Tonsillectomy and Adenoidectomy

Definition
Excision of the faucial (palatine) and nasopharyngeal tonsils (adenoids).

Discussion

T & A is routinely performed to excise chronically infected tonsils and adnoids.The faucial
tonsils and the nasopharyngeal tonsils are aggregates of lymphoid tissue in the posterior
pharynx and nasopharynx; the tissue hypertrophies secondary to infection (usually). In
children, tonsillectomy is relatively simple, whereas in adults, because of chronic infections
and the resultant long-standing fibrosis, the procedure is more difficult. The adenoids are
usually atrophied by age 15; hence, adenoidectomy in adults is uncommon.Whereas the
use of antibiotics has reduced the number of tonsillectomies performed for infection-related
indications, T & A are also performed to relieve pediatric snoring and sleep apnea
secondary to airway obstruction. Special preoperative teaching and orientation (video) is
provided by many facilities for the pediatric patient anticipating T & A; this often results in
reduced anxiety and increased cooperation of the pediatric patient. Traditional T & A
technique may use a cold knife (scalpel), scissors, or wire snare excision of tonsils, alone or
in combination with low-energy monopolar electrosurgery, bipolar diathermy, or laser (CO 2,
KTP, or Nd:YAG) for the extracapsular tonsillar excision (all tonsillar tissue is excised,
including the capsule). When monopolar electrosurgery is employed, the tissue is dessicated
to effect cauterization, causing increased postoperative pain.The laser is less injurious to
surrounding tissues than electrosurgery, as the size of the area and the amount of energy
used can be better controlled. Either of these extracapsular techniques exposes throat
muscles, large blood vessels, and nerves to bacterial toxins that increase pain and swelling.
Intracapsular T & A uses the microdebrider, radio-frequency (RF) coblation, or the
Harmonic Scalpel to excise tissues more precisely. When each of these techniques is
employed, the result is decreased pain and morbidity postoperatively; the patient returns to
his/her usual activities sooner. The surgeon considers the cost, the amount of postoperative
pain, the possibility of complications, and his/her familiarity with the technology and
instrumentation. Complications of T & A include swallowing difficulties, vomiting, fever, ear
and throat pain, and hemorrhage.

Procedure
Traditional cold knife T & A is described.The operating microscope may be employed.The
mouth is retracted and held open with a self-retaining mouth gag.The tongue is depressed
with a tongue blade.A soft catheter (e.g., Foley) may be passed via the nose into the
nasopharynx and grasped orally to retract the soft palate and enhance exposure.
Adenoidectomy is performed with an adenotome, adenoid curette, or punch; a dental-type
mirror aids visualization. In tonsillectomy, the tonsil is grasped, and the mucosa is
dissected free, preserving the posterior tonsil pillar.The capsule of the tonsil is separated
from its bed.A forceps is passed through the loop of the snare, and the tonsil is seized.The
snare loop is passed over the free portion of the tonsil, and the tonsil is amputated. During
any of the approaches, great care is taken during intraoperative suctioning not to dislodge
the endotracheal tube, while preventing blood from being aspirated or from entering the
stomach.The tonsillar fossa is usually packed with a tonsil sponge. Bleeding may be
controlled with electrosurgery, ties (slip knot), and/or by suture ligature. The procedure is
repeated on the contralateral tonsil.

Alternate Approaches
Laser T & A may be performed utilizing a contact CO2 or the Nd:YAG laser, [e.g., SLT
Contact Laser system (Surgical Laser Technologies)]; tissue is vaporized.The laser may be
handheld, or a laser beam or fiber may be directed through a microscope or endoscope. T &
A by micro debrider, a powered rotary shaving device [e.g., Straightshot M4 (Medtronic)]

that uses interchangeable outer cutting tubes, and special blade (e.g., RADenoid ) with
continuous suction; better visualization of the operative area is permitted. Harmonic
Scalpel T & A utilizes high-frequency ultrasonic vibration (e.g., ultrasound power for
oscillating vibration) of the titanium blades to simultaneously cut and coagulate tissue,
thereby reducing blood loss. The Harmonic Scalpel offers precise cutting with minimal
thermal damage. (RF) coblation T & A uses bipolar radio frequency low-level l energy
delivered by probe; the probe is applied to the tonsillar tissue in a saline medium. This
method shrinks the tissues in the nasopharynx, improving airway patency. Multiple
treatments may be required to achieve the desired results. RF coblation causes shrinking of
tonsillar tissue using low-level heat (140_ to 185_F, 60_ to 85_C) from radiofrequency energy.After 8 to 12 weeks, the residual tissue is reabsorbed. As bipolar RF
coblation reduces tonsillar tissue size utilizing a lower output of energy; there is no open
wound and the patient has less discomfort. This modality is being used with increasing
frequency. Transoral or transnasal endoscopic adnoidectomy may be performed in
conjunction with electrosurgical, laser, or microdebrider instrumentation. The endoscopic
approach is preferred over
cold knife adnoidectomy, as it more completely enables elimination of adenoidal tissues that
may obstruct the eustachian tubes.

