ADENO TONSILLITISADENO TONSILLITIS

Dr. A. KARUNAGARAN, M.S. Dr. A. KARUNAGARAN, M.S. D.L.O,D.L.O,

AnatomyAnatomy

• Waldeyer`s inner ring consists Waldeyer`s inner ring consists collection of sub epithelial lymphoid collection of sub epithelial lymphoid tissuetissue

• AdenoidsAdenoids

• Palatine tonsilPalatine tonsil

• Tubal tonsilTubal tonsil

• Lingual tonsilLingual tonsil

Anatomy – tonsil Anatomy – tonsil

• Bilateral ovoid masses of lymphoid Bilateral ovoid masses of lymphoid tissuetissue

• Almond shapeAlmond shape• Partly covered by capsulePartly covered by capsule• Medial surface has 15 – 20 crypts, Medial surface has 15 – 20 crypts,

biggest is crypta magnabiggest is crypta magna• Mucosal folds – in superior pole plica Mucosal folds – in superior pole plica

semilunaris, in inferior pole plica semilunaris, in inferior pole plica triangularistriangularis

Anatomy – adenoids Anatomy – adenoids

• Present at the junction of roof and Present at the junction of roof and posterior wall of nasopharynxposterior wall of nasopharynx

• Has furrows and ridgesHas furrows and ridges

• Appear like bunch of bananaAppear like bunch of banana

• Feels like bag of wormsFeels like bag of worms

Anatomy Anatomy

Blood supply - TonsilsBlood supply - Tonsils

Facial a.Facial a.

Lingual a. Dorsal lingual Tonsil Lingual a. Dorsal lingual Tonsil

Ascending pharyngeal TonsilAscending pharyngeal TonsilMaxillary Maxillary Lesser descending palatine Lesser descending palatine

TonsilTonsil

Tonsillar branch Tonsil (main branch)

Ascending palatine Tonsil

AnatomyAnatomy

Blood supply – AdenoidsBlood supply – Adenoids

• Ascending palatine branch of facial a.Ascending palatine branch of facial a.

• Ascending pharyngeal a.Ascending pharyngeal a.

• Pharyngeal branch of IMAX.Pharyngeal branch of IMAX.

• Ascending cervical branch of Ascending cervical branch of thyrocervical trunk.thyrocervical trunk.

Tonsils AdenoidsPaired structure Solitary structure

Present in lateral wall of oro pharynx

Present in naso pharynx

Covered by non keratinizing stratified sqamous epithelium

Coverd by ciliated columnar epithelium

Covered by capsule on the lateral wall

No capsule

Has crypts No crypts, only furrows

Almond shaped Bunch of banana

Both afferent and efferents present

no afferent only efferents present

Surface IgA present No capsule secretory IgA

Differences between tonsils and adenoids

Infecting Organisms Aerobic Bacteria

• Strep pyogenes (Gr A beta-hemolytic)

• Strep pneumoniae

• Strep viridans & other Streptococci

• Staph aureus

• H. Influenzae

• Diphtheroids

• Neisseria spp.

Infecting Organisms

Anaerobic Bacteria

• Bacteroides

• Peptococcus

• Peptostreptococcus

• Veillonella

• Fusobacteria

Infecting Organisms

Viruses• Epstein-Barr• Cytomegalovirus• Adenovirus• Herpes simplex• Influenza A and B• Parainfluenzae

Microbiology of Tonsillitis Group A beta-hemolytic • Is most recognized - associated with a risk of

rheumatic fever and glomerulonephritis

Beta-lactamase producing organisms • Are of particular importance.• Produced by Staph aureus, M. catarrhalis &

H.influenzae• Protect Group A Streptococci from eradication

with penicillins • Accounts for 39% of all cultured organisms

Who gets Tonsillitis ?

• Most often occurs in children – all experience at least 1 episode

• Rarely in children younger than 2 yr• Viral tonsillitis in younger children• Streptococcal tonsillitis in children

aged 5-15 yr• Poor socioeconomic status & over

crowding

PathophysiologyPathophysiology

• Viral InfectionsViral Infections

• Bacterial InfectionsBacterial Infections

• Inflammatory exudates of the cryptsInflammatory exudates of the crypts

• Epithelial keratinisationEpithelial keratinisation

• Deep-seated multiple abscess formation Deep-seated multiple abscess formation with increasing germ centerswith increasing germ centers

• Parenchyma destructionParenchyma destruction

• Immunologic FactorsImmunologic Factors

Unanswered QuestionsUnanswered Questions

• Do virus infections in the pharynx and Do virus infections in the pharynx and tonsils predispose to bacterial infection?tonsils predispose to bacterial infection?

