Operation to remove glands in adults and children: the pros and cons

If you often get angina, then after examining the palatine tonsils, the ENT doctor, having weighed all the pros and cons, can recommend surgically solve this problem and carry out removal of the glands.

And although this operation, called medical tonsillectomy, is now performed less often than half a century ago, it still remains one of the most frequent surgical procedures, especially the removal of the glands in children. For example, about 400 thousand such surgical interventions are annually conducted in the EU countries.

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Indications for the procedure

Tonsils palatina can be removed for various reasons. The most common clinical otolaryngology - recurrent pain in the throat, associated with frequent  inflammation of the tonsils. And the main indications for the operation of removal of tonsils include both recurrent acute tonsillitis (purulent sore throats) and their chronic forms.

Since the size of the tonsils reaches its maximum at the age of three to four years, and then gradually regresses, the removal of the glands in children is usually postponed for several years - if the frequency of angina in a child during the year and their severity are not critical. And one or two cases, even severe ones, as a rule, are not a sufficient basis for the operation.

Currently, the criteria for sending patients to remove tonsils in tonsillitis (acute recurrent) are recognized as such: at least seven anginas in the past year or at least five acute tonsillitis a year for two years. Either three or more cases of inflammation of the glands per year for three years (necessarily fixed in the patient's medical record). Also, in favor of the appointment of surgery, ENT doctors decline: angina with a high temperature (> 38.3 ° C), an increase in the mandibular lymph nodes, the presence of purulent exudate and the detection of a beta-hemolytic group A streptococcus in the smear.

Much more often remove the tonsils in chronic tonsillitis, especially in its so-called decompensated form: when neither antibiotics nor washing lacunae of tonsils (to remove purulent plugs) do not give a stable effect, and the focus of strepto or staphylococcal infection remains in the pharynx. Everyone knows  what is dangerous for angina, especially frequent purulent, so - to prevent chances of bacterial toxins spread throughout the body and damage cells of the myocardium, joints, vascular walls and kidneys - a strategic decision is to remove the glands in adults and children.

Obstructive nocturnal sleep apnea, in cases of its pathophysiological connection with hypertrophy or hyperplasia of the tonsils, is also one of the most common indications for the removal of palatine tonsils.

In addition, the tonsils are removed with: a significant increase in their size due to the deposition of calcium salts in the lacunae (tonsil stones or tonsillolitis), which can cause dysphagia (difficulty swallowing); if large papillomas, fibromas or cysts were formed on the tonsils or palatines.

[2], [3], [4], [5]

Preparation

Preparation for this operation consists in laboratory tests of blood, as well as in general therapeutic (for children - pediatric) examination and in the conclusion of a cardiologist after an ECG.

The necessary analyzes for the removal of glands - a blood test of the general and clinical (hemogram), the level of platelets, the factors of blood clotting (fibrinogen).

To avoid bleeding, according to the results of the analysis, a week before tonsils can be removed, patients can be prescribed calcium preparations or fibrinolysis inhibiting agents.

[6], [7]

Technique of the removal of the glands

The traditional technique of this operation, as well as the surgical instrument used to remove the glands, is described in detail in the material -  Surgery for the removal of tonsils (tonsillectomy)

The duration of the operation is an average of half an hour, but how long the removal of glands lasts in each particular case depends on the technique used, since in addition to the classical method, more modern technologically advanced methods for removing glands are used in ENT surgery.

As in many other areas of surgery, an ultrasound surgical instrument (called an ultrasound scalpel) can be used to simultaneously dissect and coagulate tissue by vibrating its molecules at an ultrasound frequency (55 kHz) that generates heat (t≤ + 100ºC). Carry such a removal of glands under general anesthesia.

The positive moment of removal of glands by high-frequency bipolar electrocoagulation is minimal bleeding due to simultaneous cauterization of blood vessels. This method removes the glands under local anesthesia (injections of the anesthetic into the paratonsillar areas). However, the high temperature created in the manipulation zone can lead to thermal damage to the surrounding tonsil tissues, which causes great discomfort in patients in the postoperative period.

Removal of glands by thermal welding TWT (Thermal Welding Tonsillectomy) - using a temperature of + 300 ° C (at which the grasped tonsil tissue sublimes) and pressure (for simultaneous coagulation of blood vessels). In this case, the surrounding tissue glands are heated only 2-3 degrees above normal body temperature. As evidenced by patients' reviews, postoperative pain is tolerable, and you can switch to normal diet quickly enough.

Cryoablation or cryotosyllectomy - removal of glands by nitrogen (having in the liquid state t <-190 ° C), which is supplied to the tissues to be removed by cryoprobe and freezes them to the state of necrosis.

The removal of glands by laser - ablation using medical lasers of various modifications (usually carbon dioxide) - is considered an effective and safe procedure, the duration of which is on the average 25 minutes; is performed under local anesthesia. However, it is often necessary to repeat it, and pain after laser ablation can be more intense than other methods. Because the procedure requires complete immobility of the patient, this method of removing glands is not suitable for young children.

