Removal of tonsils (tonsillectomy): indications and contraindications

Indications for tonsillectomy (removal of tonsils) are quite numerous, but there are no fewer contraindications to this surgical intervention. Failure to comply with strict indications (contraindications) to 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, in the patient, constantly suffering from "throat diseases", carcinophobia, neurotic indromom.

In relation 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 angina, parathonsillar abscesses, depriving them of their ability to work and gradually worsen the 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 can be attributed to tonsillogenic rhinitis, sinusitis, conjunctivitis, dacryocystitis, cervical lymphadenitis, pharyngitis, laryngitis, tracheobronchitis, gastroenteritis, appendicitis, colitis, etc. The third group includes patients with metatonsillar complications arising "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, lesions of the nervous system, etc.

In determining the indications of tonsillectomy (removal of tonsils) in "rheumatoid" complications, it is necessary to distinguish between genuine rheumatism (primary, atopic disease of connective tissue) from tonsillogenic infectious polyarthritis. In practice, however, these two conditions do not differentiate in everyday practice, and the presence of signs of chronic tonsillitis, on the one hand, and "rheumatoid factor" on the other, serves as an excuse for the appointment of tonsillectomy (tonsillectomy). Only in the first case this operative intervention does not reduce the rheumatic process and quite often, on the contrary, it aggravates it, but in the second case, after a few hours after the operation, the joint pains disappear, the mobility in them increases, and along with the tonsils a toxic infectious focus of infection recovery comes.

With a decompensated form of chronic tonsillitis and the presence of cardiovascular diseases, tonsillectomy (tonsillectomy) can be prescribed only after a thorough examination of the state of the cardiovascular system and, if necessary, rehabilitating in relation to this system of activities.

In case of kidney diseases of tonzillogenous nature, tonsillectomy (removal of tonsils) is performed in the first place, since the preservation of the primary focus of infection in the treatment of kidney diseases is ineffective, and only after removal of the tonsils, even without special treatment in the kidneys, reparative-recovery processes begin to normalize their functional state.

With endocrine disorders (hyperthyroidism, dysmenorrhea, diabetes, etc.), if they are caused by the toxic-allergic effect of chronic tonsillitis, removal of palatine tonsils can lead to some improvement in endocrine status indirectly through inhibition of hyaluronidase activity due to intensive stimulation of the adrenal cortex due to "stress" arising from tonsillectomy (tonsillectomy).

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

With regard to the hypertrophy of palatine tonsils, in which their volume, rather than infection, plays a decisive role, indications for tonzillectomy (tonsillectomy) or tonsillotomy are mainly determined by those mechanical disorders that cause increased palatine tonsils (respiratory disturbance during sleep, snoring, swallowing and phonation, various kinds of reflex disorders and, more rarely, disturbances in the function of the auditory tube and hearing).

Unilateral tonsillectomy (tonsillectomy) is indicated in case of cancer changes in the structure of the amygdala. In these cases, the so-called expanded tonsillectomy (tonsillectomy) is performed, followed by a histological examination of the removed tonsil.

When determining indications for tonsillectomy (removal of tonsils) are based on the following criteria.

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

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

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

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

Absolute contraindications include diseases that negatively affect the blood coagulation system and the state of the vascular wall (hemophilia, leukemia, agranulocytosis, malignant anemia, scurvy, Osler's disease). Tonsillectomy (tonsillectomy) is contraindicated in atherosclerosis, severe arterial hypertension, hyperazotemia, acute hepatic insufficiency, decompensated cardiovascular conditions, acute cardiopulmonary insufficiency, as well as fresh cases of syphilis and tuberculosis in the active phase. Tonsillectomy (tonsillectomy) is also contraindicated in severe disorders of endocrine functions (hyperthyroidism, thymic-lymphatic status, insufficiency of the pancreas insulin system and adrenal cortex functions.) Contraindications to tonsillectomy (tonsillectomy) are acute childhood infections, influenza, adenovirus infection, herpetic diseases, rheumatoid conditions in the acute stage.

Relative contraindications include those conditions of the patient that currently prevent any planned surgical intervention (including tonsillectomy (tonsillectomy)), while tonzillectomy (removal of the tonsils) may be delayed for the period necessary to eliminate this condition with the help of appropriate therapeutic treatment. First of all, this refers to conditions after acute acute infectious diseases, requiring for a full rehabilitation of the patient not less than 1-1,1 / 2 months. These conditions include a decrease in the function of the blood coagulation system, banal (alimentary) anemia, menstruation, pregnancy at the first and last 3 months, some organic diseases of the nervous system (but agreement with the neurologist), psychasthenic conditions and certain mental illnesses (in agreement with the psychotherapist and psychiatrist). With tonsillitis sepsis, it is possible to perform tonsillectomy (removal of tonsils) against a background of massive antibiotic therapy and other methods of treating sepsis. With exacerbation of chronic tonsillitis (remitting angina), tonsillectomy (removal of tonsils) is possible only 10-14 days after the disappearance of acute signs of the disease.