• Is it possible to have an infective Is it possible to have an infective condition involving the pharyngeal condition involving the pharyngeal lymphoid tissue without affecting the lymphoid tissue without affecting the tonsils?tonsils?

• Is there such a condition as chronic Is there such a condition as chronic tonsillitis?tonsillitis?

• Why are some patients susceptible to Why are some patients susceptible to acute pharyngitis and acute tonsillitis acute pharyngitis and acute tonsillitis and others not?and others not?

• Does the tonsil become irreversibly Does the tonsil become irreversibly diseased after many episodes of acute diseased after many episodes of acute tonsillitistonsillitis? ?

Acute TonsillitisAcute Tonsillitis

Symptoms:Symptoms:FeverFeverSore throatSore throatDysphagia or OdynophagiaDysphagia or OdynophagiaAirway ObstructionAirway ObstructionLethargy / malaiseLethargy / malaise

Acute Tonsillitis - SignsAcute Tonsillitis - Signs

• EnlargedEnlarged

• ErythematousErythematous

• Exudative forming Exudative forming at times at times pseudomembranepseudomembrane

• Enlarged neck Enlarged neck nodesnodes

Grading the Size of TonsilsGrading the Size of Tonsils

Grading system:A. 0 – tonsils in fossaB. +1 – tonsils less than 25%C. +2 – tonsils less than 50%D.+3 – tonsils less than 75%E. +4 – tonsils greater than

75%

Features of adenoid faciesFeatures of adenoid facies

• Open mouth and mouth breathingOpen mouth and mouth breathing• Pinched nostrilsPinched nostrils• Crowded teeth andhyper plasia of gumsCrowded teeth andhyper plasia of gums• Loss of naso labial foldLoss of naso labial fold• Under slung mandibleUnder slung mandible• High arched V shaped palateHigh arched V shaped palate• Short upper lipShort upper lip• Hypo plasia of maxillaHypo plasia of maxilla• Vacant expressionVacant expression• Pectus excavatumPectus excavatum• Rouned shouldersRouned shoulders• Voice changes- nasal and lifelessVoice changes- nasal and lifeless

Lingual TonsilsLingual Tonsils

• Hyperplasia is the most common abnormality of the Hyperplasia is the most common abnormality of the lingual tonsil. lingual tonsil.

• Lingual tonsils sit on the base of the tongue and Lingual tonsils sit on the base of the tongue and extend to the vallecula and do not have a capsule. extend to the vallecula and do not have a capsule.

• Can be visualized by indirect mirror or flexible Can be visualized by indirect mirror or flexible laryngoscopylaryngoscopy

• Clinically, infection is marked by erythema and Clinically, infection is marked by erythema and enlargement of tonsillar tissue.enlargement of tonsillar tissue.

• Suspension microlaryngoscopy with removal by COSuspension microlaryngoscopy with removal by CO22 laser, sharp dissection or hot knife cautery are some laser, sharp dissection or hot knife cautery are some of the treatments available.of the treatments available.

Lingual TonsilLingual Tonsil

• History and Physical:History and Physical:– Sore throatSore throat– Globus sensation Globus sensation – Speech changeSpeech change– Dysphagia Dysphagia – Obstructive sleep apnea in adultsObstructive sleep apnea in adults– Pediatric airway obstruction Pediatric airway obstruction – Often discovered incidentally during intubation in Often discovered incidentally during intubation in

preparation for surgery that is unrelated to the preparation for surgery that is unrelated to the ear, nose, and throat. ear, nose, and throat.

