Surgery for chronic tonsillitis

Chronic tonsillitis is a common disease with an incidence of about 2% to 20%. There are many children and adolescents with no obvious gender differences. The main pathogens of chronic tonsillitis are type B hemolytic streptococcus, Staphylococcus aureus, Streptococcus viridans, Pneumococci and influenza bacillus. In recent years, adenovirus infection has also been found to be a causative agent. Although the pathogenesis of chronic tonsillitis is not fully understood, the body's resistance and allergic reactions have been identified as two important factors in the pathogenesis. Chronic tonsillitis recurrent, can cause a variety of diseases and local lesions. The human tonsil tonsils begin to sprout during the embryo's 3-6 months, and develop rapidly after birth. By the age of half a year, the shape is almost complete. It continues to develop between the ages of 14 and 16, and gradually degenerates after the age of 20. In recent years, foreign studies have demonstrated that the autonomic and sensory nerves that innervate the tonsils are the way for the immune system to transmit information directly to the central nervous system. Domestic scholars have found lymphoid follicles and plasma cells in the human embryonic amygdala, and found the morphological basis of the immune function of the tonsils, indicating that the immune function of the tonsils is acquired. Therefore, strict control of indications for tonsill surgery is necessary. Since the immunoglobulin has not reached the level of normal adults in childhood, surgery should be considered carefully during this period. Some scholars suggest that children under 5 years of age need surgery. If excessive hypertrophy affects breathing, unilateral tonsillectomy can be performed, which not only restores the satisfactory respiratory tract and pharynx, but also improves lung ventilation and significantly reduces the incidence of upper respiratory tract infection. The other side of the tonsil can play an immune compensatory role. At present, the number of people undergoing tonsil surgery, especially children, is significantly reduced, which is inseparable from the improvement of human health, the improvement of medical conditions, and the understanding of tonsil function in modern medicine. Chronic tonsillitis has been treated for more than 2,000 years. It has undergone different stages of finger digging, puncture, electrocautery, electrolysis and trapping. At present, the peeling method and the extrusion method are mainly used. The former has clear surgical procedures, complete resection, less damage to surrounding tissues, and is suitable for various types of tonsils, so it is commonly used by most otolaryngologists; the latter is generally suitable for children or The tonsils are prominent and the adhesion is less. The biggest advantage is that the use of less instruments, simple process, rapid operation, and smooth scars on the wounds is also a commonly used method for tonsillectomy. Treatment of diseases: chronic tonsillitis Indication 1. Chronic tonsillitis repeated acute hair, or had a parapharyngeal infection, peritonitis and history of abscess around the tonsils. 2. Chronic tonsillitis is ineffective by conservative treatment, tonsil is buried, crypts are not arranged neatly, there are pus in the crypt, the surface of the tonsils is uneven, adhesion to the surrounding, localized congestion of the tongue and bow, and -hemolytic chain on the surface. Cocci. 3. Chronic tonsillitis leads to diseases of adjacent organs, such as chronic rhinitis, sinusitis, cervical lymphadenitis, eustachian tube inflammation, chronic simple otitis media with hearing loss, chronic pharyngitis and chronic laryngitis. 4. Other diseases of the tonsil, such as tonsil keratosis, tonsil stones, tonsil polyps or cysts, other tonsil benign tumors, and early tonsil malignancies. 5. Tonsil lesions cause diseases in other organs of the body, such as: rheumatism, nephritis, myocarditis, arthritis, uveitis, certain skin diseases, and low fever with unknown long-term causes. 6. Tonsils are hypertrophied and affect normal physiological functions such as breathing, swallowing, sleep or speech. 7. One side of the tonsil is swollen, suspected of being a malignant tumor. Patients over the age of 50 should have their enlarged tonsils removed without any symptoms. 8. Preoperative surgery for some operations. For example: excessive styloid shortening, pharyngoplasty, etc. Contraindications 1. The acute inflammatory phase of tonsils, generally advocated surgery 2 to 4 weeks after the acute inflammation subsided. 2. Hematological diseases and liver diseases with bleeding tendency. For some blood diseases that can be cured or treated for a long period of time after treatment, it is necessary to perform tonsil surgery in the case of strict surgical control and careful preoperative preparation. However, there is a risk of surgery. If you do not have the conditions, do not perform surgery lightly. 3. Women's menstrual period and pregnancy, surgery should be slow. 4. During the epidemic of acute infectious diseases. 5. Serious heart disease, hypertension, nephritis, rheumatism, active tuberculosis, diabetes, and mental patients. 6. Long-term, high-dose administration of salicylic acid or adrenocortical hormone drugs. The immunoglobulin content of children under 7.8 years of age has not yet reached the human level, and the tonsils are mostly physiological hypertrophy, and surgery should not be performed immediately. 8. No immunological function tests or immunoglobulin levels are significantly lower. 9. Family members have immunoglobulin deficiency or a family history with a high incidence of autoimmune diseases. Preoperative preparation 1. Inquire about the medical history and physical examination in detail, paying particular attention to the history of bleeding with or without abnormality and the history of exposure to infectious diseases. Patients with general anesthesia should have chest X-ray, and children should pay attention to the size of the thymus. 2. Do blood routine, platelet count, clotting time check, liver function, and Australian anti-examination. Patients over 40 years old should have an electrocardiogram. 