Removal of tonsils (tonsillectomy) - Indications and contraindications

Indications for tonsillectomy (removal of tonsils) are quite numerous, but contraindications to this surgical intervention are no less numerous. Failure to comply with strict indications (contraindications) for tonsillectomy (removal of tonsils) and its implementation often turns a patient with a relatively favorable course of chronic tonsillitis (although accompanied by periodic exacerbations, but in the absence of metatonsillar complications), which can be cured with a set of therapeutic agents and an appropriate patient attitude to this process on the part of the doctor, into a patient constantly suffering from "throat diseases", cancerophobia, neurotic syndrome.

With respect to indications for tonsillectomy (removal of tonsils), all patients can be divided into 3 categories (groups). The first group, the most numerous, includes patients who periodically experience exacerbations of chronic tonsillitis in the form of sore throats, paratonsillar abscesses, which deprive them of their ability to work and gradually worsen their general condition. The second group is represented by patients with various diseases, etiologically and pathogenetically associated with chronic tonsillitis and its periodic complications. These diseases may include tonsillogenic rhinitis, sinusitis, conjunctivitis, dacryocystitis, cervical lymphadenitis, pharyngitis, laryngitis, tracheobronchitis, gastroenteritis, appendicitis, colitis, etc. The third group includes patients with metatonsillar complications that occur “at a distance” due to the presence of an infectious-allergic focus of infection in the palatine tonsils, causing infectious polyarthritis, cardiovascular and renal complications, damage to the nervous system, etc.

When determining indications for tonsillectomy (removal of tonsils) in case of "rheumatoid" complications, it is necessary to distinguish between true rheumatism (primary, atopic disease of connective tissue) and tonsillogenic infectious polyarthritis. In practice, however, in everyday practice these two conditions are not differentiated, and the presence of, on the one hand, signs of chronic tonsillitis, and, on the other, the "rheumatoid factor" serves as a reason for prescribing tonsillectomy (removal of tonsils). Only in the first case, this surgical intervention does not reduce the rheumatic process and often, on the contrary, exacerbates it, but in the second case, literally a few hours after the operation, joint pain disappears, mobility in them increases, and after the elimination of the toxic-infectious focus of infection along with the tonsils, recovery occurs.

In the case of decompensated chronic tonsillitis and the presence of cardiovascular diseases, tonsillectomy (removal of the tonsils) can be prescribed only after a thorough examination of the state of the cardiovascular system and, if necessary, rehabilitation measures for this system.

In case of kidney diseases of tonsillogenic nature, tonsillectomy (removal of tonsils) is performed first of all, since preservation of the primary source of infection during the treatment of kidney diseases is ineffective, and only after removal of tonsils, even without special treatment, do reparative and restorative processes begin in the kidneys, normalizing their functional state.

In case of endocrine disorders (hyperthyroidism, dysmenorrhea, diabetes, etc.), if they are caused by the toxic-allergic influence of chronic tonsillitis, removal of the palatine tonsils can lead to some improvement of the endocrine status indirectly through the suppression of hyaluronidase activity due to intensive stimulation of the adrenal cortex caused by the “stress” that occurs during tonsillectomy (removal of the tonsils).

In various skin diseases (streptoderma, eczema, chronic urticaria, erythroderma, psoriasis, etc.), tonsillectomy (removal of the tonsils) in approximately 64% of cases leads to a cure or a significant reduction in their severity.

With regard to hypertrophy of the palatine tonsils, in which their volume plays a decisive role, and not infection, the indications for tonsillectomy (removal of the tonsils) or tonsillotomy are determined mainly by those mechanical disorders that are caused by enlarged palatine tonsils (sleep breathing disorder, snoring, swallowing and phonation disorders, various types of reflex disorders and, less commonly, dysfunction of the auditory tube and hearing).

Unilateral tonsillectomy (removal of the tonsils) is indicated for carcinoid changes in the structure of the tonsil. In these cases, so-called extended tonsillectomy (removal of the tonsils) is performed with subsequent histological examination of the removed tonsil.

When determining indications for tonsillectomy (removal of tonsils), the following criteria are used.

