Surgery to remove tonsils (tonsillectomy)

Tonsillectomy (removal of tonsils) requires special surgical skills, precision of manipulation, the ability to operate with an increased pharyngeal reflex and often with profuse bleeding. Each experienced surgeon has his own operating style and his own techniques, developed in the process of practical work.

Preparing for Tonsillectomy

Preparation for tonsillectomy involves examining the state of the blood coagulation system (coagulogram, bleeding time, hemogram parameters, including the number of platelets, etc.), along with a set of other laboratory tests that are standard for any surgical intervention, which represents a certain risk factor for possible bleeding and other possible complications. If these parameters deviate from normal limits, their cause is examined and measures are taken to restore them to normal levels.

Anesthesia

In the vast majority of cases, tonsillectomy in adolescents and adults is performed under local anesthesia. Modern technology of general anesthesia allows this operation to be performed at any age. For local anesthesia, a 1% solution of novocaine, trimecaine or lidocaine is used. Before the operation, an intradermal test is performed for the sensitivity of the anesthetic substance used. In case of increased sensitivity, the operation can be performed under pressure infiltration of the peritonsillar region with an isotonic solution of sodium chloride. If possible, application anesthesia should be avoided, especially spraying, since it blocks the tactile receptors of the laryngopharynx, which contributes to the flow of blood into the larynx and esophagus. Adding adrenaline to the anesthetic solution is also undesirable, since it causes temporary vascular spasm and after removal of the tonsil creates the illusion of no bleeding, which may occur already in the ward due to the cessation of the effect of adrenaline.

Infiltration anesthesia is performed using a 10 ml syringe and a long needle on a thread fixed to the surgeon's IV finger (to prevent the needle from getting into the throat if it accidentally "jumps off" the syringe). With each injection, 3 ml of anesthetic is administered, while trying to create a depot of this substance behind the tonsil capsule. It is additionally recommended to administer anesthetic into the lower pole (the area in the projection of which the tonsils are excised) and into the middle part of the posterior arch. Carefully administered anesthesia allows for a virtually painless and unhurried operation on both tonsils and subsequent hemostasis. Some authors recommend performing the operation "in a dry field", for which, instead of a raspatory spoon, a gauze ball fixed in a Mikulich clamp is used to separate the tonsils, which is used to separate the tonsil from the underlying tissues and simultaneously to dry the surgical field.

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Technique for tonsillectomy

Below we will dwell on the general rules of tonsillectomy, which can be useful for novice ENT surgeons. In technical terms, tonsillectomy consists of several stages. 5-7 minutes after anesthesia, a sharp-tipped scalpel is used to make an incision along the entire thickness of the mucous membrane (but not deeper!) between the anterior arch (along its posterior edge) and the palatine tonsils. To do this, the tonsil is grasped with a clamp with a rack or Brunings forceps closer to the upper pole and pulled inward and backward. This technique straightens and stretches the fold of the mucous membrane located between the arch and the tonsil, which facilitates the incision to the specified depth. The incision is made along this fold from the upper pole of the tonsil to the root of the tongue, trying not to “jump” the scalpel onto the arch, so as not to injure it. At the same time, the triangular fold of the mucous membrane located at the lower end of the anterior palatine arch is also dissected. If it is not dissected with a scalpel, then in order to free the lower pole, it is dissected with scissors before cutting off the tonsil with a loop. After the mucous membrane has been cut along the anterior arch, a similar action is performed with respect to the mucous membrane located at the upper pole of the tonsil, with a transition to the fold of the mucous membrane lying between the posterior edge of the posterior palatine arch and the tonsil; this incision is also carried out to the lower pole of the tonsil.

The next step is separating the tonsil from the arches. To do this, use the hook end of the raspatory spoon, which is inserted into the previously made incision between the anterior arch and the palatine tonsils, deepen it and, with “soft” up-and-down movements along the arch, carefully pressing against the tonsil, separate it from the anterior arch. It should be noted here that a correctly made incision and unforced separation of the arch from the tonsil allow avoiding a rupture of the arch, which often occurs in inexperienced surgeons with cicatricial adhesion of the arch to the tonsil capsule. In these cases, one should not force the separation of the arch from the tonsil using a hook raspatory, since this inevitably leads to a rupture of the arch. If cicatricial fusion of the arch with the tonsil is detected, the scar is dissected with scissors, pressing against the tonsil, after drying the surgical cavity with a gauze ball. A similar manipulation is performed with respect to the posterior arch. The most important stage of this part of the surgical intervention is the extracapsular isolation of the upper pole of the tonsil, since everything that follows does not present any particular technical difficulties. With the normal structure of the palatine tonsils, the isolation of the upper pole is carried out by preliminary separation from the fornix of the niche with a hook-shaped raspatory and subsequent lowering with a raspatory spoon. Certain difficulties with the isolation of the upper pole arise in the presence of a supratindalar fossa, in which a lobe of the tonsil is located. In this case, the raspatory spoon is inserted high along the lateral wall of the pharynx between the palatine arches with the convexity laterally, and the above-mentioned lobe is removed medially and downwards with a raking motion. Next, fixing the tonsil with clamps 1 or 2, slightly pulling it medially and downwards, separate it from its niche with a raspatory spoon, gradually moving the spoon between it and the wall of the niche and moving it in the medial direction. No rush is required at this stage. Moreover, if bleeding interferes, the separation should be stopped and the released part of the niche should be dried with a dry gauze ball clamped with a Mikulich clamp using a rack. In order to avoid aspiration of gauze or cotton balls, the severed tonsil, etc., all "free" objects in the oral cavity and pharynx must be securely fixed with clamps with locks. For example, it is impossible to cut off the palatine tonsils with a loop, fixing it only with the force of the hand with Bruenigs forceps, which do not have a lock. If necessary, the bleeding vessel is clipped with a Pean or Kocher clamp, if necessary, it is ligated or subjected to diathermocoagulation. Next, complete the isolation of the tonsil to the very bottom, including its lower pole, so that it remains fixed only on a flap of mucous membrane. After this, to achieve hemostasis, some authors recommend placing the separated (but not yet removed) palatine tonsil back into its niche and pressing for 2-3 minutes. The explanation for this technique is based on the assumption thatthat on the surface of the removed tonsil (specifically on its back side facing the niche) biologically active substances are released that increase blood clotting and promote faster thrombus formation.

