history vessels within tonsillar fossa was considered

history

 The tonsils are
lymphoid organs strategically
located at the entrance of the digestive and respiratory systems**4 First
known tonsillectomy was performed by Cornellus Celsus almost 2000 years
ago.15**** Modern tonsillectomy began in early years of this century
with development of Dissection tonsillectomy in Baltimore by Worthington
(1907) & in London by Waugh (1909) & Guillotine tonsillectomy
in New Castle by whillis and Pybus (1910).Ligation of bleeding vessels within
tonsillar fossa was considered extremely difficult and was first employed on a regular
basis by Cohen (1909).  1

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   Throughout the world,
tonsillectomy is one of the most frequently performed otorhinolaryngological procedures2******  
Tonsillectomy was initially
performed by general surgeons, but at the end of 19th century it became an ENT
doctor´s care, due to the best techniques of illumination that they knew.
Important steps in the progress of the tonsillectomy were taken using mouth-gag
and tongue-depressors, besides the positioning of patient with leaning and
suspended head. This position was first described by Killian in 1920, but only
adopted after improvements on anesthesia techniques (4).It is estimated that in the United States 1,400,000
tonsil surgeries were performed in 1959, around 500,000 in 1979 and 250,000
ones per year in the last decade 4 .Data
show that in during the 40´s and 50´s many illnesses, of which the etiology or
physiopathology were not known, were associated to tonsils as possible
infectious focus. This resulted in thousand of surgeries 4 .As time went by, due to lack of convincing results and
excess of indications, this procedure lost its reputation, and as a consequence
it was not recommended even for caseswhentherewassuchneed.4
Therapeutical advance on medicine, especially
with the use of antibiotics and improvement on work conditions on public health
services and on group medicine also contributed for a reduction on tonsil
removal surgery.(4)The laser of carbon dioxide, introduced in medicine in 1960,
proved to better reduce and control bleedings than ruby laser, introduced soon
after the World War II. The first report of laser of carbon dioxide use in
tonsillectomies was in 1973. The advance on technology of intensity and
frequency control of the laser allowed it to be used in such a way as a scalpel
as much as coagulator4

Otorhinolaryngology
was the first surgical specialty in which laser features of carbon dioxide were
recognized and applied successfully in clinical situations in great amount 4

In
1968, Remington-Hobbs described the use of monopolar diathermy for removal of tonsils
14 Further, Andrea defined the first microsurgical bipolar cautery technique in
1993 ******15

Anatomy

The
circular band of lymphoid tissue within the pharynx consisting of the adenoids,
the

palatine
tonsils (Figure 1), and lingual tonsils is known as Waldeyer’s ring. The
palatine

tonsils
are lymphoid tissue with prominent germinal centers and the palatine tonsils,
in

contrast
to the lingual tonsils and adenoids, have a distinct capsule1which separates
the

tonsils
from the lateral pharyngeal walls. The tonsil lies within a bed of three
muscles that

make
up the tonsillar fossa. Forming the anterior pillar is the palatoglossus muscle
and the

posterior
pillar is the palatopharyngeus muscle, while the superior constrictor muscle
makes up the bed of the fossa. Medially, the tonsil crypts lay exposed to the
oropharynx with specialize stratified squamous epithelium.*****16

Blood
supply of the tonsils: blood supply  to
the palatine tonsils is variable, but
in general, they are supplied by several branches of the
external carotid artery:

·       
ascending
pharyngeal,

·       
ascending palatine,

·       
and branches of the
lingual and facial arteries.

The blood supply enters from the lower portion of the palatine tonsil pole. The internal
carotid artery (ICA) lies approximately 2 to 2.5 cm deep and posterolateral to the palatine tonsil; howevr case reports (14) exist of aberrant ICA courses which come within 1 cm of
the inferior pole. The ICA may have a tortuous and convoluted course of which the surgeon must be cognizant.

