154

T H E REMOVAL OF TONSILS A N D ADENOIDS. *

(Report on 1,500 Operations.)

By BRIAN O'BRIEN.

T HE increasing knowledge of the lay public and their dissatisfaction with the frequent necessity £or two or more operations to secure the removal of tonsils have struck at the conscience of the medical

profession. My first introduction to the operation of tonsillectomy was in the National Throat, Nose and Ear Hospital, London, at that time known as the Central London Throat, Nose and Ear Hospital. The method of dissection was the only operation in use or taught there, and one could not help being impressed with the simplicity, safeness and completeness of the operation.

On my return to Dublin I found that the dissection method was only used with reluctance and was reserved for adults when the patient expressed a preference for this method, which preference was often voiced, or when it was believed that factors were present that might render the guillotine operation unsatisfactory. The main reluctance to use the dissection method was based on the erroneous belief that it was so much more time-consuming than the guillotine method that its use

• was impractical. No one suggested that the guillotine operation was ideal, but it was undoubtedly a very rapid one. My early days in hospital were fraught with considerable difficulty and I am afraid I had to overcome a good deal of prejudice amongst those who had been used t o the rapid guillotine method and did not view with enthusiasm a method which introduced new and at first sight complicated modifications of their technique. To my horror I saw my own tonsil operations occupying the theatre for periods up to an hour. Prior to my advent ten guillotine operations could comfortably be performed inside an hour. Either I must abandon dissection or else the operating time must be radi- cally shortened. Everyday experience in a busy O.P.D. strengthened my determination to continue dissecting tonsils. A steady stream of children appeared, recommended by School Services and others, for tonsillectomy in spite of .having already undergone a previous operation for this purpose. , I saw daily children who had one tonsil remaining, part of both tonsils remaining, injuries to the soft palate with severe scarring (even with peritonsillar abscesses) after having undergone previous operations for removal of the tonsil. These mishaps were not frgm the hands of inexperienced operators. ~Except in rare cases, these patients had been operated on by laryngologists, of high standing. I t was clear to me that if tonsillectomy were to be complete dissection must be used for all cases and not reserved for difficult cases, which difficulties could not with certainty be foreseen in advance. Widespread reports revealed that even in the most skilled hands the guillotine operation was incomplete in a percentage of cases, the percentage varying considerably,

*From the Children's Hospital, Temple Street, Dublin.

THE REMOVAL OF TONSILS AND ADENOIDS 155

but probably not falling below 10 per cent. No justification could be argued for such a method. Imagine the outcry that would arise if 10 per cent. of interval appendicectomies required re-operation! In addition, the guillotine operation made no provision for accurate ha~mostasis, reliance being placed on the contractile vessels supplying the tonsils to check h~emorrhage, and we kne~ from our experience as house surgeons that quite a large number of tonsil cases did bleed to a dangerous ¢xtent. Finally, the guillotine operation prevented the use of adequate premedication, which lessens so much the psychological trauma to the patient and adds so much to his comfort.

I therefore set about to simplify the technique of dissection to solve the tonsil problem in a busy hospital. We found that with the co- operation of ward sister and theatre sister the transport of patients to and from the theatre could be greatly accelerated. My anmsthetist colleague (Dr. Nagle) organised his department to such a degree that it has been a major factor in the reduction of operating time.

Our ward is fortunately situated on the same floor as the theatre. The child is wheeled from the ward to the anaesthetic room adjoining the theatre and is there an~esthetised whilst on the stretcher before being transferred to the operating table. Immediately the first operation com- mences the next patient is brought from the ward to the anaesthetic room, where induction is commenced by a house surgeon while the senior anmsthetist controls the anmsthetic of the patient undergoing operation. The operation over, the second child is ready to be placed on the table immediately and the second operation commenced.

(1) With the operator sitting at the head of the table and the head of the patient extended some 4 ~r below the level of the shoulders, a good view of the nasopharynx can be secured by retracting the soft palate with the retractor end of the Mollison's tonsil dissector. The adenoids are removed before the tonsils, so that oozing will have ceased before the patient leaves the table. This is followed by inspec/ion of the naso- pharynx to ensure that all adenoid tissue has been removed. The theatre sister, standing behind the operator, now inserts the suction over the left shoulder of the operator into the nasopharynx, while he picks up a gauze wipe which is then placed into the nasopharynx to control and absorb oozing.

