Adenotonsillectomy: Basic Technique Using Electrocautery

Contributors: Deepak Mehta (Children’s Hospital of Pittsburgh of UPMC)

Purpose: Adenotonsillectomy is a procedure removing the tonsils and ablating the adenoids. Most commonly this is performed when the tonsils and adenoids have become obstructive, causing sleep disordered breathing or sleep apnea, or are recurrently or chronically infected.

Key Instruments: McIvor mouth gag, Curved and Straight Allis clamps, Monopolar electrocautery with insulated blade set at 15W for removal, suction monopolar cautery set at 35 for adenoidectomy and 20 for cauterization of the tonsillar fossa.

Anatomical Landmarks: Anterior and posterior pillars of the tonsil, vomer, torus tubarius of the Eustachian tube. Procedure: Tonsillectomy begins by placing the McIvor mouth gag into the oral cavity. The soft palate is palpated to assess for submucous cleft palate. One tonsil is grasped with the Allis clamp and retracted medially. This allows identification of the lateral extent of the tonsil. A mucosal incision is made at or slightly medial to the lateral extent and the fascial plane is entered between the tonsil and the pharyngeal musculature. Continuing in this plane throughout the dissection, the tonsil is effectively removed. The posterior pillar must be preserved. Hemostasis of the tonsillar fossa is achieved using the monopolar electrocautery. The contralateral tonsil is removed similarly. Monopolar adenoidectomy is performed using indirect mirror visualization of the adenoid tissue. Suction electrocautery is used to ablate the adenoid tissue up to the posterior choana and lateral to the torus tubarius.

Conflict of Interest: None


Epiglottopexy for Severe Laryngomalacia with Epiglottic Prolapse

Contributors: Deepak Mehta (Children’s Hospital of Pittsburgh of UPMC)

Laryngomalacia is the most common cause of stridor in newborn infants. The majority of cases resolve spontaneously. Common surgical therapy consists of division of the aryepiglottic folds combined with trimming of the arytenoid mucosa and/or cuneiform cartilages. Less frequently, epiglottopexy is required. Initially, flexible laryngoscopy illustrated prolapse of the epiglottis into the laryngeal lumen causing severe obstruction. Microlaryngoscopy, bronchoscopy, and supraglottoplasty (division of the aryepiglottic folds only) were performed, however improvement did not occur due to persistent epiglottic prolapse. Transoral epiglottopexy was performed. A Lindholm laryngoscope was used for exposure. A needle point cautery was used to remove the mucosa of the lingual surface of the epiglottis and the base of tongue. Alternatively, a carbon dioxide laser could used. 5-0 polydioxanone suture on a P-2 needle was to suspend the epiglottis to the base of tongue using 3 sutures. Photographs of the suspension conclude the procedure.


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