Introduction:
Tonsils are a part of the immune system that filter out germs entering through the nose and mouth. When these tonsils get infected and become reddish, the condition is called tonsillitis. Severe tonsillitis can cause breathing problems, sleeping disorders, or difficulty in swallowing; in such cases, tonsillectomy is performed, but complications such as bleeding, pain, infection, nerve injury, and airway obstruction can occur. In addition, hemorrhagic complications are a major issue that requires immediate treatment which includes, in case of severe bleeding, adequate oxygen and tissue perfusion should be secured, hemodynamic stabilization should be obtained by administering fluids through peripheral venous access, and in severe cases, a blood transfusion should be done, and food or fluids by mouth should not be given in case of bleeding, which may cause the swallowing of blood, resulting in hematochezia.
What Are Tonsils?
Tonsils are a pair of lymph nodes that are pinkish-rounded masses located at the back of the throat. Tonsils are a part of the immune system with plenty of white blood cells that protect the body from germs entering the mouth and nose. They are also called palatine tonsils. Inflammation of these tonsils is called tonsillitis.
What Is Tonsillectomy?
Tonsillectomy is a minimally invasive surgical procedure of removing tonsils. total tonsillectomy or partial tonsillectomy can be performed depending on the condition. A tonsillectomy is indicated when these tonsils get infected and swollen and do not get better with medications.
What Is the Procedure of Tonsillectomy?
The tonsil has a covering of thin fibrous tissue, which separates it from the underlying muscles. The tonsillectomy can be extracapsular, where the entire tonsil is removed along with its covering, or intracapsular, where only tonsil tissue is removed without the removal of the capsule. The techniques include:
Hot Technique: A monopolar cautery is used in this technique. Using an Allis clamp, the superior part of the tonsil is grasped, the lateral aspect is identified, and it is incised. The avascular plane between the muscle of the pharynx and the tonsil is identified, and the entire tonsil is removed. Bleeding is controlled with the help of suction cautery or ties.
Cold Technique: This technique uses a sharp dissection method. The tonsil is grasped using an allis clamp, and the lateral part is identified and incised using a scalpel. With the help of a fisher tonsil dissector, the tonsil is removed from the fossa except for its inferior pole. Then a Tyding snare separates the tonsil from the inferior pole, and bleeding is controlled.
Coblation: This technique is similar to monopolar cautery and uses minimal heat. This system uses saline irrigation, which converts into an ionized plasma layer and causes tissue breakdown. This technique is used in the case of partial tonsillectomies.
What Are the Indications of Tonsillectomy in Kids?
The indications of tonsillectomy are:
- Severe chronic tonsillitis.
- Recurrent tonsillitis.
- Recurrent throat infection along with fever and sore throat.
- Drainage from the tonsils.
- Swollen lymph nodes.
- Infected or inflamed tonsils that cannot be cured with medications.
- Breathing problems such as snoring or sleep apnea due to enlarged tonsils.
- Tonsil cancer.
- Peritonsillar abscess.
- PFAPA (periodic fever, aphthous stomatitis, pharyngitis, adenitis) syndrome.
- Tonsil asymmetry.
- Psoriasis (chronic autoimmune skin disorder), variant psoriasis guttate, has an impact on streptococcal tonsillitis.
- IgA nephropathy (inflammation of the kidney due to increased buildup of IgA in it) also has an impact on tonsillitis.
What Are the Complications of Tonsillectomy in Kids?
The complications of tonsillectomy include:
- Incisional pain due to tonsillar dissection with heat-generated instruments such as electrocautery, monopolar cauterizing needle, bipolar forceps, and scissors induces more pain than non-heat-generating instruments such as scissors, loops, and raspatory. In addition, heat-generating instruments have more risk of post-operative bleeding.
- Hemorrhagic complications are the major complication that occurs due to differences in the size and age of the patient; these cases may require a blood transfusion.
- Odynophagia (pain during swallowing).
- Dehydration, in cases of reduced intake of food and fluids due to the pain.
- Swelling of the soft palate and tongue can cause breathing problems.
- Airway obstruction due to edema (swelling).
- Aspiration.
- Infection.
- Disturbance of taste.
- Reaction to anesthesia, such as headache, vomiting, and nausea.
- Hypoglossal or lingual nerve injury (which can cause paralysis of the tongue and altered salivary secretion).
- A dental injury such as a dislocation of the jaw.
- Meningitis (inflammation of the membranes surrounding the brain and spinal cord).
- Necrotizing fasciitis (a bacterial infection that involves subcutaneous tissue and fascia, which requires emergency treatment).
- Velopharyngeal dysfunction (a disorder of the velopharyngeal sphincter, which separates the nasal and oral cavities during swallowing, speech, blowing, sucking, or vomiting).
- Recurrent laryngeal nerve injury, which can cause vocal cord paralysis and result in hoarseness.
- Carotid artery injury.
- Acute allergic reaction.
- Respiratory distress.
- Grisel syndrome (a condition characterized by subluxation of the atlantoaxial joint and is associated with an inflammatory condition of the neck and head).
- Emphysema (lung disorder that causes difficulty in breathing).
- Pneumomediastinum (a condition where the air is trapped in the middle of the chest).
- Pneumothorax (a condition where the air is collected between the lungs and chest wall).
How to Manage the Hemorrhagic Complications of Tonsillectomy in Kids?
The hemorrhagic complication is the major event, and the management includes:
- In severe bleeding, adequate oxygen and tissue perfusion should be secured. If the child is in hypovolemic shock, the emergency team should imply resuscitation efforts; endotracheal intubation is used to protect the airway; if intubation is difficult due to bleeding, surgeons should use supraglottal auxiliary measures such as laryngeal tubes and masks. The child should be in a lateral decubitus position (lying on the side) to avoid airway obstruction.
- Hemodynamic stabilization should be obtained by administering fluids through peripheral venous access. In severe cases, a blood transfusion is done.
- Food or fluids by mouth should not be given in case of bleeding, which may cause the swallowing of blood, resulting in hematochezia (blood in the stools).
Conclusion:
Therefore, tonsillectomy is a minimally invasive surgical procedure; after removing the lymph nodes, the patient has a better prognosis, can breathe properly, and have fewer ear and throat infections.
