Surgical treatment of chronic tonsillitis

Semi-surgical methods are effective only when they are performed according to the relevant indications and in the absence of significant pathological changes in the tonsil parenchyma and metatonsillar complications. In essence, they should be considered an auxiliary method that optimizes subsequent non-surgical treatment. First of all, it is aimed at opening the lacunae and facilitating their emptying from detritus, encapsulated abscesses and eliminating closed spaces in the tonsil tissues. Galvanocautery, diathermocoagulation and lacunae dissection were used for this purpose in previous years. Currently, only lacunae dissection remains relevant in the lacunar form of chronic tonsillitis.

For this, one of two methods is used - dissection of the lacuna using a special narrow, curved, scythe-shaped scalpel (lacunotome) or the galvanocautery method. In both cases, it is advisable to wash the lacunae the day before the intervention, freeing them from pathological contents. Immediately before the intervention, the lacunae are washed again with a small amount of antiseptic solution (furacilin or antibiotic) and after application anesthesia, one of the above methods is used. When using a lacunotome, its blade is inserted deep into the lacuna, trying to reach its bottom, and with an outward movement it is dissected, thereby splitting the tonsil along the crypt. The same manipulation is done with the other lacunae accessible to this method. To prevent the healing of the wound surfaces, they are lubricated with a 5% solution of silver nitrate for several days. If the lacuna is not cut to its very bottom, then there is a danger of isolating the uncut part with scar tissue and forming a closed space - a closed source of infection and allergization of the body. In these cases, compensated tonsillitis gradually acquires the character of decomposed and the patient's condition worsens.

Lacunotomy using galvanocautery is performed as follows. After the preparation described above, a button probe bent at a right angle is inserted into the lacuna and, starting from the entrance to the lacuna, it is gradually dissected with a hot cautery to the very end of the probe. If necessary, the galvanocautery is advanced further by 2-3 mm (no more!) in order to reach the bottom of the crypt.

Surgical methods of treatment for chronic tonsillitis and physiological hypertrophy of the palatine tonsils.

Surgical treatment of chronic diseases of the tonsils has been practiced since the time of Hippocrates and Celsus. Thus, Aulus Cornelius Celsus, who lived at the end of the 1st century BC and in the first half of the 1st century AD, removed the tonsils with the nail of his index finger or cut them out with a scalpel when there was “resistance” from the cicatricial capsule in the 10s of the last century BC. Oetius, fearing bleeding, removed only the free part of the tonsils. He recommended gargling with cooled vinegar water after removing the tonsils. Paul of Engina, who practiced around 750 AD, reduced the indications for tonsil removal to a minimum. Abulkar (Abulkar) at the beginning of the 2nd millennium describes the operation of removing the palatine tonsils as follows: the patient's head is clamped between the surgeon's knees, the assistant presses the tongue down, the tonsils are grabbed with a hook and cut out with scissors or a knife with an arcuate blade. Sushruta - the great ancient Indian doctor and scientist - encyclopedist, one of the compilers of Ayurveda, even before Abulkar proposed an operation of removing the palatine tonsils by grabbing it with a hook and cutting it off with a sickle-shaped knife.

In the early Middle Ages, up until the 14th century, there was a tendency to remove tonsils as a panacea for many diseases (by the way, revived by some therapists in the second half of the 20th century). Around 1550, the French doctor J. Guillemeau was the first to suggest using a wire loop to remove hypertrophied tonsils, the principle of which has survived to this day. Around 1900, this method was improved by the Italian Ficano and the Frenchman Vacher.

Cryosurgery of the palatine tonsils. Cryosurgery is a method of local exposure to low temperatures for the destruction and removal of pathologically altered tissues. As noted by E.I. Kandel (1973), one of the founders of Russian cryosurgery, attempts to use cold to destroy tissues were undertaken in the 1940s, when the American surgeon T. Frey cooled cancerous tumors in inoperable patients for a long time and obtained, albeit temporary, but noticeable slowdown in growth and even destruction of tumors.

The method allows for the complete destruction of a given volume of tissue both on the surface of the body and in the depth of any organ; it does not cause damage to surrounding healthy cells. Cryodestruction sites usually heal without the formation of coarse scars or large cosmetic defects. In otolaryngology, cryosurgery is used to remove tonsils and laryngeal tumors. Cell death when exposed to temperatures significantly below 0°C occurs for the following reasons:

1. dehydration of cells during the formation of ice crystals, which is accompanied by a sharp increase in the concentration of electrolytes and leads to “osmotic shock”;
2. denaturation of phospholipids of cell membranes;
3. mechanical damage to the cell membrane as a result of expansion during freezing of intracellular fluid, as well as acute-angled external and intracellular ice crystals;
4. thermal shock;
5. blood stasis in the freezing zone and disruption of microcirculation in the capillaries and arterioles, leading to ischemic necrosis. Currently, three methods of local freezing are used: application (the cryoprobe is placed on the area to be cryodestructed); intra-tissue (the sharp tip of the cryoprobe is inserted into the deep sections of the tissue); irrigation of the freezing zone with a coolant.