(2) Next, the theatre sister places a Luc's forceps in the left hand of the operator with which he picks up the right tonsil by the posterior lip of its upper pole. The Luc's forceps is now transferred to the right hand, at the same time rotating its axis so as to bring the posterior aspect of the tonsil into view, where an incision is made with the scissors through mucous membrane, and the layers of fibrous tissue are teased away until the white tonsil capsule is exposed.. The capsule, glistening and pearly grey in colour, stands out clearly from the connective tissue encircling it. The incision is then continued downwards to the base of the tongue parallel with and close to the posterior lip of the tonsil. In this way the entire posterior pillar of the fauces will be preserved intact.*

*The frequent removal of this important sl~rue~ure in the guillotine operation given rise to scarring and to a chronic pharyngitis which is a source oF trouble

the patient for the rest of his life.

156 IRISH JOURNAL OF MEDICAL SCIENCE

(3) The Luc's forceps is now transferred to the left hand and with the scissors, now in the right hand, the incision is continued around the upper pole of the tonsi" on to the anterior aspect and down to the base of the ton~o~e, again parallel and close to the anterior lip of the tonsil, this time so as to preserve the anterior pillar of the fauces. Next the scissors is excb .~ged for-the dissector, with which the tissues are very gently pushea away from the tonsil capsule. The grasp on the tonsil has not been changed since the upper posterior lip was first gripped. Further dissection is continued with mild medial traction on the tonsil, which comes away surprisingly easily and, provided dissection has kept close to the capsule, with little or no h~morrhage. Whatever bleeding occurs will gravitate to the nasopharynx away from the larynx, there to be removed by the theatre sister with suction. As the lower pole of the tonsil is being freed, the grip on the tonsil is for the first time shifted from the upper lip to a firmer hold on the body of the tonsil. This move is important in order to facilitate the dissection of the lower pole of the tonsil, neglect of which will make possible regrowth of the tonsils.

(4) A six inch square of gauze loosely compressed and held in a dissecting forceps is passed by the theatre sister into the left hand of the operator, and by him inserted into the empty tonsil bed and pressure exerted on it by means of the tonsil dissector. A second square of gauze, if necessary, is similarly placed over the first and compressed to absorb any overflow of blood through the first piece of gauze, which alone is left in the tonsil fossa until the second tonsil has been removed in a manner similar to the first.

When both tonsils have been cleanly removed in this manner the tonsil beds will usually be seen to be quite dry. Should there now be any bleeding the vessel should immediately be located and a ligature applied. The long straight ligature forceps is first used, followed by the curved Negus forceps, which, applied deep to the straight forceps, greatly facilitates the application of the ligature which is held in tt~e Negus ligature adjuster.

In this way the patient leaves the table free from all h~emorrhage. I-Ie is placed on a stretcher, lying flat on the side without a pillow.. I t is very important to ensure that the child has a clear airway and can breathe freely without the necessity of supporting the jaw on the return to the ward. The journey from the theatre to the ward is to my mind potentially the most dangerous part of all operative procedures, but the danger is prevented by ensuring that the patient leaves the theatre with an unaided clear airway.

As the patient leaves the theatre the operator immerses his gloved hands in dettol followed by sterile water and is ready to commence the next patient who has meanwhile been wheeled in and placed, fully an~esthetised, on the operating table. In the interval the instrument table has been freshly draped and a second set of sterile instruments left ready for use.

A further important factor in reducing time has been the limitation of unnecessary instruments. We find that the following instruments are quite adequate:

1. A Boyle-Davis gag with two tongue plates of different sizes.

THE REMOVAL OF TONSILS AND ADENOIDS 157

2. A curved nasal scissors. 3. One Luc's forceps. 4. A Mollison's tonsil dissector and a di~'seeting forceps.

These are all that are required for routine use, but in addition a long straight artery" forceps, a curved Negus artery forceps and a ligature adjuster for convenience are left in reserve, sterilised and ready for use. In this way sterilising between operations is greatly facilitated. Two sets of these instruments are used, so that while one set is in use ¢~he other set is being sterilised.

At this stage it might be well to give a summary of our method of anaesthesia in these cases. Particular importance is attached to the pre- medication of the children, who range in age from two to thirteen years. All receive a hypodermic injection of atropine sulphate (gr. 1/100), half to one hour before the operation. In addition, seeonal (gr. ![) is given by mouth up to the age of five years and gr. 1½ to older children. Higher dosage is not considered safe for routine use. With this pre- medication the childrer~ arrive in the anaesthetic room in a drowsy sta.te, and no restraint is required.

