Tonsillectomy - removal of palatine tonsils - adults

Tonsillectomy (a procedure for the removal of the tonsils) is a routine surgical procedure that allows to permanently solve the problem of chronic palatine tonsillitis when the conservative methods do not bring results.

Tonsillectomy - characteristics

The palatine tonsils are part of the lymphatic system of the throat, from the name of the discoverer known as the Waldeyer absorbent ring. In addition to the palatine tonsils, the lymphatic ring also consists of: lingual tonsil, pharyngeal tonsils, trumpet tonsils, lumps of the posterior throat wall and sidebands. Due to the fact that these structures lie on the border of the respiratory and digestive tract, i.e. in a place that is in frequent contact with pathogens and allergens, both inhaled and derived from food, it is desirable that they perform their immune function efficiently. The palatine tonsils and the pharyngeal tonsil are the most important structures of the throat immune system, and within them the production of lymphocytes and appropriate antibodies takes place, which constitute a defense against the antigens penetrating into the body. However, it may happen that due to various pathological processes taking place in the lymphatic tissue of the throat, such as a chronic inflammatory process, the immune function will be lost and it will be more beneficial to remove the palatine tonsils, i.e. tonsillectomy. Another term, tonsillotomy, is used to determine the procedure for trimming (partial removal) of the palatine tonsils, but currently this procedure is performed less and less frequently.

Tonsillectomy - benefits

The benefits of tonsillectomy in each patient will result directly from the indications, and therefore due to their diversity - they will also vary. For example: when referring a patient to a tonsillectomy due to unilateral enlargement of the tonsil, which raises the concerns of the ongoing cancer process, we can confirm or exclude it with the help of histopathological examination. If the patient, due to overgrown palatine tonsils, has a problem with sleep apnea - if it is the only cause, because even obesity or laxity of the soft palate may overlap - one can successfully get rid of this discomfort. The removal of palatine tonsils can eliminate the problem of recurrent angina as well as halitosis (halitosis).

It has been demonstrated that after tonsillectomy, the level of IgA, IgM, IgG protective immunoglobulins decreases in the whole organism (compared to pre-operative values), IgA concentration decreases in upper respiratory tract secretion, as well as polio antibodies against previously vaccinated ones. Before performing the procedure, one should be sure that the indications have been correctly determined and the benefits will be measurable and will prevail over the "costs" that the body will suffer as a result of such an operation. Sometimes tonsillectomy is performed together with adenoidectomy, i.e. "Third tonsil" - pharyngeal tonsils.

Tonsillectomy - indications for the procedure

Although tonsillectomy is one of the most frequently performed surgical procedures in the world, the indications for enucleation of palatine tonsils are not unambiguous and it is necessary to consider the appropriateness of performing such a procedure in a patient every time. However, it can be generally accepted that the indications for surgery fall into three categories: infection (primarily chronic palatine tonsillitis), enlargement with impaired patency of the airways and neoplastic changes.

Detailed indications for tonsillectomy:
• periapillary abscess
• sepsis or phlegmon, having exit in the tonsils
• palmar palatal hemorrhage, not available via other methods
• chronic palatine tonsillitis with inflammation of the paranasal sinuses and / or otitis
• hypertrophy of the palatine tonsils impeding swallowing and causing pain (dysphagia, odynophagia) or impaired patency of the airways - often leading to sleep apnea
• frequent, recurrent angina: 3 angina / 5 angina in 2 years / 7 angina in 3 years
• carrier of bacteria that cause diphtheria
• tuberculous cervical lymphadenitis
• recurrent lymphadenitis neckhalitosis - smelly smell from the mouth due to chronic retention of food residue in tonsil crypts and ongoing putrid processes
• suspicion of ongoing throat malignancy (such suspicion should be particularly prominent in the case of unilateral palatal tonsil enlargement) - squamous cell carcinoma is the most common tumor of adult tonsil. Not every enlargement or asymmetry of the tonsils must point to a tumor, it may also be a foreign body or a stone that remains in the tonsil.
General indications include chronic glomerulonephritis and rheumatic disease.

Tonsillectomy - contraindications for the procedure

Among the contraindications to perform tonsillectomy in adults should be mentioned:

• leukemia
• hemophilia (although according to some authors, the removal of palatine tonsils in hemophiliacs can be performed with adequate coagulation supplementation)
• plate defects
• poorly controlled diabetes due to the difficulty of post-operative wound healing with persistently high glycemia
• severe general diseases with poorly controlled course (severe circulatory failure, respiratory failure)
• cleft palate (this remains a relative contraindication)
• dry (atrophic) rhinitis mucosa
• the patient's age - old age is not absolute contraindication, however, due to the common occurrence of comorbidities after the age of 60, the safety of palatal tonsillectomy should be considered. Tonsillectomy is not performed in children under the age of 4 due to incomplete development of the immune system.

Tonsillectomy - before the procedure

Before the procedure, laboratory tests should be performed to assess the coagulation system (platelet count, prothrombin time, bleeding time and coagulation time, fibrinogen concentration and kaolin-cephalin time), especially if the patient is easily bruised and prone to prolonged bleeding after cuts. The qualifying physician should rule out cardiovascular diseases or diabetes. The patient reports on an empty stomach, at least 8 hours after the last meal and stops taking anticoagulants early enough. Before the procedure, no inflammatory process can take place within the teeth, and even if it is not visible to the naked eye and pain is present, you should first go to the dentist.