For cryosurgical impact, devices and apparatuses have been created, both universal and narrowly functional for autonomous and stationary use. They use various refrigerants - liquid nitrogen, nitrous oxide, solid carbon dioxide, freon. Testing of freon and other refrigerants showed that liquid nitrogen (- 195.8°C) is most suitable for cryosurgery.

The cryosurgical method is widely used in brain surgeries. In 1961, it was first used in the USA in stereotactic surgeries to create a strictly localized focus of destruction measuring 7-9 mm in the deep subcortical structures of the brain.

Pathomorphological changes. As noted by V.S. Pogosov et al. (1983), as a result of local freezing, an ice zone is formed, which is clearly delimited from the surrounding tissue. In the zone of ice conglomerate formation, tissue necrosis occurs, but the cryodestruction focus is always smaller than the freezing zone. Cryonecrosis develops gradually over several hours and reaches its maximum development in 1-3 days. During histological examination of the necrosis zone, the contours of cellular elements are traced for a long time. The process ends with the formation of a delicate scar. If the intended volume of tissue destruction is not achieved as a result of one cryotherapy session, then repeated cryotherapy sessions are performed. In 1962, Soviet scientists A.I. Shalnikov, E.I. Kandel and others created a device for cryogenic destruction of deep brain formations. Its main part is a thin metal tube (cannula) with an independent reservoir into which liquid nitrogen is poured, stored in a Dewar vessel.

Different tissues have different sensitivity to cryotherapy. The most sensitive tissues are those containing a large amount of water (parenchymatous organs, muscle and brain tissue); connective tissue (bone, cartilage, scar tissue) has low sensitivity. Organs and tissues that are well supplied with blood, including blood vessels, have lower sensitivity to cryotherapy than tissues with a lower blood flow rate. As noted by V.S. Pogosov et al. (1983), local freezing is safe, bloodless, and is not accompanied by significant reflex reactions of the cardiovascular system; therefore, local cryotherapy should be classified as a gentle and physiological method. According to the authors of this method, it is the method of choice for some ENT diseases and in some cases can be successfully used in the presence of contraindications to surgical treatment; in addition, this method can be used in combination with the latter.

There are various modifications of cryo-devices, created both for general use and specifically for cryo-impact on a particular area or organ. For cryosurgery of the palatine tonsils, both autonomous cryo-applicators and applicators operating in a stationary mode can be used. The difference between them is that the autonomous cryo-applicator combines a heat-insulated reservoir with a 120 ml coolant with a coolant conductor attached to it with a working tip connected to the cannula using a hinge. Cooling of the tip in cryo-devices for contact cryo-impact is achieved by circulating the coolant in the tip.

Cryotherapy for chronic tonsillitis. Cryotherapy for the palatine tonsils is used in patients with chronic tonsillitis in the presence of contraindications to surgical removal of the palatine tonsils. Considering the virtually non-invasive method of freezing the palatine tonsils and the absence of pain and pathological reflexes that occur with surgical removal of the tonsils, local freezing can be used in patients with severe cardiovascular diseases, such as hypertension grades II-III, heart defects of various etiologies, severe atherosclerosis of the cerebral and cardiac vessels with clinically manifested signs of their insufficiency. The authors indicate that the use of cryosurgical treatment of the palatine tonsils is permissible in diseases associated with blood clotting disorders (Werlhof's disease, Schonlein-Henoch disease, hemophilia, etc.), kidney diseases, endocrine system diseases, general neurosis with cardiovascular reactions, menopause. In addition, cryosurgery of the palatine tonsils may be the method of choice in elderly people with atrophic phenomena in the upper respiratory tract, pathologically altered remnants of the palatine tonsils after their removal in the past, etc.

The procedure of cryosurgical intervention on the palatine tonsils is performed in a hospital setting. Two days before the operation, the patient is prescribed sedatives and tranquilizers, if necessary, the functions of the cardiovascular system, blood coagulation system, etc. are corrected. Preoperative preparation is the same as for tonsillectomy. The operation is performed under local anesthesia (application of 2 ml of 1% dicaine solution, infiltration through the anterior arch into the retrotonsillar space of 10 ml of 1% novocaine or lidocaine solution).

