Sarah Maurrasse MD, Vikash Modi MD
Weill Cornell Medicine, Department of Otolaryngology
Tonsillectomy is one of the most common surgical procedures performed in children. The two main indications for tonsillectomy are sleep disordered breathing and recurrent infections, both of which are common in the pediatric population. This video includes 1) a detailed introduction including relevant anatomy 2) a discussion of the indications for total tonsillectomy 3) surgical videos and diagrams to explain the steps of the surgical procedure and 4) an explanation of possible post-operative complications.
A Crowe-Davis or McIvor mouth gag is gently placed into the patient's mouth with the endotracheal tube fixed between the tongue and the blade. The endotracheal tube should fit securely into the groove in the blade. The soft palate is then retracted with catheters to stabilize the tonsil and to pull the uvula out of the way. A debakey forcep or alice clamp is used to retract the tonsil medially and a flat tip or needle tip bovie is used to dissect in the capsular plane. A total tonsillectomy requires careful dissection in the subcapsular plane between the tonsil and the underlying muscular bed. After removal of the tonsil, a suction bovie is used to achieve complete hemostasis. After removal of the right tonsil, the same procedure is carried out on the left side. Total tonsillectomy leaves the musculature of the pharynx exposed to heal by secondary intention. Patients can experience significant pain, and approximately a 2% risk of post-operative bleeding, as the exposed muscle remucosalizes.
1) Sleep disordered breathing including a spectrum of disorders from primary snoring to obstructive sleep apnea
2) Recurrent throat infections, which are defined as 7 or more throat infections in 1 year, 5 infections per year for 2 consecutive years, or 3 infections per year for 3 consecutive years
3) Tonsillar asymmetry
4) Concern for malignancy
Relative contraindications include:
1) Acute infection or presence of a peritonsillar abscess
2) Submucous cleft
3) Bleeding diathesis
4) Comorbidities that would increase anesthetic risk
N/A
Preoperative workup includes a detailed history and physical exam. The history of present illness should address the presence of the following symptoms: snoring, witnessed apneas, daytime somnolence or hyperactivity, nocturnal enuresis. difficulty concentration, recurrent throat infections, throat pain, history of missed school days, and antibiotic usage. The physical exam should include a careful oral cavity exam to assess for tonsillar hypertrophy and/or signs of infection. Nasal endoscopy should also be considered if there is concern for coexisting adenoid hypertrophy.
The advantages of total tonsillectomy compared to partial tonsillectomy are related to the removal of all of the lymphoid tissue and include 1) mininmal risk for regrowth and need for further surgery and 2) a decreased risk of recurrent post-operative infection. Disadvantages of total tonsillectomy compared to partial include more post-operative pain (and subsequent dehydration and readmission) and a risk of post-operative bleeding.
Complications of tonsillectomy include damage to nearby structures--such as tooth trauma, lip lacerations or burns, injury to the pharyngeal wall, or injury to the soft palate--and bleeding. Post-operative complications include pain, nausea, vomiting, dehydration, otalgia, or neck pain. Post operative complications may also result in readmission or further surgery, such as control of hemorrhage. Velopharyngeal insufficiency is a long-term complication that should be considered, especially in the presence of a submucous cleft, or when adenoidectomy is performed at the same time.
No conflicts of interest to disclose
Thank you to Vidal Maurrasse for providing voice over material.
This video shows a transotic approach for a cochlear schwannoma in a 59-year-old female who presented with sudden sensorineural hearing loss in her left three years prior. She was found to have subsequent growth of her tumor on imaging and elected to undergo surgery. The transotic approach is a valuable approach within the armamentarium of a skull base team and differs from the transcochlear approach in the handling of the facial nerve. Techniques for ear canal overclosure, eustachian tube packing and mastoid obliteration are also highlighted.
Here, we have a 39 yrs old female with complaints of noisy breathing for last two years post thyroidectomy. Flexible laryngoscopy confirmed bilateral vocal cord paralysis. She was planned for coblation assisted cordectomy.
Patient was taken up for procedure under general anaesthesia. She also started having stridor after induction. Nasopharyngeal intubation with spontaneous breathing technique was used. Entropy leads were placed over forehead to monitor the depth of anaesthesia. Tube position was confirmed with endoscopic view and Benjamin lindohlm laryngoscope was suspended. As the patient was spontaneously breathing, the stridor became more prominent, with stable vitals and the procedure was continued. The vocal cord retractor was fixed and coblation wand was then used with 7:3 settings for ablation and coagulation respectively. The surgical limits were-anteriorly the junction between ant 2/3 and post 1/3 of the vocal cord, posteriorly just anterior to the vocal process of arytenoid to prevent cartilage exposure and post operative granulations. Superely till the ventricle and inferioly till the medial most surface of the subglottis. Laterally approx. 5 mm depth was defined to prevent injury to the superior laryngeal artery branch and further bleeding. Once the final airway was achieved , the topical lignocaine was used to prevent laryngeal spasm post extubation.
The patient was shifted to the ward without oxygen, the voice was assessed on post op day 2.
Patient was called for follow up on post op day 14th and good voice outcomes were achieved.
So lets have a look on some tips & tricks for the safe procedure—–
Nasopharyngeal insufflation technique with entropy monitor will give adequate and safe surgical field
2. Appropriate exposure will help you to delineate the surgical margins
3. Topical anaesthesia before and after the procedure will prevent sudden laryngeal spasm
4. Firm holding of coblation device will help to prevent injury to surrounding structures like anterior 2/3 vocal cord, opposite side vocal cord, medial surface of vocal cord or aryteroid posteriorly
5. Do not ablate more laterally to prevent bleeding, if at all it happens, use patties or coagulation switch for hemostasis.
6. And at the end of the procedure ,use catheter suction to suck out blood clots or saline from the airway if any….
To Conclude-Coblation Assisted Cordectomy( CAC) can be performed safely with good outcomes in case of bilateral vocal cord paralysis using tubeless anesthesia technique without tracheostomy !
We present the harvest of a osteocutaneous fibula free flap for head and neck reconstruction performed at the University of Cincinnati. This reconstructive technique has a wide variety of implications but has found greatest utility in the reconstruction of mandibular defects.
Review Total Tonsillectomy.