Acute & chronic tonsillitis and their management

52
Acute & Chronic Acute & Chronic Tonsillitis Tonsillitis Presented By Presented By MAJID NAWAZ MAJID NAWAZ & &

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Transcript of Acute & chronic tonsillitis and their management

Page 1: Acute & chronic tonsillitis and their management

Acute & Chronic Acute & Chronic TonsillitisTonsillitis

Presented By Presented By MAJID NAWAZ MAJID NAWAZ & & TEHSINA NAWAZTEHSINA NAWAZ

BANNU Medical College BANNU Medical College Bannu k.p.k Pakistan.Bannu k.p.k Pakistan.

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IntroductionIntroductionThe palatine tonsil is an ovoid The palatine tonsil is an ovoid

mass of lymphoid tissue mass of lymphoid tissue located in the oropharynx located in the oropharynx between the between the

anterior and posterior pillarsanterior and posterior pillars

It has 2 surfaces –It has 2 surfaces – 1. medial surface1. medial surface 2. lateral surface 2. lateral surface It ha 2 poles –It ha 2 poles – 1. upper pole 1. upper pole 2. lower pole2. lower pole

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Medial surfaceMedial surfaceIt is lined by stratified squamous non It is lined by stratified squamous non

keratinising epithelium which dips keratinising epithelium which dips into the crypts into the crypts

The crypts are 12-15 in number The crypts are 12-15 in number Secondary crypts arise from the Secondary crypts arise from the

primary crypts and extend into the primary crypts and extend into the substance of the tonsil substance of the tonsil

One of the crypts located in the upper One of the crypts located in the upper part is larger than the rest – crypta part is larger than the rest – crypta magna magna

The crypts serve to increase the The crypts serve to increase the surface area of the tonsil surface area of the tonsil

The crypts may be filled with cheesy The crypts may be filled with cheesy material – epithelial debris, food material – epithelial debris, food particles and bacteriaparticles and bacteria

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Lateral surfaceLateral surface It is covered by the fibrous capsule of the tonsilIt is covered by the fibrous capsule of the tonsil The tonsillar bed is separated from the capsule by loose The tonsillar bed is separated from the capsule by loose

areolar tissueareolar tissue This makes it is easy to dissect the tonsil from its bed during This makes it is easy to dissect the tonsil from its bed during

tonsillectomy tonsillectomy

It is the site of collection of pus in peritonsillar abscess It is the site of collection of pus in peritonsillar abscess (quinsy) (quinsy)

Some fibers of palatoglossus and palatopharyngeus Some fibers of palatoglossus and palatopharyngeus muscles get attached to the capsule of tonsil muscles get attached to the capsule of tonsil

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Upper poleUpper pole

It extends into the soft palate It extends into the soft palate

There is a semilunar fold of mucous membrane There is a semilunar fold of mucous membrane which covers the medial part of the upper pole which covers the medial part of the upper pole

It extends from anterior pillar to posterior pillar It extends from anterior pillar to posterior pillar

It encloses a potential space – supratonsillar fossa It encloses a potential space – supratonsillar fossa

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Lower poleLower poleIt is attached to the tongueIt is attached to the tongue A triangular fold of mucous membrane extends from the A triangular fold of mucous membrane extends from the anterior tonsillar pillar to the lower pole anterior tonsillar pillar to the lower pole

It encloses a space – anterior tonsillar spaceIt encloses a space – anterior tonsillar space The lower pole is separated from the tongue by the tonsillo-The lower pole is separated from the tongue by the tonsillo-

lingual sulcuslingual sulcus This sulcus may harbour carcinoma This sulcus may harbour carcinoma

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Bed of tonsilBed of tonsil

It is formed by the 2 It is formed by the 2 musclesmuscles

1.Superior constrictor1.Superior constrictor 2.Styloglossus 2.Styloglossus

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Structures related to the Structures related to the bed of tonsilsbed of tonsils

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Blood supplyBlood supplyBlood supply is from the branches of 4 major Blood supply is from the branches of 4 major

arteries all of them are the braches of a main arteries all of them are the braches of a main artery i.e external carotid artery . These are artery i.e external carotid artery . These are

1.Maxillary artery descending palatine 1.Maxillary artery descending palatine arteryartery

2.Ascending pharyngeal artery Tonsillar 2.Ascending pharyngeal artery Tonsillar branchesbranches

3.Facial artery tonsillar artery(main 3.Facial artery tonsillar artery(main artery) & ascending palatine arteryartery) & ascending palatine artery

4.Lingual artery dorsal lingual branches.4.Lingual artery dorsal lingual branches.

