Tonsillectomy Part 4 - Procedure & Post operative care

🩺 Tonsillectomy: Surgical Steps & Post-Operative Care

Continued from Part 3 - Hot Tonsillectomy vs Interval Tonsillectomy.

In this post, we continue the tonsillectomy series and discuss:

• Step by step surgical procedure of tonsillectomy
• Post operative care and patient advice

This topic is high yield for viva and practical exams.

🔹 Anesthesia and Pre-operative Preparation

• Tonsillectomy is performed under general anesthesia

• Endotracheal intubation is mandatory

• In pediatric patients, informed consent is taken from parents

📌 Important Consent Point

• Examine for loose teeth

• If present, consent for removal must be taken
  → Prevents medicolegal issues if a tooth dislodges intra-operatively

🔹 Patient Positioning - Rose’s Position

• Patient lies supine

• Sandbag / head ring placed under shoulders

• Head extended at atlanto-occipital joint

• Neck extension with head supported

What are other surgeries where Rose's position is used?

🔹 Steps of Tonsillectomy - Dissection and Snare Method

1️⃣ Mouth Opening and Exposure

• Insert Boyle Davis mouth gag

• Retract tongue adequately without injuring posterior pharyngeal wall

• Fix gag using Draffin’s bipod stand

• Insert wet throat pack to prevent aspiration

2️⃣ Grasping the Tonsil

• Hold tonsil at upper pole using Dennis Brown tonsil holding forceps

• Pull tonsil medially

• Identify plane between:

  • Tonsil
  • Anterior tonsillar pillar

3️⃣ Incision

• Make incision in mucosa between tonsil and anterior pillar

• Use Waugh's forceps

• Extend incision from upper pole to lower pole

4️⃣ Dissection

• Use Mollison’s dissector

• Dissect tonsil from upper pole → lower pole

• Sharp dissection with scissors if:

  • Fibrosis
  • Scarring
  • Adhesions present

5️⃣ Snaring the Lower Pole

• Apply Eve’s tonsillar snare

• Encircle lower pole pedicle

• Snare and remove tonsil

6️⃣ Hemostasis

• Pack tonsillar fossa with gauze

• Apply pressure

• Identify bleeding points

• Ligate or cauterize if required

7️⃣ Completion

• Repeat procedure on opposite side

• Clear:

  • Postnasal space
  • Oropharynx
  • Laryngeal inlet

• Release mouth gag slowly

• Recheck lower pole for bleeding

• Remove throat pack

• 🚩 Count all swabs before closure

🔹 Post-Operative Care After Tonsillectomy

🛏️ 1. Position

• Left lateral position
• Head kept low
• Allows drainage of blood and secretions
• Prevents airway obstruction

📊 2. Monitoring

• Monitor every 4 hours:

  • Pulse
  • Blood pressure
  • Respiratory rate

• Watch for signs of bleeding:

  • Tachycardia
  • Hypotension
  • Frequent swallowing

💊 3. Medications

• Injectable antibiotics and analgesics initially

• On discharge:

  • Oral antibiotics for 7 days
  • Analgesic–anti-inflammatory syrup

🧴 4. Hydrogen Peroxide Gargles

• Diluted hydrogen peroxide gargles after every meal

What is the Mechanism of Action of Hydrogen Peroxide Gargles in post Tonsillectomy case?

🍽️ 5. Diet Advice

📌 Each feed should be followed by gargles

🔹 Normal Post Operative Findings

The following are normal and not alarming:

• Vomiting on operative day
• Mild fever
• Ear pain (referred otalgia)
• Difficulty swallowing initially
• White membrane over tonsillar bed
• Temporary change in voice

📌 Exam & Viva Pearls

• Most common method: Dissection and snare
• Position used: Rose’s position
• Most important post-op danger sign: Bleeding
• Hydrogen peroxide gargles: Always mention mechanism

📚 Next Part:
Complications of Tonsillectomy