Cryotherapy is performed using a surgical cryoapplicator with a tube, through which a cannula is brought to the distal end of the tube, selected according to the size of the palatine tonsil, to the end of which the tip supplied with the cryoapplicator is attached through a hinged retainer. The lumen of the tube should freely pass the tip fixed to the cannula. Assembled in this state, the device is ready for cryotherapy. The tip should correspond to the frozen surface of the tonsil and ensure tight contact with the tonsil. Immediately before cryotherapy, the reservoir of the cryoapplicator is filled with liquid nitrogen. The operation begins when the tip cools to a temperature of - 196°C; this moment corresponds to the formation of transparent drops of liquid air on the surface of the tip. Local freezing of the tonsil is performed using a two-cycle method, i.e. during the operation, each tonsil is frozen and thawed twice. The whole procedure consists of 6 stages:

1. After the tip temperature has been brought to the required level, the tube is brought to the surface of the tonsil and fixed on it;
2. advance the cannula with the tip along the tube towards the tonsil and press it firmly against the latter;
3. freeze the tonsil for 2-3 minutes;
4. removal of the applicator with the tip from the oropharynx;
5. thawing of the tonsils;
6. tube removal.

Carrying out the cryoapplication procedure for chronic tonsillitis requires special knowledge and skills, no less complex and precise than those for tonsillectomy. Before the cryoapplication procedure, the surface of the tonsil is thoroughly dried with a gauze ball, otherwise an ice layer will form between the tip and the tonsil, preventing the heat transfer from the palatine tonsil to the tip. The position of the cryoapplicator and tube during freezing relative to the surface of the palatine tonsil remains unchanged. In the absence of tight contact between the tonsil and the tip, only superficial freezing occurs; excessive pressure on the applicator leads to deep immersion of the cooled tip into the tonsil and its “capture” by the frozen tissue. In this case, the operation becomes uncontrollable, since after the freezing exposure (2-3 minutes) it is impossible to remove the tip (4th stage of the operation) and stop the cryoexposure in a timely manner. This leads to significant reactive changes in the tonsil area, the lateral surface of the pharynx and the oropharynx and a pronounced general reaction of the body (severe pain in the throat, paresis of the soft palate and tongue, a significant increase in body temperature, etc.). Insufficiently tight fixation of the tube to the surface of the tonsil leads to saliva entering the cryotherapy zone and freezing of the tip to the tonsil, as well as to the spread of the freezing zone beyond the tonsil.

After the freezing exposure has expired, only the applicator (the cannula with the tip attached to it) is removed from the oropharynx, and the tube is left fixed on the tonsil (as during freezing) and its lumen is closed with a sponge or cotton wool. The tonsil, isolated by the tube from the surrounding warm air and tissue, thaws within 4-5 minutes. After the first cycle of cryotherapy on the right tonsil, the same cycle is performed on the left tonsil. Then, in the same sequence, the second freezing cycle is repeated first on the right, then on the left tonsil.

After cryotherapy, the following visual and structural changes occur in the tonsils. Immediately after freezing, the tonsil turns white, decreases in size, and becomes dense. After thawing, it swells and undergoes paretic dilation of the vessels, creating the impression that the tonsil is filled with blood. Serous discharge appears from the lacunae. In the next few hours, hyperemia increases, and the tonsil becomes bluish-purple. A day later, a thin white necrotic coating with a clear demarcation line appears on its surface. After 2-3 days, the swelling of the tonsil disappears, the necrotic coating becomes denser and becomes gray. After 12-21 days, the surface of the tonsil is cleared. With complete destruction of the palatine tonsil, a thin, delicate, barely noticeable scar is formed in the niche, which does not deform the arch and soft palate. With partial destruction of the palatine tonsils, scar tissue is not determined. To achieve a positive therapeutic effect, V.S. Pogosov et al. (1983) recommend repeating the cryotherapy session after 4-5 weeks to achieve destruction of the majority of tonsil tissue.

The effectiveness of cryosurgery in chronic tonsillitis depends on several factors. First of all, it is determined by the depth of destruction of tonsillar tissue. With sufficiently complete elimination of pathologically altered parts, clinical signs of chronic tonsillitis, including relapses, exacerbations, signs of tonsillocardial syndrome disappear or become weakly expressed. Metatonsillar complications of rheumatoid, cardiac, renal, etc. nature cease to progress and are more effectively subjected to appropriate special treatment.

Experts studying the problem of cryotherapy of the palatine tonsils do not recommend using this method for large tonsils and in the presence of a pronounced triangular fold fused with the tonsil. If there are no contraindications to tonsillectomy, then priority in the treatment of chronic tonsillitis should be given to this method.

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