Anamnesis: general condition, frequency of exacerbations of chronic tonsillitis, degree of exacerbation, presence or absence of local and general complications, disability associated with throat disease, etc.

Pharyngoscopy data: objective signs of chronic tonsillitis, indicating the presence of pronounced organic changes in the palatine tonsils, as well as examination data of other ENT organs and regional lymph nodes.

Data from examination of internal organs (cardiovascular system, blood system, urinary system, rheumatoid factors, etc., which may indicate the presence of metatoisillar complications). It is necessary to conduct mandatory laboratory tests for preoperative preparation to exclude specific infectious diseases, contraindications from the blood coagulation system, etc.

Contraindications to tonsillectomy (removal of tonsils) are divided into absolute and relative.

Absolute contraindications include diseases that adversely affect the blood coagulation system and the condition of the vascular wall (hemophilia, leukemia, agranulocytosis, pernicious anemia, scurvy, Osler's disease). Tonsillectomy (removal of tonsils) is contraindicated in widespread atherosclerosis, severe arterial hypertension, hyperazotemia, acute liver failure, decompensated states of the cardiovascular system, acute cardiopulmonary failure, as well as recent cases of syphilis and tuberculosis in the active phase. Tonsillectomy (removal of tonsils) is also contraindicated in cases of severe disorders of endocrine functions (hyperthyroidism, thymic-lymphatic status, insufficiency of the insular system of the pancreas and functions of the adrenal cortex. Contraindications to tonsillectomy (removal of tonsils) are acute childhood infections, influenza, adenovirus infection, herpes diseases, rheumatoid conditions in the acute stage.

Relative contraindications include conditions of the patient that currently prevent any planned surgical intervention (including tonsillectomy (removal of the tonsils)), while tonsillectomy (removal of the tonsils) can be postponed for the period necessary to eliminate this condition with the help of appropriate therapeutic treatment. First of all, this applies to conditions after acute infectious diseases that require at least 1-1.1 / 2 months for complete rehabilitation of the patient. These conditions include a decrease in the function of the blood coagulation system, banal (alimentary) anemia, menstruation, pregnancy in the first and last 3 months, some organic diseases of the nervous system (but with the consent of a neurologist), psychasthenic conditions and some mental illnesses (with the consent of a psychotherapist and psychiatrist). In tonsillogenic sepsis, tonsillectomy (removal of the tonsils) can be performed against the background of massive antibiotic therapy and other methods of treating sepsis. In case of exacerbation of chronic tonsillitis (remitting angina), tonsillectomy (removal of tonsils) is possible only 10-14 days after the disappearance of acute symptoms of the disease.

A relative contraindication to tonsillectomy (removal of tonsils) is a paratonsillar abscess in the infiltration stage, however, in recent years, the abscess-tonsillectomy operation has become widespread, which prevents the possibility of unpredictable complications of metatonsillar abscess formation (phlegmon of the pharynx, neck, mediastinitis, sepsis, etc.). Such an operation can be performed in the "warm" period with a formed abscess or in the "warm" delayed period 3-7 days after opening the abscess. Tonsillectomy (removal of tonsils), performed simultaneously with opening the abscess or on the 2nd day after that, does not present any difficulties for either the surgeon or the patient. Anesthesia is as effective as in a conventional planned tonsillectomy (tonsil removal), the tonsil on the side of the abscess is easily enucleated, with minimal or no bleeding. Body temperature decreases by the 2nd or 3rd day. After such an operation, there is no need to spread the edges of the incision when opening the abscess, the healing of the niches occurs in the same time frame as in tonsillectomy (tonsil removal) performed in the "cold" period. Abscess tonsillectomy is mandatory in cases where after wide opening of the abscess cavity, the general condition of the patient does not improve over the next 24 hours, the body temperature remains high, and the discharge of pus from the abscess cavity does not stop. With such a clinical picture, there is a possibility of the purulent process spreading beyond the peritonsillar space, which dictates the need for urgent removal of the primary source of infection and possible opening of the peripharyngeal space for its drainage, if necessary.