Cold-plasma method - removal of glands by a cobblomer - is carried out only under general anesthesia. This technology consists in passing radio-frequency energy through an isotonic sodium chloride solution (saline solution), which creates a plasma field capable of destroying the molecular bonds of tissues without increasing their temperature above +60-70 ° C. This factor makes it possible to minimize or even avoid damage to the surrounding healthy tissue. COBLATION technology, according to surgeons, reduces pain and swelling after surgery and is characterized by a lower incidence of intraoperative or delayed bleeding, as well as secondary infections.

Finally, monopolar radiofrequency thermal ablation or radiowave removal of glands performed under local anesthesia is in fact recommended and applied to reduce the size of hypertrophied palatine tonsils - due to the processes of scar tissue formation in the glands at the site of the removed lymphoid.

Contraindications to the procedure

Surgery to remove glands is contraindicated for:

• hemophilia, leukemia, thrombocytopenia and / or agranulocytosis, pernicious anemia;
• acute forms of cardiovascular, pulmonary or hepatic insufficiency;
• thiorethoxycose;
• diabetes mellitus of the third degree;
• active form of tuberculosis;
• acute infections of different etiology and localization, as well as exacerbation of chronic diseases;
• serious mental disorders;
• oncological diseases.

Do not remove the glands during pregnancy. Relative contraindication is the age of children under five years.

[8], [9], [10], [11]

Consequences after the procedure

There are certain risks to this operation and the consequences after the procedure.

Considering the pros and cons of removing glands, otolaryngologists, in the first place, indicate a real benefit of the operation - getting rid of the source of infection in the throat and associated tonsillitis, and, hence, the elimination of pain.

Indeed, tonsillitis after removal of glands no longer bothers, but life after removal of the glands can present an unpleasant "surprise": angina can be replaced by inflammation of the mucous epithelium of the throat -  pharyngitis. According to the Finnish otolaryngologists who studied this problem, 17% of the patients experienced six or more episodes of acute pharyngitis within a year after removing the glands.

According to the experts of the American Academy of Otolaryngology, patients experience this after only 12-15 months: the average number of episodes of sore throat is reduced and, accordingly, the number of visits to the doctor and the volume of analgesics and antibiotics taken are decreasing. But there is not enough clinically valid evidence to confirm the long-term benefits of tonsillectomy.

However, as noted above, tonsils can be removed not only because of persistent angina, but also for the treatment of sleep apnea. And in this case, plus this operation is obvious, especially in young men with overweight.

According to many experts, the biggest disadvantage should be considered a possible weakening effect of removal of glands on immunity. Being an active immunological organ, palatine tonsils (along with other nasopharyngeal tonsils) enter the lymphoepithelial ring of Valdeyer, which protects the body from getting a bacterial and viral infection through the mucous membranes of the respiratory tract and gastrointestinal tract. And cells of lymphoepithelial tissue of tonsils produce T and B lymphocytes, immunomodulating cytokines, immunoglobulins (IgA).

But the counterarguments of opponents of this point of view, too, are not without logic, since tonsils are removed, which because of the relapse of infection and inflammation are no longer capable of performing a protective function. So discussions on this issue continue.

Complications after the procedure

Blood supply of palatine tonsils is provided by tonsillar branches of several arteries, therefore bleeding after removing glands can be quite intense. And this is one of the key complications of this procedure. Moreover, increased bleeding may occur immediately after surgery, and after 7-12 days (noted in approximately 2-3% of patients) - if the scab on the surface of the wound falls off prematurely. In some cases, real bleeding opens, to stop which may require surgical intervention.

Complications after the procedure - swelling of the mucosa in the throat and severe pain after removal of the glands - occur with any method of tonsillectomy: the most modern surgical technologies simply reduce their intensity and shorten the duration. Usually, the throat hurts after removing the glands during the whole time of formation of the scab (up to two weeks or slightly longer); Pain passes when the scab leaves. Removal of the glands in children can cause postoperative pain in the ears, and this is the irradiation of pain from the pharynx, associated with the anatomical features of the nasopharynx in childhood.

It is necessary to prescribe pain killers after removal of the glands (most often - Paracetamol); The use of NSAIDs should be avoided, since prolonged use or exceeding the dose of non-steroidal anti-inflammatory drugs reduces the level of platelets in the blood.

The subfebrile temperature does not cause fear, since physicians consider this a sign of activation of immunity and the beginning of postoperative recovery. But if the temperature after removing the glands rises above + 38.5 ° C, this is a bad sign: most likely, a secondary bacterial infection has activated, which can cause inflammation of the regional lymph nodes, pharyngeal abscess after removal of the glands and even septicemia. That's when you need systemic (injectable) antibiotics after removing the glands (most commonly cephalosporins of the 3rd generation and combined penicillins are prescribed).