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Veins, lymphatics & Veins, lymphatics & nervesnerves

LymphaticsLymphatics pierce the superior pierce the superior constrictor and drain into upper deep constrictor and drain into upper deep cervical (jugulo-digastric) nodes cervical (jugulo-digastric) nodes located below the angle of mandible.located below the angle of mandible.

VeinsVeins from the tonsils drain into from the tonsils drain into paratonsillar vein which then joins the paratonsillar vein which then joins the common facial vein and pharyngeal common facial vein and pharyngeal venous plexusvenous plexus

NervesNervesLesser palatine branches of Lesser palatine branches of

sphenopalatine ganglion and sphenopalatine ganglion and glossopharyngeal nerve provide glossopharyngeal nerve provide sensory nerve supply.sensory nerve supply.

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Function on tonsilsFunction on tonsils It has a protective It has a protective

function in that it prevents function in that it prevents entry of pathogens entry of pathogens through the nasal and through the nasal and oral route oral route

The crypts on the surface The crypts on the surface of the tonsil serve to of the tonsil serve to increase the surface area increase the surface area and increase the and increase the efficiency of protection efficiency of protection against pathogens against pathogens

It forms a part of It forms a part of Waldeyer’s lymphatic Waldeyer’s lymphatic ring.ring.

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TonsillitisTonsillitis Inflammation 0f tonsils due to Inflammation 0f tonsils due to

bacterial or viral infection bacterial or viral infection causing a sore throat , fever, causing a sore throat , fever, and difficulty in swallowing is and difficulty in swallowing is called tonsillitis.called tonsillitis.

There are 3 types of itThere are 3 types of it

1.Acute tonsillitis1.Acute tonsillitis 2. chronic tonsillitis2. chronic tonsillitis 3. Compensated3. Compensated tonsillitis tonsillitis

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Local signs of tonsillitisLocal signs of tonsillitisUnpleasant mouth odor

Unpleasant feeling in the throat

Pus or tonsil stones in lacunae

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Local signs of tonsillitis - Local signs of tonsillitis - changes in the palatine changes in the palatine arches arches Hyperemia

Cicatricles formation

Slight swelling

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Acute tonsillitisAcute tonsillitis Mostly affects children in the age group of 5-15 Mostly affects children in the age group of 5-15

years, may also affect adultsyears, may also affect adults Organisms Organisms beta-hemolytic streptococci beta-hemolytic streptococci

(most common), staphylococci, pneumococci, (most common), staphylococci, pneumococci, H.influenzaeH.influenzae

Symptoms: sore throat, difficulty in swallowing, Symptoms: sore throat, difficulty in swallowing, fever, ear ache, constitutional symptomsfever, ear ache, constitutional symptoms

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Types of acute tonsillitisTypes of acute tonsillitis1).1).Acute catarrhal/superfficial here tonsillitis is a here tonsillitis is a

part of generalized pharyngitis, mostly seen in part of generalized pharyngitis, mostly seen in viral infectionsviral infections

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Types of acute tonsillitisTypes of acute tonsillitis2).Acute follicular 2).Acute follicular infection spread into the infection spread into the

crypts with purulent material, presenting at crypts with purulent material, presenting at the opening of crypts as yellow spots.the opening of crypts as yellow spots.

