Surgical treatment of chronic tonsillitis

Semi-surgical methods are effective only in cases when they are carried out according to the appropriate indications and in the absence of significant pathological changes in the parenchyma of the tonsils and metatonsillar complications. In essence, they should be referred to an auxiliary method that optimizes subsequent nonoperative treatment. First of all, it is aimed at uncovering lacunae and facilitating their emptying from detritus, encysted abscesses and the elimination of enclosed spaces in the tissues of the amygdala. For this, galvanocaustic, diathermocoagulation and dissection of lacunae were used in previous years. At present, only the dissection of lacunae in the lacunar form of chronic tonsillitis remains relevant.

For this, one of two methods is used: dissection of the lacuna by means of a special narrow scalpel (lacunotoma) curved in the form of a braid or by galvanocaustic method. In both cases on the eve of the intervention, it is advisable to wash the lacunae, freeing them from pathological contents. Immediately before the intervention, the lacuna is again washed with a small amount of antiseptic solution (furacilin or antibiotic) and after applying anesthesia one of the above methods is used. When using lacunotoma, its blade is inserted deep into the lacuna, trying to reach its bottom, and dissecting it outward from the outside, thereby splitting the tonsil along the course of the crypt. The same manipulation is done with the other gaps available to this method. To avoid fusion of wound surfaces, they are lubricated with 5% silver nitrate solution for several days. If the lacuna is not cut to its very bottom, then there is a danger of isolation of the undissociated part of the scar tissue and the formation of a closed space - a closed foci of infection and allergic organism. In these cases, compensated tonsillitis gradually acquires the character of decompiled and the patient's condition worsens.

Lacunotomy with galvanocaustic is carried out as follows. After the preparation described above, a curved probe is bent into the lacuna and, starting from the entrance to the lacuna, it is gradually dismembered by its glowing cauter to the very end of the probe. If necessary, the galvanic cautery is advanced to a depth of 2-3 mm (no more!) To reach the bottom of the crypt.

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

Surgical treatment for chronic diseases of the tonsils has been practiced since the time of Hippocrates and Celsus. So, Aulus Cornelius Celsus, who lived at the end of the 1st century. BC. E. And in the first half of the first century. N. E., produced the removal of palatine tonsils with the finger of the index finger or cut them with a scalpel in the "resistance" of the scar-modified capsule in the 10th years of the last century BC. E. Etius (Oetius), for fear of bleeding, removed only the free part of the palatine tonsils. He recommended after the removal of the tonsils to rinse the throat with chilled vinegar water. Paul of Engin (Paul dc Engina), who practiced around 750 AD. E., reduced to a minimum the indication for the removal of palatine tonsils. Abulkar at the beginning of the second millennium describes the operation of removal of palatine tonsils as follows: the head of the patient is sandwiched between the surgeon's knees, the assistant presses the tongue downwards, the tonsils are hooked and cut with scissors or a knife with an arcuate blade. Sushruta - a great ancient Indian physician and scientist - encyclopedist, one of the compilers of Ayurveda, even before Abulkar proposed the operation of removing palatine tonsils by grasping it with a hook and cutting off a sickle-shaped knife.

During the early Middle Ages, up to the XIV century, there was a tendency to the general removal of tonsils as a panacea for many diseases (by the way, reanimated by some therapists in the second half of the 20th century). Around 1550, the French doctor J. Guillemeau was the first to use a wire loop to remove hypertrophied tonsils, the principle of which has survived to this day. Around 1900, this method was perfected by the Italian Ficano and the Frenchman Vacher.

Cryosurgery of palatine tonsils. Cryosurgery is a method of local exposure to low temperatures for the destruction and removal of pathologically altered tissues. As EI Kandel (1973) notes, one of the founders of Russian cryosurgery, attempts to use cold for tissue destruction, were undertaken in the 1940s when the American surgeon T. Frey continued to cool cancerous tumors in inoperable patients and received, although a temporary, but noticeable slowing of growth and even destruction of tumors.