Venous drainage is by way of a peritonsillar venous plexus, which surrounds the capsule and drains into the
lingual and pharyngeal veins (12).   BB  p 
1432——10

The
nerve supply of the tonsils arise from the ninth

cranial
nerve and descending branches from the lesser palatine nerves and the tympanic

branch
of CN IX is thought to account for the referred ear pain found in some cases of

tonsillitis.
The tonsils have no afferent lymphatic vessels. Their efferent lymph drainage
is

through
the upper cervical nodes, especially to the jugulodigastric group. Tonsils and

adenoids
are immunologically most active between the ages of 4 and 10 years, and tend to

involutes
after puberty*******17

indication:

    Absolute

1.
Obstructive sleep apnea

2.
Cardiopulmonary complications secondary to airway obstruction (e.g., cor
pulmonale,

alveolar
hypoventilation)

3.
Suspected malignancy

4. Hemorrhagic tonsillitis

5.
Tonsillitis causing febrile seizures

1.2.2
Relative

1.
Recurrent acute tonsillitis meeting one or more of the following criteria:

? Seven episodes in 1 year

? Five episodes/year for 2 consecutive
years

? Three episodes/year for 3 consecutive
years

? Two weeks of missed school or work in 1
year

2.
Chronic tonsillitis refractory to antimicrobial therapy

3.
Tonsillolithiasis with associated halitosis and pain, unresponsive to
conservative

measures

? Peritonsillar abscess

? Dysphagia due to tonsillar hypertrophy****************5

Contraindications


leukemia, hemophilia, agranulocytosis, uncontrolled systemic disease

(diabetes,
TB)


Relative Contraindications: cleft palate, acute infection*********18

technique

According
to the latest survey of members of the American Academy of Otolaryngology and
the American Society of Pediatric Otolaryngology, electrocautery is the
preferred method for tonsillectomy by roughly 55% of Otolaryngologists.21
Coblation tonsillectomy is estimated to be the preferred method by 20%–25%, cold
steel techniques by 10% and other techniques including microdebrider partial
tonsillectomy by the remaining 10%. Although popular, the electrocautery
technique has its drawbacks as it has been shown to be a more painful surgery
than cold techniques, due to the additional thermal injury inflicted upon the exposed
musculature. Recently, there has been increasing interest in performing a
partial tonsillectomy, or tonsillotomy, to maintain the tonsillar capsule and
reduce postoperative pain and bleeding. As with every surgical technique,
intracapsular tonsillectomy also has its drawbacks. Large case series have
shown that tonsillar regrowth occurs in about 0.5%–6% of patients with a
smaller percentage requiring completion tonsillectomy. The operation takes
several minutes longer than electrocautery tonsillectomy, which adds to the
surgical costs. Intraoperative blood loss is greater but appears to not be
clinically significant. The role of intracapsular techniques for managing
children with recurrent tonsillitis is still unproven though initial studies are
encouraging for this indication.(22) this 22 of book not serch  *********19

Types of Tonsillectomy Procedures:

Techniques
and technologies

The
techniques of Tonsillectomy can be broadly divided into 2 major categories:

extracapsular
(total tonsillectomy, subcapsular) and intracapsular (partial tonsillectomy).

Intracapsular
is also known as “subtotal,” and this procedure is referred to as tonsillotomy

in
some literatures. Extracapsular tonsillectomy involves dissecting lateral to
the tonsil in

the
plane between the tonsillar capsule and the pharyngeal musculature, and the
tonsil is

generally
removed as a single unit. Partial tonsillectomy, or tonsillotomy, involves
removal of most of the tonsil, while preserving a rim of lymphoid tissue and
tonsillar capsule in the most recent iteration of this older technique.16
Preservation of this margin of tissue, this “biologic dressing,” may promote an
easier recovery, with lower hemorrhage rates and better recovery of diet and
activity reported in comparison with traditional monopolar tonsillectomy
techniques.The most common extracapsular techniques use a “cold” knife (sharp
dissection), monopolar electrocautery, bipolar cautery (or bipolar scissors),or
harmonic scalpel. Intracapsular techniques may use the microdebrider, bipolar radiofrequency
ablation (which can also be used to remove the entire tonsil), and carbon dioxide
laser  ********************20