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Types of acute tonsillitisTypes of acute tonsillitis3).Acute membranous3).Acute membranous follows stage of acute follows stage of acute

follicular tonsillitis where exudates coalesce to follicular tonsillitis where exudates coalesce to form membrane on the surfaceform membrane on the surface

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Types of acute tonsillitisTypes of acute tonsillitis4).Acute parenchymatous4).Acute parenchymatous tonsil is uniformly tonsil is uniformly

enlarged and congestedenlarged and congested

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SymptomsSymptoms:: Sore throatSore throat Difficulty in Difficulty in

swallowingswallowing Generalised body Generalised body

acheache FeverFever Earache and Earache and

Thick speechThick speech

SignsSigns:: Swollen congested Swollen congested

tonsils with tonsils with exudatesexudates

Enlarged tender Enlarged tender Jugulo-diagastric Jugulo-diagastric lymph nodeslymph nodes

Coasted tongueCoasted tongue Foetid breathFoetid breath Hyperaemia of Hyperaemia of

pillars soft palate & pillars soft palate & uvula.uvula.

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TREATMENTTREATMENT Bed restBed rest Plenty of oral fluidsPlenty of oral fluids AnalgesicsAnalgesics Antimicrobial therapyAntimicrobial therapy penicillin penicillin In case of penicillin sensitivity In case of penicillin sensitivity

erythromycin are given.erythromycin are given. Antibiotics should be continued for 7_10 Antibiotics should be continued for 7_10

daysdays

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COMPLICATIONSCOMPLICATIONS chronic tonsillitischronic tonsillitis peritonsillar abscessperitonsillar abscess parapharyngeal abscessparapharyngeal abscess cervical abscesscervical abscess acute otitis mediaacute otitis media rheumatic feverrheumatic fever acute glomerulo nephritisacute glomerulo nephritis sub acute bacterial endocarditis sub acute bacterial endocarditis

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DIFFERENTIAL DIAGNOSIS DIFFERENTIAL DIAGNOSIS OF MEMBRANE OVER THE OF MEMBRANE OVER THE TONSILTONSIL Membranous tonsillitisMembranous tonsillitis DiphtheriaDiphtheria Vincents anginaVincents angina Infectious mononucleosisInfectious mononucleosis AgranulocytosisAgranulocytosis LeukaemiaLeukaemia Traumatic ulcerTraumatic ulcer Aphthous ulcerAphthous ulcer malignancymalignancy

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CHRONIC TONSILLITISCHRONIC TONSILLITIS Aetiology: Aetiology: Complication of acute tonsillitisComplication of acute tonsillitisSub clinical infection of tonsilSub clinical infection of tonsilChronic sinusitis or dental sepsisChronic sinusitis or dental sepsis

Mostly affects children and young adultsMostly affects children and young adults

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TYPES OF CHRONIC TYPES OF CHRONIC TONSILLITISTONSILLITIS

1). Chronic follicular tonsillitis1). Chronic follicular tonsillitis

tonsillar crypts are full of cheesy tonsillar crypts are full of cheesy material resulting in yellow spots material resulting in yellow spots on the surface.on the surface.

2). Chronic parenchymatous 2). Chronic parenchymatous tonsillitistonsillitis

tonsils are very much enlarged tonsils are very much enlarged almost touching each other and almost touching each other and may interfere with speech, may interfere with speech, deglutition and respiration, long deglutition and respiration, long standing cases may develop standing cases may develop pulmonary hypertensionpulmonary hypertension

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types of Chronic types of Chronic tonsillitistonsillitis

3).Chronic fibroid tonsillitis 3).Chronic fibroid tonsillitis Tonsils are small but infected , with Tonsils are small but infected , with

history of repeated sore throat.history of repeated sore throat.

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CLINICAL FEATURESCLINICAL FEATURES

recurrent attacks of sore throatrecurrent attacks of sore throat chronic irritation in throat with coughchronic irritation in throat with cough halitosishalitosis dysphagiadysphagia odynophagiaodynophagia thick speech thick speech

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ExaminationExamination Tonsil may show varying degree of enlargement Tonsil may show varying degree of enlargement

depending on the typedepending on the type

Irwin-moore signIrwin-moore sign tonsils are small but pressure on the tonsils are small but pressure on the anterior pillar expresses pus or cheesy material anterior pillar expresses pus or cheesy material mainly seen in fibroid typemainly seen in fibroid type

