Overview
Inflamed tonsils
Tonsillitis is inflammation of the tonsils,which are lymphatic tissue at the back of the throat on each side.
Signs and symptoms of tonsillitis include swollen tonsils, sore throat, difficulty swallowing and tender lymph nodes on the sides of the neck.
Most cases of tonsillitis are caused by infection with a common virus, bacterial infections . The most
common type of bacteria involved is streptococcus
Tonsillectomy indication:
Treatment of obstructive sleep apnea/hypopnea syndrome (OSAHS) in pediatric patients
High ASO titre >200
Essential component of uvulopalatopharyngoplasty (UPPP).
Paradise criteria: Recurrent sore throat
7 episodes in a year
5 in 2 consecutive years
3 in 3 consecutive years
Other relative indications: peritonsillar cellulitis or abcess
PANDAS (Pediatric autoimmune neuro psychiatric disorders associated with streptococcal infections
Halitosis, dental malocclusion, controlling chronic pharyngeal carriage of group a beta haemolytic streptococci
Types of tonsillectomy procedures
- Conventional tonsillectomy
- Laser assisted tonsillectomy
- Coblation technology
We prefer coblation tonsillectomy which is the most recent intervention for tonsillar surgery.
Mechanism of coblation– An electrical field is generated between the active electrode(s) and the return electrode which interacts with surrounding fluid (e.g. saline) to excite electrolytes and molecules in the solution, creating a high-density energy field called glow plasma. Ions and molecules of the tissue absorb this energy causing the tissue particles to vibrate resulting in heat.
Advantages of coblation Adeno tonsillectomy:
- Less bleeding
- We do surgery magnification with capsule preservation. Advantage is less post operative pain compared to conventional technique.
Post Operative Care and Instructions Following Tonsillectomy
The following instructions will help you know what to expect in the days following surgery. Do not, however, hesitate to call if you have any questions or concerns.
Physical Activities
After this surgery, children should rest but may play inside after one or two days and may be outside after seven days, if they feel up to it. Strenuous physical activity following surgery is discouraged. Children may return to school after one week when they are comfortable; but 10 days is not unusual.
Diet
The more your child drinks, the sooner the pain will subside. Water, apple juice, juice, ORS juices are excellent sources of liquid. Soft foods such as ice cream, sherbet, yogurt, pudding, apple sauce and jello, should also be encouraged. Other soft, easily chewed foods are also excellent. Avoid hot or spicy foods, oily or foods that are hard and crunchy. Often, chewing gum speeds comfortable eating by reducing the spasm after surgery and can be started anytime after surgery. Detailed precautions about diet will be explained by us during discharge.
Pain
For the first several days (occasionally up to 10 days) following surgery, pain in the throat is to be expected and will be bearable due to postop analgesic. Avoid medication containing aspirin, other anticoagulant or antiplatelet drugs 2 weeks prior and after surgery. Ear pain, especially with swallowing is also a common occurrence; it is not an ear infection but due to referred pain from the surgery
Causes of change in voice:
Acute Laryngitis
Acute laryngitis is the most common cause of hoarseness and voice loss that starts suddenly. Usually caused by viral infection.When the vocal cords swell, they vibrate differently, leading to hoarseness. The best treatment for this condition is to stay well hydrated and to voice rest.
Laryngopharyngeal Reflux Disease (LPR)
Reflux of stomach juice into the throat can cause a variety of symptoms in the esophagus (swallowing tube) as well as in the throat. Hoarseness (chronic or intermittent), swallowing problems, a lump in the throat sensation, or throat pain are common symptoms of stomach acid irritation of the throat.
Benign Vocal Cord Lesions
Non-cancerous growths on the vocal cords are most often caused by voice misuse or overuse, which causes trauma to the vocal cords. These lesions (or bumps) on the vocal cord(s) alter vocal cord vibration and lead to hoarseness. The most common vocal cord lesions are nodules, polyps, and cysts. Vocal nodules occur on both vocal cords opposite each other at the point of maximal wear and tear, and are usually treated with speech therapy.if they doesn’t resolve. It has to be treated by surgery. Vocal cord polyps and cysts are the other common benign lesions. These types of problems typically require microlaryngeal surgery with conventional, laser or use of coblation technique.
Coblation has distinct advantage over laser as heat generated in coblation is quite lesser than any laser, so injury to surrounding areas will be much lesser with accurate precision
Vocal cord paralysis\paresis– many conditions cause these. After identification of initial cause we do necessary training or surgery for relief of breathing or correction of voice
Foreign bodies in aero-digestive tract
Accidental inhalation of both organic and non-organic FBs continue to be a cause of childhood morbidity and mortality.
Prevention is best, but early recognition remains a critical factor in the treatment of FB inhalation in children.
Patients comes with choking, acute dyspnoea, and sudden onset of wheezing are the most common symptoms.
Laryngeal FBs (airway/ wind pipe foreign body) can cause hoarseness, aphonia, wheezing, and dyspnoea. In some cases parents see or hear from kid inserting or swallowing a foeignbody. But most of the times parents will be unaware of such event and feel their kids got some airway infection. One should suspect a foreignbody in cases of Prolonged Lung\airway infections not subsiding with repeated paediatrician medication treatent. In such cases physician, paediatrician or ENTs do a clinical examination, hear lung sounds (auscultate) and look for signs of diminished or absent airway. Then a radiological investigation is done to confirm level of obstruction. As early as possible child is sedated and we remove foreignbody via telescopy guided bronchoscope instrument. We use a storz system (german optics) which is one of the best devices used to visualize ,hold and remove foreign body from lungs.
Metallic foreign body
Foreign body seed-bronchus (lungs)
Once after removing we inspect bilateral bronchus (above photo- post foreign body removal image of wind pipe bifurcation/bronchi)
Digestive track/oesophageal foreign body
If the foreign body enters oesophagus and stucks at entry or middle. Presentation will be unable to swallow and vomiting. We identify level and remove with the help of oesophagoscopes.
Snoring- evaluation and management
Snoring is the sound produced while sleeping due to vibration of lax of muscles during sleep or any anatomical obstruction in the upper respiratory tract from nose to larynx. It may be the first symptom of obstructive sleep apnea(OSA). It can lead to many problems some of which are shown below.
When a patient comes to us with snoring we calculate body mass index and advise them to undergo polysomnography to grade the disease.
If apnea hypoapnea index is high in sleep study.
We advise them to have sleep endoscopy (DISE: Drug induced sleep endoscopy) under sedation as this will mimic sleep and we will know exact obstruction region or extent of collapse in airway.
Based on all the above tests we can conclude whether patient needs surgery or not.
If there is no anatomical obstruction we advise them to reduce weight / life style modification.
If there is anatomical obstruction (most cases) -like deviated nasal septum, hypertrophied inferior turbinate, nasal polyps, adenoids, elongated uvula, bulky soft palate,hypertrophied tonsils, large tongue base and epiglottic collapse.
we advise different types of surgery based on the level of obstruction taking help of coblation technology.
preop photo. Above photo shows surgical area with blue marking and one of the coblation wands which we use for surgery
Above image is post op photo afterwidening is done
| Nasal cavity | Polypectomy, partial inferior turbinectomy | |
| Septoplasty | ||
| Nasopharynx | Adenoidectomy | |
| Oropharynx | Tonsillectomy, UPPP, LAUP, Zetaplasty, Palatal implants | |
| Hypopharynx | Midline glossectomy, tongue base reduction | |
| Mandibular advancement, genioglossal advancement, hyoid myotomy suspension | ||
| Oro and hypophanrynx | Maxillomandibular advancement, epiglottoplasty |
