Monday, 25 November 2013

Tonsillectomy

Tonsillectomy:
The indications for tonsillectomy/adenotonsillectomy are:
1. Children with Obstructive Sleep Apnoea [OSA ]
2. Frequent Recurrent Acute Tonsillitis
3. Peritonsillar Abscess
4. Suspected Neoplasm
An increase in access to adenotonsillectomy for children with moderate/severe
obstructive sleep apnoea [OSA] is urgently required not mild.
7 in the previous year, 5 episodes in each of the previous 2 years, or 3 episodes in each of the previous 3 years was old criterio.
New criteria says more than 4 episodes with single episode of quinsy or cervical lymphadenopathy
Rose position best for surgery and left lateral after surgery.
New technique includes
A.COLD METHODS:
Dissection and snare guillotine method
Intracapsular tonsillectomy with debrider
Ultrasound harmonic scalpel
Cryosurgery
Plasma mediated surgery
B.HOT METHODS
ELECTROSURGERY
COBLATION SURGERY
RADIOFREQUENCY.
LASER TONSILLECTOMY
New technique always cause less bleed.
KTP laser is best laser
Indication or laser tonsillectomy—Bleeding disorders and contraindications to general anesethesia
Bleeding in cryosurgery is due to thrombosis of veins.
Cold method always cause less pain.
The harmonic scalpel is an ultrasonic dissector coagulator that utilizes ultrasonic vibration with a vibratory frequency of 55.5 kHz over a distance of 89 μm. The temperature of the harmonic scalpel is lower than electrocautery (50° – 100° C, 150° – 400° C, respectively), and there is less thermal damage to tissues.  The harmonic scalpel is an expensive product.
Postoperative pain scores tended to be lower in the harmonic scalpel group. 
The incidence of postoperative bleeding in the harmonic scalpel group is twice that of the electrocautery group.
Coblation, or cold ablation, is a technique that utilizes a field of plasma, or ionized sodium molecules, to ablate tissues.  Bipolar radiofrequency energy is transferred to sodium ions, creating a thin layer of plasma.  This effect is achieved at temperatures from 40° to 85° C, in comparison to electrocautery which can reach above 400° C.
Postoperative recovery following intracapsular adenotonsillectomy in children with obstructive sleep apnea is significantly earlier with use of either the coblator or microdebrider versus traditional extracapsular tonsillectomy with electrocautery.
Hemorrhage
Primary is during surgery ..most common is venous bleed due to paratonsillar vein which is also known as descending palatine and dennis brown vein.
Second most common is arterial which is due to tonsillar branch of facil artery.
Reactionary is due to slippage of ligature and management is Re ligate
Secondary is after 24 hrs and due to infections therefore management is I.V antibiotics.
Secondary haemorrhage is most commonly seen on 5-7 day
Average loss during tonsillectomy is 60-80 ml while during adenotonsillectomy is 80-120 ml
Epidemic of polio is clinically very important contraindication as glosspharyngeal nerve is involved.

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