersensitization of efferent nerve fibers to the CNS. People think that surgery can cause this syndrome leading to a protracted course of postoperative pain. Of course, the inflammatory response in general, the more inflammation, the more edema, the more pain. Infection. Tonsillectomy creates an open wound that has to heal by secondary intention. Of course, this occurs in a cavity that is filled with pathogenic bacteria. So, infection of the tonsillar fossa can lead to significant postoperative pain. Some people believe that it also is related to postoperative pain. As I looked at the literature, what I tried to keep in mind and what I would like you to also keep in mind is that the best studies are randomized. They have controls. They have adequate numbers so you can have statistical power. There are standardizations, and they use validated means of measurement when they tabulate their results. Local anesthetics should be able to block this input. The Pivocaine is used most commonly. It is an amide analgesic. It has high fat solubility, about 6-9 hour half-life. More importantly, they believe that not only will the effect be within that 6-9 hours but because if you block the stimulation or the hyperstimulation of the nerve fibers, you should have a more prolonged effect with respect to postoperative pain. There have been about 30 published studies on this topic. Six had the best criteria, and if you look at the results of those six studies, there does seem to be a decrease, a transient decrease, in postoperative pain. However, after 6 hours, there does not seem to be any difference. So, in other words, if you inject the Pivocaine within the tonsillar fossa either before the procedure or after the procedure, patients probably have less pain initially but when they get home and the next day, they are in just as much pain as anyone else. The other thing to keep in mind is that vasoconstrictors, if you use them, they can reduce intraoperative bleeding. However, there are some studies that suggest that there is an increased risk in secondary bleeding. It is poorly understood why but you may want to keep that in mind. Getting back to our concept map. So we know nociceptive input can be blocked temporarily. What about blocking inflammatory responses? Of course anti-inflammatory drugs should work in that arm. Steroids are the stereotypical drugs used for anti-inflammatory effects. As you can imagine, the data is conflicting. There have been about seven control studies, and what they found is in children, there does seem to be decreased postoperative emesis. Patients are able to tolerate p.o. intake better than those who do not receive intraoperative steroids. Also, you can imagine as a result, these patients usually are able to eat a regular diet faster than those who have not received the medication. In adults, however, there does not seem to be any difference in post-op emesis or return to diet. In any population, there does not seem to be any difference with respect to pain. NSAID. Obviously, Naiad’s are great anti-inflammatory drugs. There is concern because their mechanism of action creates an increased risk of bleeding and as Harley showed, ibuprofen did seem to increase post-op bleeding in children who underwent tonsillectomy. Ketorolac or Toradol is a drug that has been studied quite extensively. It is used very commonly in Europe, and it works in the same way as ibuprofen, however, its antiplatelet effects are reversible. So, it may not be as much risk with bleeding. Older studies did show an increased risk of bleeding. However, some newer studies show that these drugs were very effective in immediate post-op period, and there was no increase in primary rates of bleeding. However, these studies did not study or look at secondary hemorrhage rates. So the best we can say about ketorolac at this point is that it needs further investigation. We know that it works in immediate post-op period but we do not know whether or not there is a real risk of increased hemorrhage rates. What about infection? Antibiotics should block the infective arm of pain. This has been well studied. This is a classic study done in 1986 at Children's Hospital. One group received placebo and another group received intraoperative doses of ampicillin followed by a seven-day course of amoxicillin. What they found was the patients had less halitosis, earlier return to regular diet, as well as less pain. This study is now the gold standard. Any kid who has tonsillectomy will be prescribed antibiotics postoperatively. What about adults? The University of Pittsburgh did the exact same study in adults except they used Timentin and Augmentin postoperatively. What they found was that there was less halitosis and an earlier return to diet but no difference in pain. Nevertheless, they still recommended using antibiotics postoperatively and indeed, this is now pretty much the gold standard. Any adult who undergoes tonsillectomy will have antibiotics prescribed post-op. There was a recent study last year that looked at topical antibiotics. This was very interesting study. There were four treatment arms, and it consisted of one group receiving clindamycin swish and spit, one hour preop, intraoperatively and then eight hours post-op. Another group receiving Augmentin swish and spit one hour preop, intra-op, and then eight hours post-op. Another group received the standard therapy, ampicillin followed by a seven-day course of amoxicillin. Then, the last group received placebo. What they found was the group that had the topical antibiotics had decreased halitosis and decreased pain. And interestingly enough, they also found that systemic antibiotics was no different that placebo. They went on to say that perhaps the antibiotic resistance of bacteria has changed over the last 12 years, 15 years, but they were not absolutely certain, and they suggested that perhaps we should go back and restudy the use of antibiotics for postoperative pain. What about the type of dissection? Obviously, cold versus electrocautery is at the heart of this debate. In general, people believe that guillotine dissection is less painful than cold dissection, which is less painful than electrocautery. It is difficult to study objectively as you can imagine. I would like to present a couple of studies to you that I think illustrate this point. There is a study published this year in International Journal of Pediatric Otolaryngology, and they looked at guillotine versus cold dissection. They grouped kids into two groups. There were 86 children