Introduction Tonsillectomy is one of the most common surgical procedures done in Otorhinolaryngologic department. Tonsillectomy is a surgical procedure that is often performed to remove the tonsils from either side of the throat. According to Eisele & Smith (2009), roughly about 500000 cases of tonsillectomy are done annually nonetheless, tonsillectomy have seen a tremendous evolution during the last two decades where patient selection and pre-operative evaluation have improved, various new techniques have been developed and the procedure has become largely ambulatory.
Hence, it is essential for all perioperative nurses to be familiar with the procedure instruments and management of a tonsillectomy patient. There are many surgical methods for tonsillectomy. The methods can be the cold steel dissection where the tonsils are removed as a whole using sharp metal instruments and the bleeding is controlled with ties or sutures (Hazarika & Nayak, 2005). Methods by using monopolar or bipolar diathermy where the tonsils are dissected using the diathermy. Tonsillectomy can also be done by using the laser and finally the most commonly used now in most hospital is the coblation method.
Coblation is a radio-frequency dissection method that cuts the tissue by breaking down the inter-cellular bonds and seals the wound at the same time. It is a bipolar system working through a medium of normal saline that is incorporated in a disposable wand and also consist of a built-in suction (De Souza, 2010). The following is a case study of a patient undergoing tonsillectomy surgery using the Coblation method. Miss D is a 19 year old female that was previously seen in the emergency department on the 3rd of October for cough.
She returned to the emergency department on the 11th of October for the same problem and claimed to have odynophagia. Aside from this, Miss D has a painful lump on the left posterior neck. This is her third episode this year. Miss D is treated with antibiotics augmentin, corticosteroid prednisolone and difflam. Miss D is given an appointment to see an Otorhinolaryngologic specialist on the 22nd October 2010 and was scheduled for surgery on the 3rd of November for Tonsillectomy. Anatomy and Physiology of the Tonsils
There are three different structures referred to as tonsils. The tonsils also known as palatine tonsils are a pair of soft tissue masses located at the rear of the throat where each tonsil is composed of tissue similar to lymph nodes that is covered by pink mucosa. Another set of tonsils called the lingual tonsils are located under the tongue and lastly are the adenoids that are embedded in the upper rear wall of the oral cavity. The adenoids also known as pharyngeal tonsils are often prominent in childhood but usually diminish in size during adulthood.
All of the tonsillar structures are part of the lymphatic system and contain lymphoid tissue. The physiological function of the tonsils is to process lymphatic fluid and it serves to fend off infections. The tonsils grow in size whenever the body is fighting an infection (Sigler & Schuring, 1993). Indications and Sign & Symptoms of Tonsillectomy. Some of the indications for tonsillectomy are recurrent episodes of acute tonsillitis where the patient suffers more than six episodes per year or more than three attacks per year for more than two years.
Chronic tonsillitis where there are signs of chronic disease such as enlarged cervical nodes or anterior pillar congestions. Other indications for tonsillectomy are peritonsillar abscess and obstructive tonsillar hyperplasia where the patient presents with varying degrees of Obstructive Sleep Apnoea (Hazarika & Nayak, 2005). The signs and symptoms are red, swollen tonsils, white or yellow coating or patches on the tonsils, sore throat, difficult or painful swallowing and fever (De Souza, 2010). Pre-operative Phase
One day before surgery, pre-operative instructions such as no eating and drinking after midnight and removing all metal objects and jewelers were reinforced to Miss D by the clinic nurse. On the morning of the surgery, Miss D is brought to the operating theatre and the operative site were confirmed along with her identity, consent, operative site, blood results and drug allergy by the reception nurse using the perioperative checklist. Following this, Miss D is brought into the assigned operating room and similar checks are done by the anesthesia nurse, circulating nurse and the scrub nurse using the perioperative checklist.