Lingual TonsilsLingual Tonsils

• Differential diagnosisDifferential diagnosis– lingual thyroid tissuelingual thyroid tissue– thyroglossal duct cyst thyroglossal duct cyst – dermoid cyst dermoid cyst – lymphangioma lymphangioma – angioma angioma – adenoma adenoma – fibroma fibroma – papilloma papilloma – lymphoma lymphoma – squamous cell carcinoma squamous cell carcinoma – minor salivary gland tumors on the base of the minor salivary gland tumors on the base of the

tonguetongue

Lingual TonsilsLingual Tonsils

• Hypertrophy of lingual tonsils in 62% of persons with laryngoscopic signs of reflux and in 75% of persons with pharyngolaryngeal symptoms of LPR.

• Although the lymphoid tissue in Waldeyer's ring tends to decrease with advancing age, the lingual tonsil may increase in size.

• The most important cause of lingual tonsil hypertrophy is the occurrence of compensatory hyperplasia following adenotonsillectomy.

Differential Diagnosis of pseudomembranous tonsillitis

Infectious MononucleosisInfectious Mononucleosis

• Cheesy exudates Cheesy exudates covering tonsilcovering tonsil

• Lymphadenopathy Lymphadenopathy ofof

neck, axilla & neck, axilla & groingroin

• Hepato/Hepato/SpleenomegalySpleenomegaly

Oral ThrushOral Thrush

• Painful throatPainful throat

• White candidiasis White candidiasis patches when patches when removed leaves removed leaves erythematous erythematous ulcerulcer

• ImmunosuppressiImmunosuppressive stateve state

Keratosis tonsilsKeratosis tonsils

• Incidental findingIncidental finding

• May cause slight May cause slight discomfortdiscomfort

• Yellow horny Yellow horny outgrowths in the outgrowths in the crypts crypts

AgranulocytosisAgranulocytosis

• Halistosis, fever, Halistosis, fever, headache & headache & dysphagiadysphagia

• Single , multiple Single , multiple or coalesce or coalesce necrotic slough necrotic slough covered ulcerscovered ulcers

• LeucopeniaLeucopenia

• H/O causative H/O causative drugs intakedrugs intake

DiphtheriaDiphtheria

• Malaise, fever & Malaise, fever & headacheheadache

• Greyish green Greyish green membrane across membrane across tonsils to larynxtonsils to larynx

• Tender bilateral Tender bilateral cervical cervical lymphadenopathylymphadenopathy

Vincent’s anginaVincent’s angina• Fetor oris, pyrexiaFetor oris, pyrexia

• Tonsillar deep ulcers Tonsillar deep ulcers with grey slough in its with grey slough in its basebase

• Necrotising gingivitisNecrotising gingivitis

• Enlarged tender Enlarged tender cervical adenitiscervical adenitis

• Smear:Smear:

Spirochaetes & Spirochaetes & Fusiform bacilliFusiform bacilli

Acute lymphatic leukemiaAcute lymphatic leukemia

• Fever, anaemia & Fever, anaemia & bleeding bleeding disordersdisorders

• Slough covered Slough covered membrane membrane forming forming ulcerationsulcerations

• Cervical Cervical lymphadenopathylymphadenopathy

• Exaggerated Exaggerated leucocytosisleucocytosis

Recurrent Acute TonsillitisRecurrent Acute Tonsillitis

• Same signs and Same signs and symptoms as symptoms as acuteacute

• Occurring in 4-7 Occurring in 4-7 separate separate episodes per episodes per yearyear

• 5 episodes per 5 episodes per year for 2 yearsyear for 2 years

• 3 episodes per 3 episodes per year for 3 yearsyear for 3 years

• Ant pillar peri Ant pillar peri tonsillar erythematonsillar erythema

• Smooth glistening Smooth glistening tonsil with dilated tonsil with dilated blood vessels on blood vessels on the surfacethe surface

• Debris in crypts Debris in crypts which are few due which are few due to loss of tonsil to loss of tonsil architecturearchitecture

Chronic TonsillitisChronic Tonsillitis

• Chronic sore throatChronic sore throat

• Malodorous breathMalodorous breath

• Presence of tonsillithsPresence of tonsilliths

• Peritonsillar erythemaPeritonsillar erythema

• Persistent cervical Persistent cervical lymphadenopathylymphadenopathy

• Lasting at least 3 monthsLasting at least 3 months

Local ComplicationsLocal Complications

• Respiratory obstructionRespiratory obstruction

• QuinsyQuinsy

• Acute retropharyngeal abscessAcute retropharyngeal abscess

• Parapharyngeal abscessParapharyngeal abscess

• Neck space infections Neck space infections

• Acute otitis mediaAcute otitis media

Retropharyngeal abscessRetropharyngeal abscess

• Dysphagia, fever Dysphagia, fever

• Pharynx either Pharynx either normal or smooth normal or smooth bulge of posterior bulge of posterior pharyngeal wallpharyngeal wall