in the study. They used nursing assessment using a validated pain instrument to follow them 24 hours after their operation, and everyone got the same pain regimen. At the end of the study, they looked at who received the most pain medicines, and which ones got the higher pain scores from the nursing assessment. What they found was that in the guillotine dissection, there seemed to be less pain and less use of rescue medications. There were some problems with the study. First and foremost, the nurses who did the pain assessment were not blinded. So, there is obvious room for bias there as well as they did not randomize the patients. They simply looked at the operative logs and decided well this group of patients is going to have guillotine and this group of patients will not. There is another study that was published this year. This has also been quoted recently. It was published in Archives of Otolaryngology in July and they looked at electrocautery versus cold dissection. 54 children were enrolled in the study. They were randomized. Every patient was given a diary to take home with them. The parents filled it out, and they also contacted the family physicians to figure out who was receiving more postoperative pain medicine and who was returned to diet faster, normal activity faster, etc. What they found was the patients who underwent cold dissection tonsillectomy had reduced analgesic usage and faster return to normal diet. Additionally, they believe from their study results that the reduction in pain and the benefit from using cold dissection tonsillectomy was equivocal to the benefit derived from prescribing antibiotics. If you look at their study, you find that they did not standardize post-op analgesic regimens. Some patients received Tylenol with Codeine. Some patients received Tylenol. Other patients received meperidine, and they do not say which patients were compared to which other patients. So, it is very hard to say that a patient who perhaps took ten doses of Tylenol had the same amount of pain or had more pain than someone who did not. So in conclusion about postoperative pain, we know that antibiotics are really the only proven benefit experimentally. The rest of them may have marginal benefit but in the long term did not seem to have any real effect. Post-op hemorrhage is the most feared complication of tonsillectomy. There is primary and secondary hemorrhage. Primary hemorrhage is thought to be due to inadequate hemostasis at that time of operation. What causes secondary hemorrhage is poorly understood. Is it infection? Is it technique? Is it demographics? It‘s hard to say. There are few prospective studies and conventional wisdom says that it is probably not related to surgical technique and preop coagulation studies probably are not cost effective. There are a couple of studies I would like to share with you on this matter. There was a prospective study done in 1992 in the United Kingdom of 1,000 patients. They looked at all the patients who have had tonsillectomy and collect information prospectively to try and figure out who was at risk for postoperative bleeding. They defined it significant bleeding as anyone who required hospitalization. They may not have required a blood transfusion but they at least needed to be hospitalized to be included in the study. Their overall hemorrhage rate, which was a little high, was 4.7%. What they found was the only risk factors were the patient's age, the time of year, and being of male sex. That suggests to me that level of activity has something to do with secondary bleeding. There was another study done at the Mayo Clinic. It was published this year in Otolaryngology, Head and Neck Surgery. This was a 13-year retrospective study. They went back and they looked at all the charts, the patients who were admitted or seen in the emergency room, and they found that 90 patients have post-tonsillectomy bleeding. For each one of those patients, they took an age matched and sex matched control patients, two aged and sexed controlled patients. So, they had 180 controls. They looked at multiple variables. They looked at time of year, sex, whether or not they underwent a cold versus hot dissection tonsillectomy, what type of anesthesia was used, what was the blood loss in the operating room. What they found was the overall risk was 1.93%, which is pretty comparable to other studies. Looking at who was at risk, the only risk factor that they could find was age. 21 and 30 years of age were at 3.6% risk for tonsillectomy and then those 11 to 20 were about 2.5% risk for tonsillectomy. In conclusion, tonsillectomy remains one of the most common surgical procedures performed in the world. Although major complications are rare, pain and bleeding still remain challenging aspects of postoperative care, and continued studies are necessary to further lessen this burden upon our patients and caregivers. Case Presentation: KM is a 30-year-old woman with a lifelong history of recurrent bouts of severe tonsillitis manifested by dysphagia and odynophagia. She has undergone repeated courses of medical therapy, which have failed to completely resolve her symptoms. On physical examination she was noted to have moderately enlarged cryptic tonsil with exudate present. She was therefore scheduled for tonsillectomy. She underwent an uneventful “cold” dissection tonsillectomy. In the PACU she required repeat doses of fentanyl and Lortab ® for postoperative pain. She was eventually discharged home that day with routine follow-up. On POD # 8, she noted bright red blood in her saliva so she sought medical attention. Upon examination in the ER, she had a clot formation in her right tonsillar fossa. Upon removal, no active bleeding was noted. She was admitted to the hospital for observation. Her admission coagulation profile and blood counts were normal. 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Recovery after tonsillectomy: Electrodissection vs. sharp dissection techniques. Otolaryngol Head Neck Surg 1996;114:576-581. Wiatrak BJ, Woolley AL. Pharyngitis and adenotonsillar disease. In: Cummings CW, ed. Pediatric Otoalryngolgy Head and Neck Surgery, 3 rd ed. St. Louis: Mosby; 1998. pp. 188-215. Wei JL, Beatty CW, Gustafson RO. Evaluation of post-tonsillectomy hemorrhage and risk factors. Otolaryngol Head Neck Surg 2000;123:229-235. Grand Rounds Archive | Department Home page BCM Public | BCM Intranet | Privacy Notices | Contact BCM | BCM Site Map | ©2001-2005 Baylor College of Medicine
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