Describe tonsillectomy with its indications and complications.

Indications and Contraindications

• Tonsillectomy is surgical removal of the palatine tonsils with their capsule, dissecting in the peritonsillar plane between capsule and superior constrictor.
• It is one of the commonest operations in ENT and one of the most frequently performed without adequate indication.
• The indications divide into absolute and relative, and the distinction should lead the answer

Technique, Complications and Aftercare

• Preoperative assessment — document the indication and the episodes; check haemoglobin and clotting where indicated; take a family and personal bleeding history; examine and palpate the palate for a submucous cleft; and assess for sleep apnoea.
• Position and exposure — supine with the rose position (head extended, shoulders raised), a BOYLE-DAVIS gag on suspension, and a cuffed oral tube
• Techniques — cold steel dissection with a snare and ligation or bipolar haemostasis.
• The guillotine (Sluder) method is of historical interest
• Complications — haemorrhage is the most important, and its classification by timing governs management:
• Primary haemorrhage — during the operation; controlled by pressure, ligation or bipolar diathermy
• Reactionary (immediate secondary) haemorrhage — within the first 24 hours.
• Secondary haemorrhage — after 5 to 10 days, caused by infection and slough separation. It is managed with admission, antibiotics and observation, though a proportion need surgery
• The management OF A post-tonsillectomy bleed IS AN exam favourite and a real emergency: admit and resuscitate; large-bore intravenous access, blood for full blood count and cross-match; keep nil BY mouth; sit the patient up and encourage them to spit rather than swallow; ice and hydrogen peroxide gargles; antibiotics; and return TO theatre if bleeding is active or continues
• Children compensate well and then decompensate suddenly — tachycardia, pallor and repeated swallowing are the early signs, and a large volume may be swallowed before any blood is seen. Do not be reassured by a normal blood pressure in a child
• Other complications — pain and referred otalgia.
• Aftercare determines the experience — regular analgesia, prescribed by the clock rather than as required; paracetamol with ibuprofen.
• Encourage eating and drinking normally — a normal diet cleans the fossae and reduces infection, and the old advice to eat only soft food is wrong
• Warn the family that the throat will look white and sloughy, which is normal healing and not infection; that pain often peaks around day 5 to 7; and to attend immediately if there is any bleeding
• Know the Paradise numbers — seven in one year, five a year for two, or three a year for three — which is what makes an answer specific
• Episodes must be documented, not merely recalled, and each needs a sore throat plus fever, exudate, nodes or a positive culture
• Tonsillectomy is the biopsy where malignancy is suspected, and a unilateral tonsil is removed rather than sampled
• The benefit in mild disease is modest, two or three fewer sore throats in the first year.
• Watchful waiting with documentation is often the right first step.
• Palpate the palate before operating, since a submucous cleft means permanent velopharyngeal insufficiency after surgery
• Cold steel has the lowest secondary haemorrhage rate, while diathermy is faster but more painful afterwards
• Intracapsular tonsillotomy suits obstruction, not infection.
• Reactionary bleeding is within twenty-four hours and needs theatre, as vessels in spasm reopen
• Secondary bleeding is at five to ten days from slough separation, and is managed with antibiotics and observation
• Sit the patient up and let them spit; swallowed blood causes vomiting and hides the true volume lost
• Children compensate and then crash, so watch the pulse and swallowing rather than the blood pressure
• Cross-match early in a post-tonsillectomy bleed rather than waiting to see whether it settles
• Prescribe analgesia by the clock, not as required.
• Ibuprofen is safe and does not increase bleeding, and combining it with paracetamol is better than either alone
• Codeine is contraindicated in children after adenotonsillectomy for sleep apnoea.