Special Surgical Procedures II
LESSON 1: Eye, Ear, Nose, and Throat (EENT) Surgery
Section IV: THROAT, TONGUE, AND NECK SURGERY
1-36
1-36. TONSILLECTOMY AND ADENOIDECTOMY
a. General. Tonsils and adenoids that are hypertrophied or chronically infected are removed, which is called a tonsillectomy and adenoidectomy (T&A). Acute bacterial infections can attack a ring of lymphoid tissue encompassing the tonsil and adenoid tissue. Pain, malaise, anorexia, and increased temperature are typical symptoms.
b. Preparation of the Operating Room.
(1) The instruments in the setup include those needed for either sharp or blunt dissection, according to the method preferred by the surgeon.
(2) The number of tonsil sponges, with cords attached for applying pressure to the tonsil fossa, is included.
(3) The lighting of the room is provided for in accordance with the desire of the surgeon. The circulator is to carefully check all details of lighting.
(4) Tonsil snare wires must be prepared correctly. The loop in the snare wire must be large enough to pass over the handle of the tenaculum, but it must not be so large that its size prevents cutting through the pedicle of the tonsil. The scrub is to prepare the snares in accordance with local policy.
(5) The mouth gag used must be of a correct size (not too large) to avoid inflicting injury to the patient's gums and lips and to avoid the danger of dislodging or breaking any teeth.
(6) Special straight or curved needles with a security stop are used for the injection of the local anesthetic agent.
(7) Sponges are normally handed on a curved hemostat.
(8) Suction cautery is used for control of bleeding.
c. Preparation of the Patient.
(1) If a general anesthetic is to be administered, the patient is anesthetized first, then placed in a slight Trendelenburg position. The neck is hyperextended by placing a roll under the shoulders. If a local anesthetic is to be administered, the patient is placed in a sitting position.
(2) The patient's face may be cleaned with a germicide. The patient is draped as follows:
(a) An opened sheet and two opened towels are placed under the head of the patient.
(b) The uppermost towel is wrapped around the head and secured by forceps, and the free ends of the towel are tucked under the head.
(c) A second sheet is placed over the patient.
d. Operative Procedure.
(1) When a general anesthetic is used, the mouth is retracted open with a self-retaining retractor, the tongue depressed with a blade retractor, and an anesthesia tube placed in the corner of the mouth. An efficient suction apparatus is most important. The tonsil suction tube is introduced gently and passed along the floor of the mouth, over the base of the tongue, and into the pharynx. During the procedure, the suctioning ensures adequate exposure of the operative site and prevents blood reaching the lungs.
(2) The tonsil is grasped with a pair of tonsil-grasping forceps and the mucous membrane of the anterior pillar incised with a knife; the tonsil lobe is freed from its attachments to the pillars with a tonsil dissector, curved scissors, and gauze sponges on a holder. The tonsil is withdrawn with forceps.
(3) The posterior pillar is cut with scissors, and the tonsil is removed with a snare. In some cases, the LaForce or Sluder tonsil guillotine clamp may be used.
(4) A tonsil sponge is placed in the fossa by a hemostat.
(5) Bleeding vessels are clamped with tonsil forceps, tied with slipknot ligatures of absorbable suture and the free ligature ends are cut.
(6) The adenoids are removed with an adenotome or curette. Bleeding is controlled by pressure with sponges.
(7) The fossa is carefully inspected, and any bleeding vessels are clamped and tied. Retractors are removed, the face of the patient is cleaned, and his head is turned to one side. The patient is kept in the semirecumbent (Fowler) position or on his side horizontally, to avoid aspiration of blood and venous engorgement.
e. Handling of Specimens. Tissue excised is processed for examination by the laboratory.
f. Suturing Types Usually Used.
(1) Absorbable suture of size specified by the surgeon--used for free ligatures.
(2) Absorbable suture, of size specified by the surgeon, affixed on tonsil needle--used for suture-ligature.
