Intracapsular tonsillectomy

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Author: Udayan Shah
Published:
Specialties: Pediatric Otolaryngology
Schools: Nemours/Alfred I duPont Hospital for Children
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Basic Info

Contributors: Dr. James Hamilton

Intracapsular tonsillectomy using the microdebrider is demonstrated here in a child with obstructive sleep apnea.

Advanced

Procedure

Intracapsular tonsillectomy

1.      Exposure of the oropharynx is achieved using a Crowe-Davis mouthgag (Pilling, Morrisville, NC) and two transnasal catheters to elevate the soft palate cephalad.
2.      Intratonsillar infiltration with lidocaine 1% with epinephrine 1:100,000 is used to achieve blanching of the tonsils
3.      A Hurd elevator (Pilling, Morrisville, NC), on the left of the screen, is used to manipulate the anterior tonsillar pillar and tonsil to permit debridement of the tonsil using the microdebrider (Medtronic, Minneapolis, MN) entering from the right .
4.      Debridement is recommended to start at a rate of 1500 revolutions per minute on the “variable” and “oscillate” settings, in a progressive fashion through the tonsillar tissue until fibrous strands are visualized. Debridement should be thought of as sculpting a dugout canoe shape, leaving an approximately 2 mm thick layer of tonsillar tissue against the fossa. Speed of debridement may be varied by footpedal control to achieve the appropriate tissue effect.
5.      Hemostasis is achieved using suction electrocoagulation (Covidien, Boulder, CO) at settings of 35 watts of coagulation power, as a “spray” configuration. The Hurd elevator or a mirror may be used to visualize the tonsillar remnants during hemostasis, being sure to keep a gloved finger between the metal of the retracting or visualizing instrument and the oral commissure and oral cavity mucosa, to prevent accidental arcing or thermal injury from electrocautery proximity to the metallic instrument. Hemostasis should aim for tissue blanching, rather than burning.
6.      Procedure is repeated for the contralateral tonsil. After intracapsular tonsillectomy is complete and hemostasis confirmed, some surgeons relax the mouth gag and palatal retraction for a fixed time period and then re-expose to confirm hemostasis, cauterizing further if needed.

Indications

Obstructive sleep apnea, sleep-disordered breathing, and/or recurrent streptococcal pharyngitis

Contraindications

Severe bleeding disorder

Instrumentation

Setup

Crowe-Davis mouthgag, soft palate elevation with two transnasal catheters, infiltration of tonsils with 1% lidocaine with 1:100,000 epinephrine, then tonsillar debridement with microdebrider and hemostasis with suction electrocautery. Debridement until fibrous strands are seen, leaving a 2-3 mm layer of tonsillar tissue before suction electrocautery further reduces this tissue layer.

Preoperative Workup

Polysomnography and laboratory evaluations (CBC, PT/INR) may be indicated

Anatomy and Landmarks

Palatoglossus, tonsil, palatopharyngeus, uvula

Advantages/Disadvantages

Complications/Risks

Intra-operative and post-operative hemorrhage (immediate and delayed), post-operative dehydration, symptomatic tonsillar regrowth

Disclosure of Conflicts

None

Acknowledgements

We thank our patients and their families for the privilege of caring for them.

References

Shah UK, editor. Tonsillectomy and Adenoidectomy: Techniques and Technologies. Omnipress, Madison WI. 2008. ISBN 978-0-615-23355-0.

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