Relative contraindications to tonsillectomy (tonsil removal) are vascular peritonsillar anomalies that manifest themselves in the corresponding arterial pulsation of the tonsil and in the area of the posterior palatine arch. In this case, tonsillectomy (tonsil removal) can be performed by an experienced surgeon, taking into account knowledge of the localization of a large pulsating vessel and the method of sparing it during separation of the palatine tonsils. In all cases of such an operation, it is necessary to be prepared for emergency ligation of the external carotid artery, and in case of urgent indications for tonsillectomy (tonsil removal) and the presence of a massive abnormal vessel in close proximity to the palatine tonsils, it is possible to apply a provisional ligature to the external carotid artery. Relative contraindications to tonsillectomy (tonsil removal) include subatrophic and atrophic processes in the upper respiratory tract. In some cases, chronic tonsillitis is the cause, then they move from the category of contraindications to the category of indications. However, tonsillectomy in cases of atrophic conditions of the mucous membrane of the upper respiratory tract often aggravates these conditions, so the decision to perform tonsillectomy (tonsil removal) should be balanced, alternative and agreed upon with the patient. When determining the indications and contraindications for tonsillectomy (tonsil removal), the professional aspect is very important, namely the possibility of performing this operation without damaging the vocal function of singers, spoken word artists, teachers, etc. At the same time, any prognosis regarding the voice is practically impossible, with rare exceptions. When considering the issue of tonsillectomy (tonsil removal) in people with voice professions, several aspects should be considered: the obligatory nature of the surgical intervention and three options for its outcome - improvement of the vocal function, its preservation without changes and its deterioration. In all cases, the decision must be made jointly with the phoniatrist with the patient fully aware of the possible outcomes of this surgical intervention. Considering the aspect of obligativity, first of all, it is necessary to assess the degree of pathological condition of the palatine tonsils, the frequency of exacerbations, their impact on the voice function, the presence of significant metatonsillar complications that negatively affect the patient's professional activity and progress towards the complete cessation of the latter. With an unfavorable combination of these factors, there are obviously direct indications for tonsillectomy (removal of the tonsils), which in most cases optimizes the patient's voice function with some change in the timbre of his voice for some period. However, surgical intervention on the palatine tonsils in such patients should be carried out with particular care by a very experienced surgeon.When determining indications for tonsillectomy (removal of tonsils) in singers and specialists in the spoken genre, one should take into account their individual psycho-emotional characteristics, since many artists are very wary of the slightest changes in their voice and have increased sensitivity to various external factors that negatively affect the function of their vocal apparatus. Such individuals are predisposed not only to organic voice disorders, but, as most often happens, to certain psychasthenias that cause functional voice disorders. During tonsillectomy (removal of tonsils) in such patients, special care should be taken with respect to the palatine arches, soft palate, and muscles of the posterior lateral wall of the pharynx. Particular care should be taken to separate the tonsil from the posterior palatine arch, in which the fibers of the muscle that raises the pharynx are located. These fibers are in close contact with the pseudocapsule of the palatine tonsils and are often eliminated together with it. Therefore, when separating the palatine tonsils in this area, it is necessary to come into direct contact with its capsule, operating under visual control in a dry field.

Separation of the posterior arch from the tonsil capsule is carried out relatively easily, starting from the upper pole to the lower third of the tonsil, below which there are cicatricial formations covering the muscle fibers involved in the motor function of the pharynx. Extracapsular removal at this level of the tonsil is invariably accompanied by damage to the said muscle fibers, therefore experienced surgeons, when operating on a singer, consciously preserve the lower pole of the tonsil, which achieves two goals: preserving the pharyngeal muscles, so necessary for maintaining the individual timbre of the voice, and preserving part of the lymphadenoid parenchyma, necessary for the implementation of its protective and trophic functions. In patients operated in this way, postoperative subatrophy of the mucous membrane of the pharynx and larynx occurs significantly less often, and the clinical course of chronic tonsillitis is reduced to a minimum or this disease disappears completely.

Removal of the palatine tonsils is not recommended for children under 3-4 years of age. In some cases of massive congenital hypertrophy of the tonsils, causing mechanical difficulties, expressed in impaired breathing, swallowing and phonation, tonsillotomy is possible with preservation of part of the parenchyma of the palatine tonsils.

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