Relative contraindication to tonsillectomy (removal of the tonsils) is paratonsillar abscess in the stage of infiltration, but in recent years the operation of abscess-tonsillectomy, which prevents the occurrence of unpredictable complications of metatonzillar abscess formation (phlegmon pharymon, neck, mediastinitis, sepsis, etc.) is spreading . Such an operation can be performed in a "warm" period with a formed abscess or in a "warm" delayed period 3-7 days after the opening of the abscess. Tonsillectomy (removal of the tonsils), performed simultaneously with the opening of the abscess or on the 2nd day afterwards, presents no difficulties for either the surgeon or the patient. Anesthesia is just as effective as with a routine planned tonsillectomy (tonsillectomy), the tonsil on the side of the abscess is easily excavated, with bleeding minimal or completely absent. Body temperature is reduced to the 2nd or 3rd day. After such an operation, there is no need to dilute the edges of the incision at the dissection of the abscess, the healing of the niches begins at the same time as in tonsillectomy (removal of the tonsils), carried out in the "cold" period. Abscess-tonzillectomy is indicated necessarily in those cases when, after a wide opening of the abscess cavity, the general state of the patient does not improve within the next 24 hours, the body temperature is kept high, the excretion of pus does not cease from the abscess cavity. With such a clinical picture, there is a possibility of the purulent process spreading beyond the limits of the proximal point space, which dictates the need for urgent removal of the primary focus of infection and possible opening of the okolobloccal space for its drainage, if necessary.

Relative contraindication to tonsillectomy (removal of the tonsils) are vascular peritonsillar abnormalities, which are manifested by the corresponding arterial pulsation of the amygdala and in the region of the posterior palatine arch. In this case, tonsillectomy (removal of the tonsils) can be performed by an experienced surgeon, taking into account the knowledge of the localization of a large pulsating vessel and the way it is shuddering when the palatine tonsils are being segregated. In all cases, such an operation requires readiness for emergency ligation of the external carotid artery, and with urgent indications for tonsillectomy (removal of tonsils) and the presence of a massive anomalous 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 (removal of tonsils) include subatrophic and atrophic processes in the upper respiratory tract. In some cases, it is the chronic tonsillitis that is their cause, then they become a discharge of contraindications from the category of contraindications. However, often the removal of tonsils with atrophic conditions of the mucous membrane of the upper respiratory tract aggravates these conditions, so the decision to perform tonsillectomy (removal of the tonsils) should be weighed, alternative and consistent with the patient. In determining the indications and contraindications to tonsillectomy (removal of the tonsils), it is very important to have a professional aspect, namely, the possibility of carrying out this operation without sacrificing the voice function of singers, actors of the spoken genre, teachers, etc. However, any forecast regarding the voice almost impossible, with a rare exception. When considering the issue of tonsillectomy (removal of tonsils) in persons of the voice professions, several aspects should be considered: the obligation of the operative intervention and three variants of its outcome - improvement of the voice function, its preservation without changes and its deterioration. In all cases, the decision must be taken in conjunction with the phoniatrist, with the patient fully aware of the possible outcomes of this surgical intervention. Considering the aspect of obligability, first of all one should evaluate the degree of the pathological condition of palatine tonsils, the frequency of exacerbations, their effect on the voice function, the presence of significant metatonsillar complications, negatively affecting the patient's professional activity and progressing towards the complete cessation of the latter. With an unfavorable combination of these factors, it is obvious that direct indications for tonsillectomy (removal of tonsils) arise, which in most cases optimizes the patient's voice function with some change for some period of timbre of his voice. However, surgical intervention in the palatal tonsils in such patients should be carried out with special care by a very experienced surgeon. In determining the indications for tonzillectomy (removal of tonsils) in singers and specialists of the colloquial genre, one should take into account their individual psychoemotional features, since many artists are very wary of the slightest changes in their voice and have an increased sensitivity to various external factors negatively affecting the function of their vocal apparatus . Such persons are predisposed not only to organic voice disorders, but, more often than not, to certain psychasthenia causing functional impairment of the voice. When tonsillectomy (removal of tonsils) in such patients, a particularly careful attitude should be in relation to the palatine arch, soft palate, the muscles of the posterolateral wall of the pharynx. Especially carefully it is necessary to separate the amygdala from the posterior palatal arch, in which the fibers of the muscle that lifts the pharynx are located. These fibers are in close contact with the pseudocapsule of palatine tonsils and are often eliminated along with it. Therefore, when vysepakrovke palatine tonsils in this area should come into direct contact with her capsule, operating under the control of vision in a dry field.

Separation of the posterior arch from the amygdala capsule is relatively easy, starting from the upper pole to the lower third of the amygdala, below which there are cicatricial structures that encompass the muscle fibers involved in the motor function of the pharynx. Extracapsular removal at this level of the amygdala is invariably accompanied by damage to these muscle fibers, so experienced surgeons, operating the singer, knowingly keep the lower pole of the amygdala, thus achieving two goals: saving the pharyngeal muscles so necessary for maintaining the individual voice of the voice, and keeping a part of the lymphadenoid parenchyma needed for the realization of all protective and trophic functions. In patients operated in this way, post-operative subatrophy of the mucous membrane of the pharynx and larynx is much less likely, and the clinical course of chronic tonsillitis is minimized or the disease completely disappears.

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

[1], [2], [3], [4], [5], [6]