The anesthesia nurse ensures the functioning and availability of the anesthesia machine that includes ventilator, vaporizers, scavenging system, gas inlets, suction machine and carbon dioxide absorber canister. The anesthesia nurse gathers all the necessary requisites for general anesthesia and ensures the availability of resuscitation drugs. The scrub and circulating nurse ensures the good functioning order of the operating table, operating light, headlight, light source, electrical surgical unit, suction machine and Coblator machine.
The operating room temperature and humidity should be kept at an optimal level. The scrub nurse and the circulating nurse gathers all the required requisites and sets needed according to the surgeon preference list. The consumables and loose instruments required include: •White soft paraffin •Xylocaine 2% with adrenaline Cartridge •ENT drape pack •Raytec gauze •Tonsil swabs •Suction tubing •Insulated diathermy forcep straight •Draffin bipods •Coblator handpiece •500mls normal saline •Hydrogen Peroxide Sets needed includes: •Tonsil set •Cleansing set
Before each case, the scrub nurse will check all the instruments for any defects and place the instruments appropriately on the trolley. The instruments are set up with commonly used instruments easily accessible. Both scrub nurse and circulating nurse performed the initial count together. While in the operating room with Miss D, the anesthesia nurse provided bair hugger to keep Miss D warm and properly placed and secured the ECG leads, blood pressure cuff and pulse oximeter on Miss D away from the surgery site to prevent any interference to the surgery.
The anesthesia nurse ensured proper taping of nasotracheal tube and eye to prevent kinking of tube and corneal abrasion to the eyes and the ensured that the eyes are free from pressure points. Miss D was placed in a supine position with a head donut under her head and sand bag under shoulder with head slightly extended. Her left arm extended on an arm board for IV access. Position of the arm on the armboard should not exceed 90 degrees to prevent brachial plexus injury. The right arm supported with arm guard must be secured correctly at patient’s side to prevent ulnar nerve injury.
A safety belt is fastened over the higher thigh to prevent patient from falling. Foot roll is placed at the foot to prevent foot drop. Intra-operative phase Once the positioning is done, an antiseptic cleansing solution of Chlorhexidine 1:2000 is used for cleansing. The surgeon and the scrub nurse proceed with the draping. The scrub nurse firstly passed the head drape to the surgeon and the drape is then secured with 3 towel clips. Following that, an abdominal drape is placed on top Miss D’s body.
The scrub nurse then set up the suction and coblator for the procedure that is then secured with a towel clip. The circulating nurse then performed surgical time out and ensures that both the suction tubing and Coblator cable is properly fixed to the machine. The Coblator consist of the first the suction cable that is connected to the suction, the second is the fluid line that is connected to 500mls Normal Saline and lastly the Coblator cable to the Coblation machine. The scrub nurse and circulating nurse will inform the surgeon the placement of the Coblator foot switch.
During the procedure, the circulating nurse anticipates the needs of the scrub nurse and the surgeon and maintains high cleanliness and housekeeping of the operating room. White soft paraffin is firstly applied around Miss D lips and then the Boyle-Davis mouth gag with the appropriate Doughty tongue plate size is given to the surgeon which is then introduced and opened with care not to damage Miss D lips, teeth and posterior pharyngeal wall with the tongue blade in midline. Draffin’s bipods are used to secure the mouth gag in optimal position.
The scrub nurse must ensure that the patient’s neck and shoulder posteriorly is properly covered with the sterile drapes to prevent Miss D from getting burn by the metal bipods stand when the surgeon uses the diathermy. Once the mouth gag is in place, the surgeon uses the Yankauer sucker end to suck the saliva of to get a good view of the tonsils. Next Xylocaine 2% with adrenaline is then injected onto the tonsil. The tonsil is then grasped with the tonsil holding forcep and drawn medially. The scrub nurse will then remove the Yankauer sucker and connect the sucker tubing to the Coblator.
Incision is then made with the Coblator at the area of the mucosa medially to the free edge of the anterior pillar to the depth of surgical capsule. The dissection is performed strictly at the loose areolar tissue between the capsule and superior constrictor muscle of pharynx. The surgeon begins the dissection in the upper pole and then inferiorly to the junction of the tonsil and base of the tongue until the final detachment of tonsil. When doing this, the surgeon has to be careful not to damage the bilateral arterial supply of the uvula (Hazarika & Nayak, 2005).