Coid
steel  tonsillectomy

The
most common method of ‘cold steel’ tonsillectomy is the dissection technique (Figure
96.2). In this, the tonsil is retracted medially, the mucosa overlying the
tonsil capsule incised and the plane of loose areolar tissue between the tonsil
and the pharyngeal musculature dissected with steel dissectors, gauze or cotton
wool until the tonsil is fully mobilized (Figure 96.3). Blood vessels traversing
the plane of dissection are dealt with either by ligature or diathermy as
required. . ***************6 scott p 1232

After
removal of tonsils we start to control bleeding for wx tonsil lower pole
bleeding is controled either by mechanical methods (sanare or ligation)
7*******

An
alternative method of ‘cold steel’ tonsillectomy
is the guillotine technique, whereby the tonsil
is amputated using a specially designed guillotine
device and haemostasis, secured as necessary by one
of the above methods. Of these two techniques, traditional
dissection remains the most frequently used.
***************6 scott p 1232

Advantages
and disadvantages of the techniques

there is argument 
regarding the benifit of different tonsillectomeis technique.some
studeis assume that the intracapsular technique result in less post operative
pain in addition low risk of tonsil regrowth.for the extra capsular
technique,cold knife technique associated with less posoperative pain compared with
an electrocautery which is faster & has less  loss of intraoperative blood.it is unkown which
technique has the lowest post operative bleeding rate the available data
suggest that  there is no variation in
the bleeding rates between different techniques******20

Post-tonsillectomy hemorrhage :

 Post-tonsillectomy
hemorrhage is divided into two types:

primary hemorrhages occurring within 24 hr  and secondary hemorrhages occurring at any
point more than 24?h after tonsillectomy . The overall
hemorrhage rate is around 4.5% , with reported rates of 0.2–2.2% and
0.1–3.5% for primary and secondary hemorrhages, respectively . Primary
hemorrhage is generally acknowledged to be caused by inadequate hemostasis
during the surgery. Secondary hemorrhage is associated with detachment of the
crust from the site of the removed tonsils .      11

 

Risk factors for postoperative hemorrhage

Patients’age
The age of patients has consistently been
described as being a major risk factor for the occurrence of hemorrhage, with
older patients being at higher risk   11

Patients’sex
There is a discrepancy concerning sex as a risk
factor for postoperative hemorrhage. Some authors found a positive correlation
for male patients being at higher risk  and others did not   11

Operationtechniques
In recent years, operation techniques have been
investigated in more detail, showing in the literature a statistically
significantly higher or lower postoperative hemorrhage rates for certain
operation techniques ? for example, bipolar diathermy for tonsillectomy shows
higher hemorrhage rates compared with cold steel dissection tonsillectomy     11 Preoperative
hemoglobin level and anemia There were no significant statistical difference as
regards the preoperative hemoglobin level in the occurrence of
post-tonsillectomy hemorrhage. Postoperative
infection of tonsillar fossa A study from
2007 showed that postoperative infection of the tonsillar fossa is no risk
factor for secondary hemorrhage , whereas another study described a
positive relationship between preoperative bacterial colonization of the
tonsillar fossa and postoperative hemorrhage, recommending
antibiotics . However, prescribed antibiotics did not reduce the risk for
post-tonsillectomy hemorrhage in general     11 .hemostasis 
by suture ligation is thought 
to  be initiated after
tonsillectomy by 1ry hemostasis,on the other hand  hemostasis by snare technique is thought to
be initiated after tonsillectomy by crushing (2ndry hemostasis) 12  wx 23 in xyad

There are two main components of hemostasis. Primary
hemostasis refers to platelet aggregation and platelet plug formation.
Platelets are activated in a multifaceted process (see below), and as a result
they adhere to the site of injury and to each other, plugging the injury.
Secondary hemostasis refers to the deposition of insoluble fibrin, which is
generated by the proteolytic coagulation cascade. This insoluble fibrin forms a
mesh that is incorporated into and around the platelet plug. This mesh serves
to strengthen and stabilize the blood clot. These two processes happen
simultaneously and are mechanistically intertwined  13

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