There bmay be yellowish beads of pus on the medial There bmay be yellowish beads of pus on the medial surface of tonsils chronic follicular tonsillitissurface of tonsils chronic follicular tonsillitis

Flushing of the anterior pillar compared to rest of the Flushing of the anterior pillar compared to rest of the pharyngeal mucosapharyngeal mucosa

Enlargement of the jugulo-digastric node soft non Enlargement of the jugulo-digastric node soft non tendertender

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TREATMENTTREATMENTConservative managementConservative managementPay attention to the general Pay attention to the general

health ,diet,and treatment health ,diet,and treatment of co- existent infections of of co- existent infections of teeth , nose , and sinuses.teeth , nose , and sinuses.

TonsillectomyTonsillectomywhen recurrent when recurrent

attacks ,interference with attacks ,interference with speech , deglutination & speech , deglutination & respiration.respiration.

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COMPLICATIONSCOMPLICATIONS Peritonsillar abscessPeritonsillar abscess Parapharyngeal abscessParapharyngeal abscess Retro pharyngeal Retro pharyngeal

abscessabscess Intra tonsillar abscessIntra tonsillar abscess Tonsillar cystTonsillar cyst TonsillolithTonsillolith Focus of infection for Focus of infection for

RF, AGNRF, AGN

Peritonsillar abscess

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Compensated tonsillitisCompensated tonsillitis Compensated tonsillitisCompensated tonsillitis it is it is

usually a type of chronic usually a type of chronic tonsillitis. clinically manifests tonsillitis. clinically manifests itself with itself with absence of any absence of any complaintscomplaints and and presence presence of only local signsof only local signs of a of a chronic inflammation of the chronic inflammation of the tonsils. It is usually revealed tonsils. It is usually revealed during prophylactic during prophylactic examinations.examinations.

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TonsillectomyTonsillectomy

It’s the surgical removal of tonsils , done in It’s the surgical removal of tonsils , done in the treatment of chronic infection of the treatment of chronic infection of tonsils ,obstructive sleep apnea , tonsils ,obstructive sleep apnea , supporative ottits media etc.supporative ottits media etc.

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IndicationsIndicationsA. AbsoluteA. Absolute

1.1. Recurrent infections of throatRecurrent infections of throat2.2. Peritonsillar abscessPeritonsillar abscess3.3. Tonsillitis causing febrile seizuresTonsillitis causing febrile seizures4.4. Hypertrophy of tonsils causing obstructionHypertrophy of tonsils causing obstruction5.5. Suspicion of malignancySuspicion of malignancy

B. RelativeB. Relative1.1. Diphtheria carriers,Diphtheria carriers,2.2. Streptococcal carriersStreptococcal carriers3.3. Chronic tonsillitis with bad taste or halitosisChronic tonsillitis with bad taste or halitosis4.4. Recurrent streptococcal tonsillitis in a patient with valvular Recurrent streptococcal tonsillitis in a patient with valvular

heart diseaseheart diseaseC. As a Part of Another OperationC. As a Part of Another Operation

1.1. PalatopharyngoplastyPalatopharyngoplasty2.2. Glossopharyngeal neurectomy. Glossopharyngeal neurectomy. 3.3. Removal of styloid process.Removal of styloid process.

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ContraindicationsContraindications1.1. Haemoglobin level less than 10 g%. Haemoglobin level less than 10 g%.2.2. Acute upper respiratory tract infection, acute Acute upper respiratory tract infection, acute

tonsillitis. tonsillitis. 3.3. Children under 3 years of age. Children under 3 years of age. 4.4. Overt or submucous cleft palate. Overt or submucous cleft palate.5.5. Bleeding disorders, e.g. leukaemia, purpura, Bleeding disorders, e.g. leukaemia, purpura,

aplastic anaemia, haemophilia.aplastic anaemia, haemophilia.6.6. At the time of epidemic of polio. At the time of epidemic of polio.7.7. Uncontrolled systemic disease, e.g. diabetes, Uncontrolled systemic disease, e.g. diabetes,

cardiac disease, hypertension or asthma.cardiac disease, hypertension or asthma.8.8. Tonsillectomy is avoided during the period of Tonsillectomy is avoided during the period of

menses.menses.