3. Check the nose and mouth. If there is an infection in the nose, mouth, nasopharynx or sinus, do it after proper treatment. 4. On the day of surgery, fasting and banned water, patients with local anesthesia, take appropriate amount of sedative before going to bed one night before surgery, subcutaneous injection of atropine 0.5mg half an hour before surgery, antibiotics may be applied as appropriate. Patients undergoing general anesthesia should be prepared preoperatively according to general anesthesia requirements. Rest should be adequate 1 day before surgery. 5. Do a good job in thinking, explain the purpose and precautions of the operation, eliminate the patient's nervousness, and strive for patient cooperation. Surgical procedure 1. Tonsilectomy - stripping method (1) Incision: The middle part of the tonsil is clamped with tonsil vise, pulled forward and inward, along the edge of the boundary between the tonsil and the lingual arch, and the mucosa is cut from the top to the bottom by a mandible knife. Then, the tonsil is pulled forward and outward, and the blade is turned over. The upper end of the incision is extended, and the mucosa at the junction of the tonsil and the pharyngeal arch is cut downward along the tongue and the bow. (2) Peeling: Insert the middle of the incision of the tongue with a tonsil stripper, and first separate the tongue and the tonsil down. This is then separated upwards, exposing the upper pole of the tonsil and separating along the pharyngeal arch incision. Continue to use the tonsil clamp to clamp the upper pole of the tonsil, use the concave surface of the stripper to stick to the tonsil capsule, and press and tear the tonsil down until only a thin pedicle is left in the lower pole. (3) Removal: Lift the tonsil inward and upward, cover the root of the tonsil with the tonsil snare, and rotate the plane of the ring of the snare to the lingual side by 90°, then insert the lower part of the tonsil and tighten the wire ring. Complete removal of the tonsils. (4) Hemostasis: Hold the cotton ball with a vascular clamp, wipe the tonsil socket, use the sacral arch to pull the tongue and open the tongue, check the tonsil fossa for residual tonsil and bleeding. If there is a residual body, use a snare to remove it again. In case of vascular rupture or active bleeding, vascular clamp hemostasis or finger knotting can be used to stop bleeding. Electrocoagulation can also be used to stop bleeding. 2. The operating principle of tonsillectomy can be summarized into four words: sleeve, lift, pressure and twist. The movements must be coherent and in one go. (1) Set: The patient's mouth is opened, the tongue is lowered by the tongue depressor, and the lower part of the tonsil is fully exposed. The squeezed knife ring is inserted obliquely from the contralateral angle to the tonsil on the side of the squeeze, and the lower part of the tonsil is placed. The leading edge of the cutter ring will be squeezed between the tonsil and the pharyngeal arch, and the upper pole direction is moved into contact with the inner side of the mandible. (2) Lifting: Pull out the tongue depressor, the shank is turned to the opposite side angle, so that the knife ring is lifted in the direction of the tongue bow. At this time, since most of the tonsils are still in front of the cutter ring, they are on the tongue bow. A bulge can be formed. (3) Pressure: With the thumb of the other hand, evenly at the bulge of the tongue, the squash is pressed backwards and backwards, and all of them are pressed into the back of the squeezing knife ring until the thumb can touch the mucous membrane of the tongue. To the edge of the cutter ring, then grasp the handle and push the knife into the squeeze ring. (4) Twisting: Rotate the squeezing knife 90° in the direction of the sag, and twist the tissue that has not been broken between the tonsil and the tonsil socket. At the same time, the wrist is shaken, the connected soft tissue is twisted, and the squeeze knife and the tonsil are pulled together from the corner of the extruded side. After the contralateral tonsil is removed in the same step in one go, the patient is spit out secretions and blood to check for residuals or bleeding. The residual body was excised with a small squeeze knife or a residual bite forceps, and the bleeding point was pressed to stop bleeding or ligation. The general anesthesia patient is lying prone and his head is turned to one side. Those who need to remove the proliferator at the same time can be performed before or after the tonsillectomy. complication 1. Bleeding: Compared with the exfoliation method, the bleeding rate after extrusion is slightly lower. The tonsillectomy bleeding is divided into primary and secondary. Primary bleeding refers to bleeding within 24 hours after surgery or after surgery, which is more common. It usually occurs within 6 hours after surgery, which may be rough operation, more tissue around the injury, or incomplete hemostasis, or due to the addition of adrenaline to the anesthetic, postoperative vasodilation due to its absorption, or residual tonsil in the operation. Body, obstructing vasoconstriction, etc. Secondary bleeding refers to bleeding after 24 hours of surgery, which often occurs on the 5th to 6th day after surgery, and is associated with wound infection or shedding of wounds. 2. Infection: mild infection of the tonsil fossa showed delayed growth of pseudomembrane, color contamination, thicker, significant congestion of the pharyngeal arch, heavier sore throat and longer duration. If the infection is serious, it may cause cervical lymphadenitis, or form cellulitis or abscess in the deep neck and the base of the tongue. It is characterized by high fever, difficulty in swallowing, neck pain and sore throat. Antibiotics should be used. If abscess is formed, it should be done. Cut the drainage. 3. Trauma: due to excessive traction or damage to adjacent tissues during operation, postoperative local tissue reaction is heavier. Soft palate and sag edema are more common, and there may be submucosal congestion. Under normal circumstances, edema is more than postoperative 4~ 5d self-resolved. 4. Tonsillary debris: may be related to the skill level of the surgeon.