The method allows to completely destroy a given volume of tissue both on the body surface and in the depth of any organ; does not cause damage to surrounding healthy cells. Foci of cryodestruction usually heal without the formation of gross scars, large cosmetic defects. In otorhinolaryngology, cryosurgery is used to remove tonsils and tumors of the larynx. The death of cells under the influence of temperature is much lower than 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 when the intracellular fluid freezes, as well as acute outer and intracellular ice crystals;
4. thermal shock;
5. stasis of blood in the freezing zone and disturbance of microcirculation in capillaries and arterioles, leading to ischemic necrosis. Currently, three methods of local freezing are applied: application (the cryoprobe is installed on the area to be cryodestructed); interstitial (the sharp tip of the cryoprobe is injected into the deep tissue sections); Refrigerant freezing zone refrigerant.

For cryosurgical action, devices and apparatus have been created, both universal and of narrow functional purpose for autonomous and stationary applications. They use various refrigerants - liquid nitrogen, nitrous oxide, solid carbon dioxide, freon. The trial of freon and other refrigerants showed that liquid nitrogen is the most suitable for cryosurgery (-195.8 ° C).

The cryosurgical method is widely used for operations on the brain. In 1961, it was first used in the US in stereotactic operations to create a strictly localized destruction site 7-9 mm in deep subcortical structures of the brain.

Pathomorphological changes. As noted by V.Pogosov et al. (1983), as a result of local freezing, an ice zone is formed, which is clearly delineated from the surrounding tissue. In the zone of formation of the ice conglomerate, tissue necrosis occurs, but the cryodestruction center is always smaller than the freezing zone. Cryonecrosis develops gradually over several hours and reaches its maximum development in 1-3 days. With histological examination of the necrosis zone, the contours of cellular elements are traced in it for a long time. The process ends with the formation of a gentle scar. If, as a result of one cryo-exposure session, the intended amount of tissue destruction is not achieved, then repeated cryo-effects are performed. In 1962, Soviet scientists AI Shalnikov, EI Kandel, and others created a device for cryogenic destruction of deep brain formations. Its main part is a thin metal tube (canula) with an autonomous reservoir into which liquid nitrogen is stored, which is stored in a Dewar vessel.

Different tissues have different sensitivity to cryoprotection. The most sensitive tissues are those containing a large amount of water (parenchymal organs, muscular and brain tissue, a small sensitivity is possessed by connective tissue (bone, cartilage, scar tissue), organs and tissues well supplied with blood, including blood vessels, to cryoactivity than tissues with a smaller flow rate of blood passing through them.As noted by V.Pogosov et al. (1983), local freezing is safe, bloodless, not accompanied by significant reflex reactions of the hearts but the local cryoexposure should be referred to sparing and physiological methods.In the opinion of the authors of this method, it is a means of choice in certain diseases of the ENT organs 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 cryopresources, created for general use, and specifically for cryoexposure to a particular area or organ. For cryosurgery of palatine tonsils can be used as self-contained cryoapplicators, and applicators working in a stationary mode. The difference between them is that the self-contained cryoapplicator combines a heat-insulated reservoir with a refrigerant of 120 ml capacity, with a cold-agent cough conductor attached to it with a working tip connected to the cannula by means of a hinge. Cooling of the tip in cryo-instruments for contact cryo-exposure is achieved due to the circulation of coolant in the tip.

Cryogenic reaction in chronic tonsillitis. Cryogenic influence on palatine tonsils is used in patients with chronic tonsillitis in the presence of contraindications to the removal of palatine tonsils surgically. Given the virtually non-invasive method of freezing tonsils and the absence of pain and pathological reflexes that arise during the surgical method of removing tonsils, their local freezing can be used in patients with severe diseases of the cardiovascular system, such as hypertension II-III degree, heart disease of various etiologies , expressed atherosclerosis of the vessels of the brain and heart with clinically manifested signs of their insufficiency. The authors point out that the use of cryosurgical treatment for palatine tonsils is permissible in diseases associated with disorders of blood clotting (Verlhof, Shenlaine-Henoch, hemophilia, etc.), kidney disease, endocrine system, general neurosis with cardiovascular reactions, menopause. In addition, cryo-exposure to the palatine tonsils can be a method of choice in the elderly with the presence of atrophic phenomena in the upper respiratory tract, the presence of pathologically altered residual tonsils after their removal in the past, etc.