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ContraindicationsContraindications1.1. Haemoglobin level less than 10 g%. Haemoglobin level less than 10 g%.2.2. Acute infection in upper respiratory tract, acute Acute infection in upper respiratory tract, acute

tonsillitis. Bleeding is more in the presence of tonsillitis. Bleeding is more in the presence of acute infection.acute infection.

3.3. Children under 3 years of age. Children under 3 years of age. 4.4. submucous cleft palate. submucous cleft palate.5.5. Bleeding disorders, e.g. leukaemia, haemophilia. Bleeding disorders, e.g. leukaemia, haemophilia.6.6. At the time of epidemic of polio. At the time of epidemic of polio.7.7. Uncontrolled systemic disease, e.g. diabetes, Uncontrolled systemic disease, e.g. diabetes,

cardiac disease, hypertension or asthma.cardiac disease, hypertension or asthma.8.8. Tonsillectomy is avoided during the period of Tonsillectomy is avoided during the period of

menses.menses.

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AnaesthesiaAnaesthesia Usually done under Usually done under generalgeneral anaesthesia anaesthesia

with endotracheal intubation. with endotracheal intubation. In adults, it may be done under In adults, it may be done under local local

anaesthesia.anaesthesia.

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PositionPosition Rose's positionRose's position, i.e. patient lies supine with head , i.e. patient lies supine with head

extended by placing a pillow under the shoulders extended by placing a pillow under the shoulders and a rubber pad under the head. In this position and a rubber pad under the head. In this position both the head and neck are extended.both the head and neck are extended.

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Advantages of Rose Advantages of Rose position:position:

1. There is virtually no aspiration of blood or secretions 1. There is virtually no aspiration of blood or secretions into the airway.into the airway.

2. Both hands of the surgeon are free. This position helps 2. Both hands of the surgeon are free. This position helps in proper application of the Boyles Davis mouth gag. in proper application of the Boyles Davis mouth gag.

3. The surgeon can be comfortably seated at the head 3. The surgeon can be comfortably seated at the head end of the patientend of the patient

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Boyle-Davis mouth gagBoyle-Davis mouth gag

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Boyles Davis mouth gagBoyles Davis mouth gag

Davis mouth gagDavis mouth gagBoyles tongue bladeBoyles tongue blade

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Boyle-Davis mouth gagBoyle-Davis mouth gag

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Set of instruments for tonsillectomy.(1) Knife in kidney tray, (2) & (3) Toothed and non-toothed Waugh's forceps, (4) Tonsil holding forceps, (5) Tonsil dissector and anterior pillar retractor, (6) Luc's forceps, (7)

Scissor, (8) Curved artery forceps, (9) Negus artery forceps, (10) Tonsillar snare, (11) Boyle Davis mouth gag with three sizes of tongue blades, (12) Doyen's mouth gag, (13) Adenoid curette, (14) Tonsil swabs,

(15) Nasopharyngeal pack, (16) Towel clips.Downloaded from: StudentConsult (on 6 December 2012 06:54 PM)© 2005 Elsevier

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Steps of Operation Steps of Operation (Dissection and Snare (Dissection and Snare Method)Method)1.1. Boyle-Davis mouth gag is introduced and Boyle-Davis mouth gag is introduced and

opened. It is held in place by Draffin's opened. It is held in place by Draffin's bipods .bipods .

2.2. Tonsil is grasped with tonsil-holding Tonsil is grasped with tonsil-holding forceps and pulled medially.forceps and pulled medially.

3.3. Incision is made in the mucous Incision is made in the mucous membrane where it reflects from the tonsil membrane where it reflects from the tonsil to anterior pillar. It may be extended along to anterior pillar. It may be extended along the upper pole to mucous membrane the upper pole to mucous membrane between the tonsil and posterior pillar.between the tonsil and posterior pillar.

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Steps of Operation cont..Steps of Operation cont..

4.4. A blunt curved scissor may be used to A blunt curved scissor may be used to dissect the tonsil from the peritonsillar dissect the tonsil from the peritonsillar tissue and separate its upper pole.tissue and separate its upper pole.