The final stage of tonsil removal is the excision of the tonsil using a loop tonsillotome. To do this, a clamp with a rack is inserted into the loop of the tonsillotome, with the help of which the palatine tonsil hanging on a stalk is securely grasped. When pulling it with the clamp, the loop is put on it and advanced to the lateral wall of the pharynx, while ensuring that the loop does not clamp part of the tonsil, but only covers a flap of the mucous membrane. Then the loop is slowly tightened, squeezing and crushing the vessels in its path, and with a final effort the tonsil is excised and sent for histological examination. Next, hemostasis is performed. To do this, a large dry cotton ball, fixed with a Mikulich clamp, is inserted into the niche and pressed against its walls for 3-5 minutes, during which, as a rule, bleeding from small arterioles and capillaries stops. Some authors practice treating niches with a gauze ball with ethyl alcohol, citing this technique as the ability of alcohol to coagulate small vessels.

Complications

When bleeding from larger vessels occurs, which is manifested by a thin pulsating stream of blood, the bleeding site together with the surrounding tissues, in which the end of the bleeding vessel should be located, is grasped with a clamp and tied with a silk thread (which is not so reliable) or stitched, bringing the end of the clamp above the ligature. If the source of bleeding cannot be determined or several small vessels are bleeding simultaneously, or the entire wall of the niche, then the niche is tamponed with a gauze swab, rolled into a ball according to the size of the niche, soaked in a solution of novocaine with adrenaline, and tightly fixed by suturing the palatine arches above it - another, in addition to the functional, reason for the need to carefully preserve the palatine arches intact. If the operation is performed in such a way that one or both palatine arches are removed together with the tonsil and there is a need to stop bleeding from the niche, then a special clamp can be used, one end of which with a gauze ball fixed in it is inserted into the tonsil niche, and the other is placed on the submandibular region in the projection of the bleeding niche and pressed to the skin. The clamp causes significant discomfort to the patient, so it is applied for no more than 2 hours. If the above procedures do not stop the bleeding, which takes on a threatening nature, then they resort to ligation of the external carotid artery.

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Ligation of the external carotid artery

When ligating the external carotid artery, the operating space is located mainly in the area of the carotid fossa or triangle of the carotid artery, limited internally and below by the superior belly of the omohyoid muscle, internally and above by the posterior belly of the digastric muscle, which serves as a continuation of the anterior belly of this muscle, connected to each other by an intermediate tendon attached to the hyoid bone, and behind by the anterior edge of the sternocleidomastoid muscle.

The operation is performed under local infiltration anesthesia with the patient lying on his back with his head turned to the side opposite to the operated side. The skin and subcutaneous muscle of the neck are incised along the outer edge of the sternocleidomastoid muscle in the area of the carotid triangle, starting from the angle of the lower jaw to the middle of the thyroid cartilage. Under the separated flaps of skin and subcutaneous muscle of the neck, the external jugular vein is found, which is either moved aside or resected between two ligatures. Next, the superficial fascia of the neck is dissected and, starting from the anterior edge, the sternocleidomastoid muscle is isolated, which is moved outward with a retractor convenient for this purpose (for example, a Farabeuf retractor).

The deep fascia of the sternocleidomastoid muscle is dissected along a ferruginous probe from below upwards along the entire wound. At the level of the greater horn of the hyoid bone, determined by palpation, which is located in the middle part of the wound, two blunt hooks are installed, and after moving the sternocleidomastoid muscle outward, the hypoglossal nerve is found in the upper part and slightly below the thyroglossal-facial venous trunk, which is moved downwards and inwards. In the triangle formed by the hypoglossal nerve, the internal jugular vein and the said venous trunk at the level of the greater horn of the hyoid bone, the external carotid artery is found along the collaterals and branches extending from it. The superior laryngeal nerve passes obliquely under the artery. After isolating the artery, it is verified by clamping it with a soft clamp and checking for the absence of blood flow in the facial and superficial temporal arteries. The absence of pulsation in these arteries indicates that the external carotid artery has been correctly identified. After this, the external carotid artery is ligated with two ligatures.

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