The procedure for cryosurgical intervention on palatine tonsils is carried out under stationary conditions. For 2 days before surgery, the patient is prescribed sedatives and tranquilizers, if necessary, correct the functions of the cardiovascular system, blood coagulation system, etc. Preoperative preparation is the same as in tonsillectomy. The operation is performed under local anesthesia (application of 2 ml of 1% solution of dicaine, infiltration through the anterior arch into the zamindalic space 10 ml of 1% solution of novocaine or lidocaine).

Cryocardial effect is performed by a surgical cryoapplicator with a tube through which a tip is attached to the distal end of the tube, matched to the size of the palatine tonsil, to the end of which a tip attached to the cryoapplicator is attached through the hinge retainer. The lumen of the tube must freely pass the tip fixed to the cannula. The device assembled in this state is ready for cryoexposure. The tip should correspond to the freezing surface of the amygdala and ensure a tight contact with the amygdala. Immediately before the cryo-action, the cryoapplicator reservoir is filled with liquid nitrogen. The operation begins when the tip is cooled 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 amygdala is carried out by a two-cycle method, i.e., during the operation, each almond is frozen and thawed two times. The whole procedure consists of 6 stages:

1. after the temperature of the tip is brought to the desired, the tube is brought to the surface of the amygdala and fixed on it;
2. advance the cannula with the tip along the tube to the amygdala and press it firmly against the latter;
3. freezing the amygdala for 2-3 minutes;
4. removal of the applicator with a tip from the oropharynx;
5. carrying out thawing of the tonsils;
6. removal of the tube.

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

After the exposure of the freeze from the oropharynx, only the applicator (cannula with attached tip to it) is removed, and the tube is left fixed on the amygdala (as during freezing) and close its lumen with a sponge or cotton wool. The amygdala, isolated by the tube from the surrounding warm air and tissues, thaws for 4-5 minutes. After the end of the first cycle of cryo-action on the right tonsil, the same cycle is performed on the left tonsil. Then, in the same sequence, repeat the second cycle of freezing first on the right, then on the left tonsils.

After cryo-exposure in tonsils, the following visual and structural changes occur. Immediately after freezing, the amygdala becomes white and decreases and becomes dense. After thawing - swollen, the paretic expansion of the vessels occurs, creating the impression that the amygdala is filled with blood. A gaping discharge appears from the lacunae. In the next few hours, hyperemia increases, and the amygdala acquires a cyanotic-purple color. A day later, a thin white necrotic plaque with a clear demarcation boundary appears on its surface. After 2-3 days puffiness of the amygdala disappears, necrotic plaque becomes denser and becomes gray. After 12-21 days the surface of the amygdala is cleared. With complete destruction of the palatine tonsil in the niche, a thin, delicate, imperceptible scar is formed, which does not deform the arch and soft palate. With partial destruction of palatine tonsils scar tissue is not determined. To obtain a positive therapeutic effect, V.Pogosov et al. (1983) recommend repeating the cryoexposure session in 4-5 weeks to achieve destruction of most of the amygdala tissue.

The effectiveness of cryosurgery in chronic tonsillitis depends on several factors. First of all, it is determined by the depth of destruction of the amygdala. 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. Metatonzillar complications of rheumatoid, cardiac, renal, etc. Character cease to progress and are more effectively treated with appropriate special treatment.

Specialists who study the problem of cryoexposure on palatine tonsils do not recommend using this method in tonsils of large size and in the presence of a pronounced, triangular folded with the amygdala. If there are no contraindications to tonsillectomy, then the priority in the treatment of chronic tonsillitis should be given precisely to this method.

[1], [2], [3], [4]