With severe weakness, dry mouth, headache and a simultaneous decrease in the number of urination, doctors detect dehydration of the patient's body, which is simply explained by the restriction of fluid intake due to pain during swallowing.

Halitosis after tonsillectomy - bad breath after removal of glands - is associated with necrosis of the remnants of damaged tissues in the wound area covered with a whitish fibrous film, under which a scab forms from the blood clot (about 12 days). In addition, while healing is in progress, full hygiene of the oral cavity is problematic, so doctors recommend rinsing your mouth (not the throat!) With salt water.

When examining the throat, in some operated patients (especially in children with weakened immunity), doctors can detect the wound on the surface and the curdled coating on the surface of the mucous membrane after removing the glands, a symptom of candidiasis. Of course, the presence of fungal infection complicates the condition of patients in the postoperative period and forces the use of fungicidal drugs.

In the list of later and rare complications, oropharyngeal adhesions are noted after the removal of glands that can occur between the root of the tongue and the region of the palatine arch due to the adhesion of scar tissue at the site of the postoperative wound. The formation of adhesions creates problems with swallowing and articulation.

Reviews of some adult patients contain complaints that the voice changes after removing the glands. Indeed, tonsillectomy can affect the voice, and this is proved by several studies that confirmed the fact of an increase in the size of the oropharynx after this operation and some changes in the resonant characteristics of the vocal tract. It is established that some people have an increase in the frequency of sound (formants) in the range up to 2 kHz and amplification of the overtone of the voice in the frequency range of about 4 kHz. Therefore, the timbre of the voice can change.

[12], [13]

Care after the procedure

The early postoperative period requires medical supervision of the patients' condition so as not to miss the development of bleeding, the risk of which, according to clinical statistics, is about 1.5-2%.

After the operation, patients are supposed to lie on their sides, the discharge from the wound can not be swallowed (they need to be spit). When you can drink after removing the glands, the doctor decides after examining the wounds in the throat and determining the amount of blood in their secretions. As a rule, in the first five to six hours, patients are forbidden not only to talk, but also to swallow anything: with the strain of the vocal cords and swallowing movements, the muscles of the larynx strain, and their contraction extends to the blood vessels, which creates the prerequisites for bleeding.

Rehabilitation and recovery after the procedure for removal of palatine tonsils can take a month, and even more: here play a role and the method of removing glands, and the individual characteristics of patients. But the hospital after removal of the glands is given to the medical institution for 14 days.

Painful sensations in the throat disturb about two weeks after the operation. In order not to further injure postoperative wounds, the diet is observed for 7-10 days after removal of the glands, which involves the use of non-hot homogenized food.

What to eat after removing the glands? You can eat liquid crumbled porridge, vegetable and fruit purees, broths, soups, mashed potatoes, etc. You can eat mousse and ice cream after removing the glands; you can drink jelly, juices, compotes, milk, fermented milk and yogurt after removing the glands. Also, you should drink enough water to maintain normal body homeostasis.

What can not be done after removing the glands? Do not eat solid hot food, drink hot tea or other hot drinks. Under absolute prohibition, acute, peppery, sour and, of course, alcohol after the removal of glands. Until the complete healing of postoperative wounds are prohibited increased physical activity (any sports training, classes in the gym); You can not take a hot shower or bath, bathe in the bath, sunbathe on the beach. And, probably, you yourself guess that doctors will answer the question - can I smoke after removing the glands?

In general, if you often have a sore throat, remember: you can solve this problem. And in most cases, life after removing glands can become more healthy - without bothersome pain in the throat and a lot of other negative effects of chronic tonsillitis.

[14], [15],

Medical errors when removing the glands

Serious complications are fraught with medical errors when removing glands, from which, unfortunately, no one is immune.

First of all, these are intraoperative burns during high-frequency electrocoagulation, laser ablation and other electrosurgical procedures, as well as dentoalveolar injuries.

Hypersalivation (increased salivation) is observed when the lower submandibular salivary gland located near the glands is touched.

The palatine tonsils are innervated by the branches of the maxillary nerve and the glossopharyngeal nerve. Due to damage to the maxillary branch - due to excessive resection of the tissues during the removal of the glands - the passage of nerve impulses into the temporomandibular joint can be disturbed, which causes difficulties with chewing and opening and closing the mouth.

Glossopharyngeal nerve innervates the back third of the tongue, providing, in particular, taste sensations, and if this nerve is damaged, the sensation of taste decreases or is lost.

The innervation of the soft palate is due to the branches of the pharyngeal plexus, with the damage of which the raising of the soft palate with the development of its partial paresis is limited. As a result, patients are observed nasopharyngeal regurgitation - the reverse course of the contents of the esophagus into the nasopharynx.

There may be a resumption of growth of the tissues of the glands, if during surgery the surgeon mistakenly or inadvertently removed the tonsils not completely.