Preparation of the Patient

The patient may be a child or an adult; however, children do not receive a local anesthetic.
For adults, the position of the patient usually depends on the type of anesthesia
administered. Most adults receive local anesthesia while children receive general anesthesia.
When local anesthetic is employed, the patient is placed in a semi-Fowlers (sitting) position
for the local injections and may stay in this position or may be placed in supine position for
the surgery. For semi-Fowlers (sitting) position, the patient is supine with knees over the
lower break of the table.The head of the table is raised from the middle break.The foot of the
table is lowered; a padded footboard supports the feet.The arms may be placed on the
patients lap on a pillow and secured with softly padded restraints. The safety strap is
secured over a blanket above the knees. For the special nursing interventions to consider
regarding the child as patient, see Pediatric General Information, p. 978.When general
anesthesia with endotracheal intubation is administered (to all children and some adults),
the patient is supine, positioned at the top edge of the table; the head may be placed on a
padded, foam, or gel headrest. A rolled towel is placed under the shoulders to gently extend
the neck. The arms may be restrained using softly padded restraints secured to the table for
either the adult or child (depending on the size of the child), or one arm is padded and
restrained and the contralateral arm is secured on a padded armboard. A pillow may be
placed under the knees to avoid straining low back muscles, or the table may be flexed for
comfort (adults). For both positions [i.e., semi-Fowlers (sitting) and supine] all bony
prominences and areas vulnerable to skin and neurovascular trauma or pressure are
padded. When monopolar electrosugery is employed an electrosurgical dispersive pad is
placed (e.g., under the shoulder).

Skin Preparation
T & A is considered a clean procedure, and there is no skin prep. The best possible
technique is employed to prevent infection.

Draping
A sheet is draped over the patients body. Use of a head drape is optional; for head drape,
see Draping, Submucous Resection of the Nasal Septum, When the operating fiberoptic microscope is used, it is not draped.

Equipment
Padded, foam, or gel headrest, e.g., donut, optional
Padded upper-extremity restraints and additional padding (e.g.,

foam padded cups on elbows and heels), as necessary to avoid

pressure injury
Shoulder roll, e.g., rolled towel, optional
Padded footboard and pillow (sitting position, adults)
Suction
Blade, (1) #12
ESU, monopolar or bipolar (monopolar for electrosurgical suction),
optional
Diathermy unit for bipolar bayonet forceps, optional
Fiber-optic headlight (may contain camera) and fiber-optic light
source (e.g., Xenon 300 W)
Operating fiber-optic microscope, e.g., Zeiss, optional
Laser, CO2 or SLT Contact Laser system and laser adaptor for
microscope (use all laser safety precautions)
Sitting stools (when microscope is used)
Fiber-optic light source (e.g., Xenon 300 W) for fiber-optic endoscope,
optional
Monitor, optional
Camera console, optional
VCR, optional
CD burner, optional
Printer, optional
Video attachment to the microscope
Microdebrider console with foot pedal, e.g., Medtronic XPS
3000, optional
Harmonic Scalpel generator with foot pedal (or hand activation),
optional
RF coblation generator, optional

Instrumentation
Tonsillectomy and Adenoidectomy tray
Electrosurgical suction (with side port) and cord (optional), Beckman
adenotomes, Guggenheim forceps, Lucs forceps, and
pilar retractor
Diathermy bipolar bayonet forceps and cord, optional
RF coblation probe and cord (radio frequency)
834

Chapter 27 Otorhinolaryngological (ENT) Surgery

Alternate technology uses adapted instrumentation similar to that

used in the open procedure
Laser
Adaptor for endoscope, laser (e.g., Nd:YAG) fiber, cord, and special
instrumentation
Microdebrider (shaver)
Handpiece, oscillating blade set with removable interchangeable 12_
and 40_ blades, outer cutting tubes, and an RADenoid blade (4.5mm blade for adults and 4.0-mm blade for children), Hurd dissector
(7 mm), pilar retractor (11 mm), and left and right stabilizers
RF Coblation
Radio-frequency probe and cord
Harmonic Scalpel (Ultrasonic)
Cord, handpiece, and open or endoscopic instrumentation
Endoscopic
Video coupler and laser adaptor, rigid Hopkins 0_ and 30_ angled,
ebonized rhinoscope and cord, and special instrumentation
for that approach

Supplies

Medicine cups (2), paper labels, and indelible marking pen

Local anesthetic, e.g., lidocaine/xylocaine 1% with epinephrine
1:100,000
Control syringes (2) and needles, e.g., 27 gauge _ 11/2 and spinal
needle, e.g., 27 gauge
Basin set
Suction tubing
Blade, (1) #12
Needle magnet
Electrosurgical pencil with extender, cord, holder, and scraper
Foley catheter for retraction
Tonsil sponges
Plain suture (usually), 20 ties or 20 swaged on tonsil needle
Microdebrider dual tubing for irrigation and suction, or polyethylene
IV tubing connected to bag of irrigation solution and
suction tubing