Tonsillectomy - a type of anaesthesia

Removal of the palatine tonsils is performed under general endotracheal anaesthesia after prior premedication. Some centers also perform this procedure under local anaesthesia.
Local anaesthesia involves the injection of surrounding tissues with an anesthetic which eliminates the feeling of pain, touch and temperature, and the patient remains conscious and minimizes the risk of complications. It is obviously reversible.

General anaesthesia of intraocular carries the patient's awareness and is divided into several stages: induction of anaesthesia, insertion of the tracheal tube into the trachea through the oral cavity, maintenance of anaesthesia and recovery.

It should be remembered that there is a risk of damage to the dentition during intubation. It is recommended to remove the dental prostheses.

Tonsillectomy - how does the procedure work?

If we perform the procedure under general anaesthesia, after anaesthesia and intubation of the patient (the patient lying down, with the head tilted back - under local anaesthesia, the patient sits), the front palatal arch is incisioned from the top and the palatine tonsil from the tonsil niche is dignified, after which it is cut off on the basis of a special tongue with a metal loop. Wounds on the cut tonsils do not suture, which is a kind of rarity in surgery, because the stitching of the palatal arches can change the color of the voice and make it difficult for the patient to swallow.

Tonsillectomy - time and course of convalescence

After the tonsillectomy, the patient usually stays in the hospital for 1-3 days, is kept under medical observation on mild painkillers and, of course, in the antibiotic cover. The first day you can not eat or drink, nutrients are given by a drip. In the following days, the liquid and semi-liquid diet is maintained, usually the patient drinks through a straw - but it is important to avoid hot and sharp foods. Difficulty swallowing and swelling of the throat walls may persist. During the first day, the patient is advised to put up only in the toilet, but as with any surgical procedure, immobilization can not be prolonged, as it may result in thromboembolic complications. For the same reason, you should ensure adequate hydration. For a few days after the procedure, subfebrile conditions may occur, which is a normal reaction of the body to the formation of an operative wound. On the palatal arches as a result of healing fibrous scabs will appear, which for a time may cause bad breath, but after healing the problem disappears. You should not go back too quickly to sports activities - you should stop for about 1.5-2 weeks.

Tonsillectomy - effects after the procedure

The effects we want to achieve after tonsillectomy depend on the purpose for which it was performed. For sure, we can expect the airway or hearing tube to overcome problems. Patients struggling with the sleep apnoe problem - sleep apnea - can count on a better night's sleep after proper healing. The majority of patients give way to recurrent angina. We can also confirm or rule out the proliferation process due to histopathological examination.

Tonsillectomy - recommendations after the procedure

Recommendations after removing the palatine tonsils are primarily related to the diet to allow proper healing of the post-operative wound. The patient is advised to initially take food in the form of easily digestible purees or creams, but care should be taken that the meals are wholesome and balanced, and so that they contain both carbohydrates, fats and proteins. For example, in one meal you can mix boiled potatoes, boiled chicken and green peas. Proper balancing of meals, even served in this form, allows for faster wound healing, which usually lasts about a week. Some doctors also recommend gargle with herbal solutions (eg sage). Do not remove the white deposits that form on the palatal arches - it is a fibrin that forms properly in the healing process.

Tonsillectomy - how long do the effects last after the treatment?

The palatal tonsils removed do not grow back, so we permanently get rid of the lymphatic tissue in this part of the throat.

Tonsillectomy - how to avoid complications after surgery?

To avoid complications after surgery, which mainly include bleeding, remember to discontinue anticoagulants before surgery. After the surgery, avoiding hot and sharp foods should be avoided, as it may predispose to bleeding through the dilation of blood vessels. A liquid and semi-liquid diet is recommended, already on the second day after the surgery. Let's remember about proper hydration - it will allow faster elimination of agents used for anastheology, as well as prevent excessive thickening of blood and development of thromboembolic complications.

Tonsillectomy - possible complications after the procedure

Complications after surgery can be mainly associated with:

• early and late bleeds (up to 10 days after surgery)
• reactions directly related to the administration of drugs required for anaesthesia

Most bleeding occurs on the first day after surgery (early bleeding), however, late bleeding resulting from the most frequent wound injury after acute bite, infection of surrounding tissues or manifestation of coagulation disorders (eg after painkillers containing ASA or indomethacin derivatives) ).

Do not forget about the possibility of iatrogenic damage to palatal arches or soft palate, which after healing and scarring may change the tone of the voice.
Bronchopneumonia may occur as a result of blood aspiration from the post-operative bed to the lower respiratory tract.

Sometimes, despite the efforts of the surgeon, the lower pole of the palatal arches may leave a fat part of the tonsil absorbent tissue, which, like the entire tonsil, may be a place of superinfection and inflammatory processes. In the case of ailments from the throat, look carefully at the treated area, especially in the place of the pedicle at the base of the tongue and remove the remains of the tonsil.

Tonsillectomy - recommended additional treatments after the procedure

Tonsillektomi treatment is usually effective in treating complaints that were the basis for eligibility for removal of palatine tonsils and no additional procedures are necessary, unless complications occur during the procedure.

Author: Wiktoria Feret
A student of the 6th year of the medical faculty of the Pomeranian Medical University in Szczecin

Literature:
W. Becker; Diseases of the ears, nose and throat; ed. Bel Corp; K. Niemczyk, Clinical Otolaryngology; H.G. Boenninghaus; Otolaryngology; ed. Springer PWN; B. Latkowski, Otolaryngology, ed. PZWL; G. Janczewski, Otolaryngological consultations, ed. PZWL

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