• Airway Airway obstruction obstruction

• Neck rigidNeck rigid

Peritonsillar AbscessPeritonsillar Abscess• Abscess formation Abscess formation

outside tonsillar outside tonsillar capsulecapsule

• Signs and symptoms:Signs and symptoms:– FeverFever– Sore throatSore throat– Dysphagia/Dysphagia/

odynophagiaodynophagia– DroolingDrooling– TrismusTrismus– Unilateral swelling of Unilateral swelling of

soft palate/pharynx soft palate/pharynx with uvula deviationwith uvula deviation

Peritonsillar Peritonsillar AbscessAbscess• Incidence: estimated 30 cases Incidence: estimated 30 cases

per 100,000 in US. per 100,000 in US.

• Diagnosis is usually by physical exam Diagnosis is usually by physical exam but other modalities have been but other modalities have been used such as US and CT.used such as US and CT.

• Widely accepted that Widely accepted that Staphylococcus Staphylococcus aureusaureus is the most common organism is the most common organism causing the infection and origin is usually causing the infection and origin is usually from the superior pole of the tonsil (from from the superior pole of the tonsil (from minor salivary gland - AKA: Weber gland).minor salivary gland - AKA: Weber gland).

Peritonsillar AbscessPeritonsillar Abscess• Quinsy tonsillectomy vs. Interval Quinsy tonsillectomy vs. Interval

tonsillectomytonsillectomy– Quinsy tonsillectomy can be a treatment option Quinsy tonsillectomy can be a treatment option

in pediatric patients to young to withstand in pediatric patients to young to withstand bedside aspiration or I&D for recurrent PTA. bedside aspiration or I&D for recurrent PTA.

– Quinsy tonsillectomy can be surgically easier Quinsy tonsillectomy can be surgically easier than interval tonsillectomy as fibrosis has not than interval tonsillectomy as fibrosis has not had time to set into the tonsillar capsule.had time to set into the tonsillar capsule.

– Review by Johnson, discussed interval Review by Johnson, discussed interval tonsillectomy for recurrent PTA with prevalence tonsillectomy for recurrent PTA with prevalence of 10%.of 10%.

– Interval tonsillectomy can be considered after Interval tonsillectomy can be considered after successful abscess drainage, usually from successful abscess drainage, usually from recurrent PTA after 6 weeks.recurrent PTA after 6 weeks.

ParapharyngealParapharyngeal abscess abscess

• Fever, Fever, dysphagia & dysphagia & airway airway obstructionobstruction

• Swelling below Swelling below soft palate over soft palate over the pharynxthe pharynx

• Tender firm Tender firm swelling in the swelling in the upper part of upper part of neckneck

Acute otits mediaAcute otits media

• Preceding URI & Preceding URI & blocked earblocked ear

• Severe otalgiaSevere otalgia

• Bulging Bulging congested ear congested ear drumdrum

• Eustachian Eustachian catarrhcatarrh

Systemic ComplicationsSystemic Complications

• Acute rheumatic feverAcute rheumatic fever

• Acute glomerulonephritisAcute glomerulonephritis

• Bacterial endocarditisBacterial endocarditis

• DermatitisDermatitis

• SepticemiaSepticemia

• Septic abscessesSeptic abscesses

• Septic arthritis Septic arthritis

• MenigitisMenigitis

InvestigationsInvestigations

• CBC & serum electrolytes CBC & serum electrolytes • Crypt swab culture & sensitivity – 60% Crypt swab culture & sensitivity – 60%

specificityspecificity• Crypt aspiration culture & sensitivity –Crypt aspiration culture & sensitivity –ed ed

specificityspecificity• A rapid antigen detection test (RADT) has 95% A rapid antigen detection test (RADT) has 95%

specificityspecificity• Serum examined for anti-streptococcal Serum examined for anti-streptococcal

antibodies – ASO titre - Useful for documenting antibodies – ASO titre - Useful for documenting prior infections in – acute rheumatic fever, prior infections in – acute rheumatic fever, glomerulonephritis or other complicationsglomerulonephritis or other complications

