Diseases Of The Nose Throat And Ear

CHAPTER 27
TONSBLLECTOMY

The operation of tonsillectomy, with or without the removal of adenoids
(p. 133), is the surgical procedure most frequently performed in the hospitals
of this country.

INDICATIONS. The indications for removal of tonsils in adult life are: (i)
repeated attacks of acute tonsillitis affecting the general health and causing
frequent absences from work and (ii) one attack of peritonsillar abscess
(quinsy) because further acute inflammation of the tonsils is apt to produce a
further quinsy.

The indications for removal of tonsils in children are the subject of some
controversy, mainly between paediatricians, who favour conservatism, and
otolaryngologists who are more surgically inclined given certain criteria in the
history and certain clinical appearances. It has been stressed (p. 96) that the
inspection of the pharynx of a child or, indeed, an adult, must be conducted
with a uniform light source if the interpretation of the appearance of tonsils
and the buccopharyngeal mucosa is to be meaningful. This uniformity is only
achieved by the use of reflected light from a standard bull's eye lamp with a
bulb of unchanging wattage, or by the use of a headlamp powered from the
mains with the reading of the transformer constant and the bulb of uniform
wattage. The laryngologist will be correct to reject descriptions of tonsils
achieved by other means.

When this has been said, it must be admitted that the clinical criteria of
what constitutes a septic tonsil are not measurable, and each surgeon, from
his experience, decides his own base lines. The appearances which suggest
tonsillar sepsis are: (i) the presence of enlarged palpable lymph nodes in the
deep cervical chain when there is no acute inflammatory lesion to account for
them; (ii) the presence of a band of congestion along the free edge of the
palatoglossal fold (anterior faucial pillar) in the absence of acute inflammation
of the pharynx; and (iii) the presence, either on inspection or after squeezing
the tonsil with a spatula, of purulent material hi the crypts of the tonsils.
Given these three criteria the tonsil may be considered to be unhealthy; given
two of the three criteria the tonsils may be suspected of being unhealthy; given
only one it may be thought unnecessary to recommend surgical removal on
clinical grounds alone.

It will be noted that the size of the tonsils is not one of the criteria of their
sepsis. It often happens in children that tonsils which are judged to be
unhealthy are also large, but in adults the small buried tonsil may prove to be
more septic than the larger one. Nor would a tonsil whose surface shows open
crypts be deemed more unhealthy than one with a smooth surface unless pus
can be seen in the crypts.

123