As soon as the tonsil is out, the fossa is immediately packed with tonsil squares. The tonsil squares is carefully removed and bleeding points are identified and diathermized using the Coblator. The scrub nurse will then pass out the tonsil and informed the circulating nurse the nature and side of specimen that is then placed in the appropriate bottle with the correct and proper labeling. Similar steps are done for the other side of the tonsil. A soak tonsil square with Hydrogen Paroxide is then placed at the operated site and removed.
Normal saline wash is then used to wash the operated site. Scrub nurse together with circulating nurse performs the closure count. Final inspection is done by surgeon to check the operated site for bleeding. At the end of the procedure, the fossa should be absolutely dry. The scrub nurse then performed the final count with the circulating nurse. Upon removal of the Boyle-Davis mouth gag, the scrub nurse must ensure that Miss D teeth has not been dislodge and the temporal mandibular joint has not been dislocated during the procedure (Hazarika & Nayak, 2005).
Post-Operative Phase During extubation, the scrub nurse maintained her sterility and the sterility of the trolley. It is also important that the suction tip and suction tubing are not dismantled until the patient is wheel out of the operating room (Fairchild, 1996). This is as a precaution that Miss D may have bleeder and the surgeon need to go in to stop and suck the bleeding points. Once extubated, the airway of Miss D is maintained and suctioning of the collected blood from the nasopharynx is done. Miss D is then transferred to the trolley with sufficient manpower.
All pressure points are assessed. Miss D is position with the head of the trolley raised up so that if the hemorrhage begins the blood will flow out of the nose and mouth and not downwards to the larynx. Finally Miss D is then transferred to the recovery room At the recovery area, it is essential for the recovery nurse to assess the ABC that is the airway, breathing and circulation. The anesthesia nurse will pass over the procedure done and the status of Miss D. The most common postoperative complications of tonsillectomy are hemorrhage.
Hemorrhage can be differentiated into primary bleeding where bleeding occurs within 24 hours of the surgery and secondary bleeding where bleeding occurs most commonly between five to nine days postoperatively (Dent, 1997). The other complications can be pain, dehydration, fever, infection and emesis (Williams, Bulstrode & O’connell, 2008). For the post-operative care, it is critical for the recovery nurse to monitor the vital signs to detect hemorrhage. Rapid increasing of pulse rate, increase pallor and vomiting of blood indicates bleeding and must be treated seriously.
Inform the surgeon if bleeding occurs. The surgeon will then carefully inspect the tonsillar fossa for bleeding and Miss D may need to be transferred to the theatre where bleeding is then ligated (Hazarika & Nayak, 2005). If patient is well, the patient is transferred to the general ward or private ward respectively. The pulse and blood pressure are monitored closely and no solid food is administered orally for a few hours. This reduces injury to the operated site but also ensures that should there be a bleeding or need to operate on the area again, the stomach is empty.
Surgery cannot be conducted on a patient with food as this can cause the patient to aspirate the gastric contents and cause choking. If no complications are seen, Miss D is encouraged to eat and drink cold and soft diet and then followed by her usual normal diet. For pain relieve, the doctor will order analgesia for the Miss D. Oral antibiotics is ordered and to be taken for one week after the surgery to decrease morbidity (Hazarika & Nayak, 2005). Miss D is allowed to go home the next day if well and appointment for follow up clinic is made.
There are basically many methods for tonsillectomy procedure, which includes cold steel dissection, monopolar or bipolar diathermy, laser and Coblation. Therefore it is important for a perioperative nurse to be knowledgeable and familiar with the procedure, methods of the surgery, surgeon preference and instruments. Besides this, it is also important for the perioperative nurse to know the possible complications that may occur and how to care for the patient not only during pre-operatively and intra-operatively but also post-operatively as all this plays the vital key to the success of the surgery.