• Monospot serum testMonospot serum test

Medical Management ofMedical Management ofAcute TonsillitisAcute Tonsillitis

Largely supportive Largely supportive Adequate hydration and caloric intakeAdequate hydration and caloric intakeControl pain Control pain Antibiotics –Antibiotics –

• Penicillin – 1Penicillin – 1stst line treatment line treatment

• Macrolides, Cephalosporins, Macrolides, Cephalosporins, ClindamycinClindamycin

• Vancomycin and Rifampin are also usedVancomycin and Rifampin are also used

Current Indications for Current Indications for TonsillectomyTonsillectomy• Recurrent tonsillitis Recurrent tonsillitis • Chronic persistent tonsillitisChronic persistent tonsillitis• Hypertrophic obstructive Tonsillitis not responding Hypertrophic obstructive Tonsillitis not responding

to medicine causing dysphagia or OSAto medicine causing dysphagia or OSA• Diphtheria carrier stateDiphtheria carrier state• Rec Peritonsillar abscess +/_ Rec tonsillitis Rec Peritonsillar abscess +/_ Rec tonsillitis • Unilateral tonsillar hypertrophyUnilateral tonsillar hypertrophy• Benign tumours of tonsil like papilloma, adenomaBenign tumours of tonsil like papilloma, adenoma• Chronic tonsillolithChronic tonsillolith• As an approach to IX nerve, elongated styloid As an approach to IX nerve, elongated styloid

process process

Adenoidectomy-IndicationsAdenoidectomy-Indications

• Recurrent or chronic sinusitis or adenoiditisRecurrent or chronic sinusitis or adenoiditis– Poorly understood - possibly caused by Poorly understood - possibly caused by

obstructive adenoid tissue causing stasis of obstructive adenoid tissue causing stasis of secretions predisposing the nasal cavity to secretions predisposing the nasal cavity to infection.infection.

• Otitis media Otitis media – Proximity of adenoid tissue to eustachian tubeProximity of adenoid tissue to eustachian tube– Adenoidectomy can be recommended on 1Adenoidectomy can be recommended on 1stst set set

of tubes if nasal obstruction and recurrent of tubes if nasal obstruction and recurrent rhinorrhea is present or on 2rhinorrhea is present or on 2ndnd set of tubes if set of tubes if needed. needed.

Contra indications for adeno Contra indications for adeno tonsillectomytonsillectomy• Epidemic of polioEpidemic of polio• Age below 3 yearsAge below 3 years• Acute infectionsAcute infections• Blood dyscrasiasis: hemophilia, purpuraBlood dyscrasiasis: hemophilia, purpura• Uncontrolled systemic diseases like diabetes and Uncontrolled systemic diseases like diabetes and

heart diseasesheart diseases• Velopharyngeal insufficiencyVelopharyngeal insufficiency

– Overt cleft palate, submucous (covert) cleftOvert cleft palate, submucous (covert) cleft– Neurologic or neuromuscular abnormality leading to Neurologic or neuromuscular abnormality leading to

impaired palate functionimpaired palate function

• AnemiaAnemia

Cold steel InstrumentsCold steel Instruments

Complications of Complications of TonsillectomyTonsillectomy• HaemorrhageHaemorrhage

• Haematoma & oedema uvulaHaematoma & oedema uvula

• InfectionInfection

• Pulmonary complicationsPulmonary complications

• Remnant tonsilsRemnant tonsils

• Referred otalgiaReferred otalgia

• Post operative scarring causing voice Post operative scarring causing voice change or nasal regurgitationchange or nasal regurgitation

ComplicationsComplications• Noniatrogenic complications after adenoidectomy

– Regrowth of adenoid tissue, particularly in very young children, which may require revision (secondary) adenoidectomy.

– Hypernasality, because of temporary pain splinting. Persistent hypernasality is rare and probably caused by unrecognized pre-existing velopharyngeal weakness.

– Atlantoaxial subluxation (Grisel’s syndrome), which presents with persistent torticollis 1-2 weeks after surgery.

