Tonsillectomy - Surgical Steps

Indications (Bailey & Love, Table 52.1)

Pre-operative Points

• Procedure ideally done when tonsils are not acutely infected
• Check bleeding history and coagulation status
• Type & screen blood in children under 15 kg
• General anaesthesia (endotracheal intubation with a south-facing RAE tube)

Step-by-Step: Dissection Tonsillectomy (Cold Steel - Standard Technique)

STEP 1 - Patient Positioning

• Rose position (supine) with neck extended over a shoulder roll
• Head ring to stabilize the head
• Boyle-Davis mouth gag inserted to retract the tongue and keep the mouth open; suspended from a Draffin bipod or Boyle-Davis stand

STEP 2 - Exposure

• The surgeon sits at the head of the table
• The soft palate and uvula are retracted superiorly
• Both tonsils are visualized simultaneously

STEP 3 - Incision of Anterior Faucial Pillar

• The mucosa of the anterior faucial pillar is incised with a curved scissors or scalpel at the junction of the pillar with the tonsil
• This exposes the tonsil capsule

STEP 4 - Grasping the Tonsil

• The tonsil is grasped with Allis forceps or a tonsil-holding forceps and pulled medially to stretch the mucosa taut and open the dissection plane

Fig 52.27 - Removal of the tonsils (Bailey & Love, 28th Edition) - The mouth gag holds the oropharynx open, tonsil is grasped medially and dissected from its bed

STEP 5 - Dissection in the Peritonsillar Plane

• Blunt dissection (with a Mollison's or St. Clair Thompson's dissector or pledget of gauze) proceeds in the plane of loose areolar tissue between the tonsil capsule and the pharyngeal constrictor muscles
• Dissection begins at the superior pole and proceeds inferiorly
• This plane is largely avascular except at the poles
• The tonsil is progressively separated from its bed, staying outside the capsule at all times

STEP 6 - Division of the Inferior Pedicle

• Once dissection is complete, a small inferior pedicle remains connecting the tonsil to the lingual tonsil / tongue base
• A tonsil snare or scissors is used to sever this pedicle
• The tonsil is then fully removed

STEP 7 - Haemostasis

• A tonsil swab (rolled gauze) is placed in the tonsillar fossa and pressure applied for several minutes
• Bleeding points are then controlled by:
  • Ligation (silk ties) - traditional preferred method
  • Bipolar diathermy - commonly used
  • Cold steel + ties has the lowest secondary haemorrhage rate (NPTA data)

STEP 8 - Inspection of the Bed

• Both fossae inspected for residual bleeding
• Mucosa of pillars may be approximated if needed (rare)
• Throat pack (if used) is removed and counted

Surgical Steps Diagram (Generated Reference)

Alternative Techniques (Scott-Brown's, p. 482)

Post-operative Care

• Recovery position (tonsillar position) - lateral decubitus (see figure below) to prevent aspiration of blood

Fig 52.28 - Lateral recovery position after tonsillectomy (Bailey & Love, 28th Ed)

• Monitor pulse and blood pressure closely - excessive swallowing = sign of bleeding
• Encourage normal diet and oral analgesics
• Warn about referred otalgia (via glossopharyngeal nerve) - this is normal
• Secondary haemorrhage can occur up to 10 days post-op (usually infective)

Complications (Bailey & Love, Summary Box 52.6)

• Primary haemorrhage (within 24 hrs) - reactionary; requires return to theatre
• Secondary haemorrhage (days 5-10) - infective; IV antibiotics + possible re-operation
• Post-op pain and otalgia
• Airway obstruction
• Velopharyngeal insufficiency
• Injury to teeth, lips, or oropharyngeal structures
• Nasopharyngeal stenosis (rare)

• [Scott-Brown's Otorhinolaryngology Head & Neck Surgery (Vol 2), pp. 481-482](Scott-Brown's Vol 2, Chapter 38) - Tonsillectomy Technique
• [Bailey & Love's Short Practice of Surgery 28th Ed, pp. 807-808](Bailey & Love, Chapter 52) - Tonsillectomy
• Cummings Otolaryngology Head and Neck Surgery - Palatine Tonsillectomy