Instruments of Tonsillectomy (as per Dhingra's ENT)

Complete Instrument Set - Dissection & Snare Tonsillectomy

1. Boyle-Davis Mouth Gag

• Self-retaining mouth gag with two parts:
  • Boyle's blade - tongue depressor blade, available in different sizes based on patient age
  • Davis's gag - frame with ratchet mechanism that holds it open

• The blade is inserted into the mouth, depressing the tongue downward
• The ratchet locks it at the desired opening width, making it self-retaining
• Blade sizes vary: small for children, larger for adults

• Opens and maintains oral cavity access throughout tonsillectomy
• Adenoidectomy
• Palatal surgeries (cleft palate repair)
• Oropharyngeal and nasopharyngeal procedures
• Craniovertebral junction surgeries

2. Draffin's Bipods and Magauren's Plate

• Metallic bipod stand with multiple rings and height adjustment
• Magauren's plate is the flat base support

• Bipods attach to the Boyle-Davis mouth gag after insertion
• Lower ends are fixed into Magauren's plate on the table
• Maintains neck extension in Rose's position (head extended, neck hyperextended over the table edge, mouth facing upward)

• Holds the mouth gag securely without an assistant
• Frees both hands of the surgeon
• Maintains the operative exposure throughout tonsillectomy and adenoidectomy

3. Denis Browne Tonsil Holding Forceps

• Angular (angled) forceps
• Atraumatic blunt jaws (no cutting edges)
• Resembles Luc's forceps in shape but blunt-tipped

• Grasps and holds the tonsil at its upper pole
• Retracts (pulls) the tonsil medially during dissection, placing the capsule-muscle plane under tension
• The medial traction facilitates subsequent dissection steps

4. Waugh's Tonsil Dissecting Forceps (Waugh's Toothed Forceps)

• Spring-joint forceps with interlocking dissecting tips
• Long-handled with fine teeth

• Makes the incision through the mucosa at the anterior pillar (some surgeons use this instead of scalpel)
• Dissection of the tonsil from upper to lower pole
• Holding swabs for pressure over bleeding points during the procedure
• Also used while packing the tonsillar fossa after removal

5. Gwynne-Evans Tonsillar Dissector and Anterior Pillar Retractor

• Double-ended instrument
• One end: rounded dissector tip
• Other end: broad, curved retractor (anterior pillar retractor)

• Dissector end: blunt dissection of tonsil away from its bed (superior constrictor muscle), developing the plane between the tonsillar capsule and the pharyngeal wall
• Retractor end: retracts the anterior pillar to visualize the tonsillar fossa after tonsil removal, checks for bleeding points and retained gauze

Note: Sometimes listed separately as the Mollison Tonsillar Dissector and Gwynne-Evans retractor, but functionally the same double-ended concept.

6. Mollison's Anterior Pillar Retractor

• Broad, curved blade instrument
• Single-ended or part of the double-ended Gwynne-Evans instrument

• Retracts the anterior tonsillar pillar
• Exposes the tonsillar fossa after tonsillectomy to check for bleeding vessels
• Checks for any tonsillar tags left behind

7. Scalpel

• Makes the initial incision along the medial edge of the anterior tonsillar pillar
• Incises the mucosa to begin the dissection

8. Eve's Tonsillar Snare

• Long cylindrical instrument
• Stainless steel wire loop (loop size approximately 4 cm)
• Sliding mechanism with finger rings to tighten the loop

• Applied around the lower pole of the tonsil (the pedicle/stalk)
• The wire loop is tightened to cut and crush the lower pole pedicle, completing tonsil removal
• Controls bleeding at the lower pole by a crushing/avulsion mechanism

9. Birkett's Tonsillar Artery Forceps (First Artery Forceps)

• Artery forceps with a specific angle and length suited for the tonsillar fossa

• First artery forceps used to clamp the primary (main) bleeding vessel in the tonsillar fossa immediately after tonsil removal

10. Wilson's or Negus Second Artery Forceps

• Long, slender hemostatic forceps
• Curved blunt jaws
• Fine transverse serrations to prevent slippage

• Clamps secondary bleeding points in the tonsillar fossa
• Used while applying ligatures to bleeding vessels
• Prevents slippage and tissue trauma during ligation

11. Negus Ligature Slipper and Knot Tier

• Long rod-like instrument
• Forked distal end with a central groove

• Guides the ligature (suture thread) over the artery forceps
• Facilitates secure vessel ligation in the deep, narrow tonsillar fossa where finger access is limited

12. Yankauer Suction Cannula (Yankeur's Suction Tip)

• Curved metal tube
• Rounded (atraumatic) tip
• One central opening + multiple side holes

• Suction of blood and pharyngeal secretions throughout tonsillectomy and adenoidectomy
• Keeps the field clear for visualization

• Rounded tip avoids injury to soft tissues
• Multiple holes prevent complete blockage by blood clots
• Curved shape avoids obstructing the surgeon's line of vision

13. St. Clair Thompson Adenoid Curette (for Adenoidectomy component)

• Primary instrument for removal of adenoid tissue (when adenotonsillectomy is performed)
• The cage type retains the curetted adenoid tissue, reducing the risk of a fragment falling into the airway

Guillotine Method - Additional Instrument

Tonsil Guillotine (La Force's Guillotine)

• Used in the older guillotine technique of tonsillectomy
• A specially designed frame with a sliding blade that amputates the tonsil in one action
• Less commonly used today due to higher risk of incomplete removal and hemorrhage compared to the dissection method

Summary Table

Key Exam Points (Dhingra-based)

• Rose's position (head hyperextended) is maintained using Draffin's bipods + Magauren's plate
• The Boyle-Davis gag is the FIRST instrument placed; it is self-retaining
• Eve's snare is used at the lower pole LAST, to complete removal
• Denis Browne forceps are blunt (atraumatic) - key distinguishing feature from other forceps
• Gwynne-Evans dissector = the workhorse instrument for the dissection plane
• Negus ligature slipper solves the problem of tying ligatures in a deep, narrow space
• Blade of choice: No. 12 (sickle) for incision of the anterior pillar mucosa