• Iatrogenic complications after adenoidectomy include– Dental injury, from intubation or the mouth gag – Nasopharyngeal stenosis, caused by excessive

tissue removal. – Eustachian tube injury

The Modern Tonsillectomy

• HistoryHistory

• IndicationsIndications

• Innovative Techniques and Innovative Techniques and ComorbiditesComorbidites– Intracapsular tonsillectomyIntracapsular tonsillectomy– Harmonic scalpelHarmonic scalpel– Laser Laser – CoblationCoblation

• Adjuvant TherapyAdjuvant Therapy– Local Anesthesia: BupivacaineLocal Anesthesia: Bupivacaine– Postoperative AntibioticsPostoperative Antibiotics

HistoryHistory• Aulus Cornelius CelsusAulus Cornelius Celsus

– 11stst Century AD Century AD– ““the tonsils are loosened by scraping around the tonsils are loosened by scraping around

them and then torn out” with a fingerthem and then torn out” with a finger– Used vinegar and medication for Used vinegar and medication for

postoperative hemostasispostoperative hemostasis

• Aetius of AmidaAetius of Amida– 66thth Century AD Century AD– Hook and knife methodHook and knife method

• Philip Syng Physick (“Father of American Philip Syng Physick (“Father of American surgery”) surgery”) – First to develop the tonsillotomeFirst to develop the tonsillotome

• MackenzieMackenzie– Late 1800sLate 1800s– Made tonsillotome use commonMade tonsillotome use common

Innovative TechniquesInnovative Techniques

• Intracapsular Intracapsular TonsillectomyTonsillectomy

• Harmonic ScalpelHarmonic Scalpel

• LaserLaser

• CoblationCoblation

• Guiding Principle: Guiding Principle: reduce morbidityreduce morbidity– HemorrhageHemorrhage– PainPain– Diet Diet – ActivityActivity– CostCost

Intracapsular TonsillectomyIntracapsular Tonsillectomy

– Tonsillar hypertrophy causing sleep Tonsillar hypertrophy causing sleep disordered breathingdisordered breathing• Intracapsular tonsillectomy Intracapsular tonsillectomy

– Microdebrider at 1500 rpm in oscillating modeMicrodebrider at 1500 rpm in oscillating mode– Hemostasis with suction cauteryHemostasis with suction cautery

•Total tonsillectomy Total tonsillectomy – SubcapsularSubcapsular

• ConclusionsConclusions– Intracapsular tonsillectomy is safe and Intracapsular tonsillectomy is safe and

efficacious in children under 3 years for efficacious in children under 3 years for tonsillar hypertrophy and sleep tonsillar hypertrophy and sleep disordered breathing without need for disordered breathing without need for admissionadmission

• LimitationsLimitations– Retrospective studyRetrospective study– Uneven distributionUneven distribution– Long term results of tonsillar regrowth Long term results of tonsillar regrowth

unknownunknown

Harmonic Scalpel Harmonic Scalpel TonsillectomyTonsillectomy

• Ultrasonic dissector and coagulatorUltrasonic dissector and coagulator• Vibratory energyVibratory energy

– Cutting: sharp blade with frequency of Cutting: sharp blade with frequency of 55.5 kHz over distance of 80 μm55.5 kHz over distance of 80 μm

– Coagulating: vibration breaks H-bonds, Coagulating: vibration breaks H-bonds, thermal energythermal energy•50° – 100° C50° – 100° C•Electrocautery 150° – 400° C Electrocautery 150° – 400° C

• Operative time statistically significantOperative time statistically significant– Harmonic scalpel 8 min 42 secHarmonic scalpel 8 min 42 sec– Electrocautery 4 min 33 secElectrocautery 4 min 33 sec

• No significant difference in intraoperative No significant difference in intraoperative blood loss and postoperative ability to eat blood loss and postoperative ability to eat and drinkand drink

• Level of activity for the first postop day Level of activity for the first postop day significantly lower in harmonic scalpel groupsignificantly lower in harmonic scalpel group

• Postoperative pain scores tended to be lower Postoperative pain scores tended to be lower in harmonic scalpel groupin harmonic scalpel group

• Postoperative bleeding Postoperative bleeding – Harmonic scalpel: 6Harmonic scalpel: 6– Electrocautery: 3Electrocautery: 3– Not statistically significantNot statistically significant