Induction of anaesthesia is by ethyl chloride, followed by ethyl ether as rapidly as possible. When the Boyle-Davis gag has been placed, the anmsthetic tube thereon is connected to a Junker's bottle containing chloroform. A "~ery little of this drug suffices to hold the child relaxed until the end of operation and is of particular value on the rare occasion when a bloodvessel needs to be ligature&

The use of anaesthetic drugs as potent as ethyl chloride and chloroform may well call for criticism. In defence, let me say that ethyl chloride is given on an open mask which is never allowed in close contact with the patient's face until the inducing vapour has been blown away. Full ether anaesthesia is established before the gag is inserted. Chloroform vapour is blown into a wide open mouth, thus greatly diluting the small amount of vapour delivered with each compression of the bellows. The cough reflex is usually recovered within one minute of the termina- tion of operation.

This technique is quite unsuitable when operating time is likely to be more than ten minut.es. In such cases an endotracheal tube should be placed and anaesthesia maintained with gas-oxygen, ether, trilene, etc. Chloroform would then be excluded.

Such is the technique which we have now stafidardised. Not all the details described were used in the early cases of this series, but there has been no change in the last 500 cases. The technique works extremely smoothly and allows an average of eight tonsil and adenoid cases to be dealt with comfortably within an hour.

Complications have been very few. There were four cases of post- operative h~emorrhage. All were brought to the theatre and re- an~esthetised and with the gag in position all clots were removed and the bleeding point secured and ligatured. One poorly nourished child developed bronchopneumonia, which yielded to treatment.

Two cases developed late hmmorrhage (five and six days after opera- ~ion) which did not require any treatment. The children were brought

158 I R I S H J O U R N , 4 L O F M E D I C A L S C I E N C E

i n by the i r pa r en t s to the 0 .P .D . the day a f t e r the hmmolThage. I n n e i t h e r case on e x a m i n a t i o n was there any evidence of f resh b l e e d i n g a n d the pa t i en t was discharged.

Summary.

The purpose o f this r epor t has been to show tha t even in a busy hospi ta l i t ~ possible for every p a t i e n t u n d e r g o i n g tons i l l ec tomy to have the benci i t of the dissect ion method. The only rea l a r g u m e n t aga ins t the opera t ion has been on the g rounds of the g rea te r t ime r equ i r ed fo r dissection. W i t h the h igh s t a n d a r d of anmsthesia now available, t ime should no longer be a p r i m a r y fac tor i n i n f luenc ing the type of opera t ion to be per formed, especia l ly when the more l e ng t hy opera t ion prolongs anmsthesia by on ly a m a t t e r of minutes .

I should like h e r e to express m y apprec i a t i on a n d thanks to m y anaesthetist colleagues. A t the Ch i ld ren ' s Hospi ta l , Temple Street , we are f o r t u n a t e to h a w a ve ry h igh s t a n d a r d of aneesthesia, o rgan ised a n d gu ided by Dr. Nagle. F i n a l l y , a well deserved word of pra ise for the n u r s i n g staff who combine a h igh degree of skill a n d an en thus i a sm fo r the i r work which make l igh t the task of the su rgeon .

ROYAL SOCIETY OF ARTS

JOHN ADAM STREET, ADELPHI, LONDO/q, W.C.2.

SWINEY PRIZE FOR A WORK ON MEDICAL JURISPRUDENCE

The Council give notice that the next award of the Swiney Prize will be made in January, 1949. the one-hundred-and-fifth anniversary of the testator's death. Dr. Swiney died in 1844, and in his will he loft a sum of money to the Royal Society of Arts for the purpose of presenting a prize, on every fifth anniversary of his death, to the author of the best published work on Jurisprudence. The Prize is a cup, in normal times of the value of ~lOO, but on this occasion of the value of ~150, and money to the value of ~100.

The award is made by a joint Committee of the Royal Society of Arts and the Royal College of Physicians, which appoints special adjudicators.

The Prize is offered alternately for l~iedieal and General Jurisprudence, but if at any time the Committee is unable to find a work of suffleient merit ia the class whose turn it is to receive the award, it is at, liberty to recommend a book belonging to the other class. On the last occasion of the award (1944) tim Prize was awarded for Gen,eral Jurisprudence. I t will, therefore, be offered on the present occasion for Medical Jurisprudence.

Any person desiring to submit a work in competition, or to recommend any work for the eonsideratior~ of the Judges, should send it to the Secretary of the Society not later than November 30th, 1948.