5.5. Now the tonsil is held at its upper pole Now the tonsil is held at its upper pole and traction applied downwards and and traction applied downwards and medially. Dissection is continued with medially. Dissection is continued with tonsillar dissector or scissors until lower tonsillar dissector or scissors until lower pole is reached pole is reached

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Steps of Operation cont..Steps of Operation cont..

6.6. Now wire loop of tonsillar snare is Now wire loop of tonsillar snare is threaded over the tonsil on to its pedicle, threaded over the tonsil on to its pedicle, tightened, and the pedicle cut and the tightened, and the pedicle cut and the tonsil removed.tonsil removed.

7.7. A gauze sponge is placed in the fossa A gauze sponge is placed in the fossa and pressure applied for a few minutes.and pressure applied for a few minutes.

8.8. Bleeding points are tied with silk. Bleeding points are tied with silk. Procedure is repeated on the other side.Procedure is repeated on the other side.

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Post-operative CarePost-operative Care

1. Immediate general care 1. Immediate general care (a)(a) Keep the patient in coma position until Keep the patient in coma position until

fully recovered from anaesthesia.fully recovered from anaesthesia.(b)(b) Keep a watch on bleeding from the Keep a watch on bleeding from the

nose and mouth.nose and mouth.(c)(c) Keep check on vital signs, e.g. pulse, Keep check on vital signs, e.g. pulse,

respiration and blood pressure.respiration and blood pressure.

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Post-operative Care Post-operative Care cont..cont..

2. Diet 2. Diet a.a.When patient is fully recovered he is to take When patient is fully recovered he is to take

liquids, e.g. cold milk or ice cream. liquids, e.g. cold milk or ice cream. b.b.Sucking of ice cubes gives relief from pain.Sucking of ice cubes gives relief from pain.c.c.Diet is gradually built from soft to solid food. Diet is gradually built from soft to solid food.

They may take custard, jelly, soft boiled eggs They may take custard, jelly, soft boiled eggs or slice of bread soaked in milk on the 2nd or slice of bread soaked in milk on the 2nd day.day.

d.d. Plenty of fluids should be encouraged.Plenty of fluids should be encouraged.

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ComplicationsComplicationsA. Immediate A. Immediate 11 immediate haemorrhage. immediate haemorrhage. Occurs at the Occurs at the

time of operation. It can be controlled by time of operation. It can be controlled by pressure, ligation or electrocoagulation of pressure, ligation or electrocoagulation of the bleeding vessels. the bleeding vessels.

2. 2. Reactionary haemorrhage.Reactionary haemorrhage. Occurs within Occurs within a period of 24 hours and can be controlled a period of 24 hours and can be controlled by simple measures such as removal of the by simple measures such as removal of the clot, application of pressure or clot, application of pressure or vasoconstrictor. vasoconstrictor.

3. 3. Injury to tonsillar pillars, uvula, soft Injury to tonsillar pillars, uvula, soft palatepalate, tongue or superior constrictor , tongue or superior constrictor muscle due to bad surgical technique. muscle due to bad surgical technique.

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Immediate Complications Immediate Complications cont..cont..

4. 4. Injury to teeth.Injury to teeth. 5. 5. Aspiration of blood.Aspiration of blood. 6. 6. Facial oedema.Facial oedema. Some patients get oedema Some patients get oedema

of the face particularly of the eyelids. of the face particularly of the eyelids. 7. 7. Surgical emphysema.Surgical emphysema. Rarely occurs due to Rarely occurs due to

injury to superior constrictor muscle.injury to superior constrictor muscle.

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Delayed Complications Delayed Complications cont..cont..

1. 1. Infection.Infection. Infection of tonsillar fossa may Infection of tonsillar fossa may lead to parapharyngeal abscess or otitis lead to parapharyngeal abscess or otitis media.media.

2. 2. Lung complications.Lung complications. Aspiration of blood, Aspiration of blood, mucus or tissue fragments may cause mucus or tissue fragments may cause atelectasis or lung abscess. atelectasis or lung abscess.

3. 3. Scarring in soft palate and pillarsScarring in soft palate and pillars. .

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