Laser TonsillectomyLaser Tonsillectomy

Compared the use of KTP laser Compared the use of KTP laser tonsillectomy versus cold dissection tonsillectomy versus cold dissection and snareand snare– KTP 532 laser at 10W, continuous beamKTP 532 laser at 10W, continuous beam– Outcomes measuredOutcomes measured

•Operative timeOperative time

•Operative bleedingOperative bleeding

•Postoperative painPostoperative pain

•Postoperative advancement to dietPostoperative advancement to diet

• ResultsResults– Operative time: Operative time:

• Laser 12 minLaser 12 min• Dissection 10 minDissection 10 min• Not statistically significantNot statistically significant

– Intraoperative blood lossIntraoperative blood loss• Laser 20 mLLaser 20 mL• Dissection 95 mLDissection 95 mL• Statistically significantStatistically significant

– Laser group with higher postop pain scoresLaser group with higher postop pain scores– Laser group with greater difficulty resuming Laser group with greater difficulty resuming

postoperative dietpostoperative diet– Readmission for delayed hemorrhage was 8% Readmission for delayed hemorrhage was 8%

in the laser group and 4% in the dissection in the laser group and 4% in the dissection groupgroup• Not statistically significantNot statistically significant

• ConclusionConclusion– KTP laser provides little benefit over KTP laser provides little benefit over

dissection tonsillectomy except to dissection tonsillectomy except to minimize intraoperative bleedingminimize intraoperative bleeding

• LimitationsLimitations– Technical expertiseTechnical expertise– Electrocautery not includedElectrocautery not included

Coblation TonsillectomyCoblation Tonsillectomy

• Bipolar radiofrequency energy transferred Bipolar radiofrequency energy transferred to sodium molecules to create an ion or to sodium molecules to create an ion or plasma fieldplasma field

• This thin layer of plasma is utilized to This thin layer of plasma is utilized to ablate tissues at molecular levelablate tissues at molecular level

• No need for electrocautery for hemostasisNo need for electrocautery for hemostasis

• Temperature from 40° to 85° C Temperature from 40° to 85° C

• Electrocautery at 20W: above 400° C Electrocautery at 20W: above 400° C

• CoblationCoblation– From surface out laterallyFrom surface out laterally– Coblate 9 setting to ablate tissuesCoblate 9 setting to ablate tissues– Coblate 5 setting to coagulate Coblate 5 setting to coagulate – Capsule not penetratedCapsule not penetrated

• ElectrocauteryElectrocautery– Bovie set to 20 WBovie set to 20 W

• Outcomes measuredOutcomes measured– QuestionnaireQuestionnaire

• PainPain• AnalgesicsAnalgesics• Nausea/vomitingNausea/vomiting• DietDiet• ActivityActivity

– Complications Complications

Coblation TonsillectomyCoblation Tonsillectomy• Future considerationsFuture considerations

– To evaluate coblation To evaluate coblation for intracapsular for intracapsular tonsillectomy, a fair tonsillectomy, a fair study would use another study would use another intracapsular technique intracapsular technique such as power-assisted such as power-assisted tonsillectomy with a tonsillectomy with a microdebridermicrodebrider

• TechniqueTechnique– Monopolar electrocautery used most oftenMonopolar electrocautery used most often

•Greatest for otolaryngologists in practice < 20 Greatest for otolaryngologists in practice < 20 yearsyears

•HemostasisHemostasis

– Sharp dissection most common for group Sharp dissection most common for group in practice > 20 years in practice > 20 years •Decreased painDecreased pain

•Method of hemostasis not mentionedMethod of hemostasis not mentioned

• Local Anesthetic evenly distributedLocal Anesthetic evenly distributed

ConclusionsConclusions

• Tonsillectomy is a surgical procedure Tonsillectomy is a surgical procedure that carries significant postoperative that carries significant postoperative morbiditymorbidity

• To minimize postoperative morbidity To minimize postoperative morbidity various techniques and adjuvant various techniques and adjuvant therapies have been studiedtherapies have been studied

• There are many options available and it There are many options available and it behooves an otolaryngologist to stay as behooves an otolaryngologist to stay as up to date as possibleup to date as possible

THANK YOUTHANK YOU