Important Ent Surgeries : Adenoidectomy, Tonsillectomy, Septoplasty

The Indications are:

• Adenoid Hypertrophy
• Recurrent rhinosinusitis
• Chronic otitis media
• Recurrent ear discharge in CSOM

The Contraindications are -

• Cleft palate or submucous cleft palate. There is a risk of velopharyngeal insufficiency after removal of adenoid.
• Haemorrhagic diathesis
• Acute infection of the upper respiratory tract.

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Complications of Ent Surgeries

• Hemorrhage can occur during adenoidectomy and it can be primary ( Intraoperative) , Reactionary (within 24 hours of the surgery) or Secondary (Due to infection after 24 hours upto 14 days of surgery).
• Eustachian Tube injury.
• Patient complains of neck pain and torticollis developed due to spasm of praspinal muscles.(Grisel’s Syndrome)
• Vellopharyngeal insufficiency.
• Nasopharyngeal stenosis

1. Tonsillectomy - The indications are 
   • Absolute Indications -
     • Recurrent infections of the throat ( >/= 7 episodes in 1 year or 5 episodes per year)
     • Peritonsillar abscess - In children, we should treat the abscess 4-6 weeks before .
     • Tonsillitis and febrile seizures
     • Hypertrophy of the tonsil causing difficulty in sleep and speech.
     • Suspicion of malignancy.
   • Relative indications-
     • Diphtheria carriers which are unresponsive to the antibiotics.
     • Streptococcal carriers
     • Chronic tonsillitis which is unsresponsive to medical treatment.
   • Contraindications
     • Hb <10g%
     • Acute upper respiratory infection.
     • Children < 3 years of age
     • Overt or submucous cleft palate.
     • During Polio epidemic.
     • Uncontrolled systemic disease e.g. Diabetes , cardiac disease.
   • Complications
     • Primary hemorrhage can occur at the time of operation which can be controlled by ligation or electrocoagulation.
     • Reactionary hemorrhage - Occurs within 24 hours post-surgery 
     • Secondary hemorrhage- It occurs due to infection and seen after 24 hours upto 14 days post surgery.
     • Facial edema
     • Aspiration of blood
2. Septoplasty- 
   • The indications are 
     • Deviated septum causing nasal obstruction on one or both sides.
     • As a part of septorhnoplasty for cosmetic reasons
     • Sinusitis due to septal deviation
     • Access to endoscopic dacryocystorhinostomy.
     • Recurrent headache due to septal touching the lateral nasal wall.
   • Contraindications are 
     • Acute nasal or sinus infection
     • Untreated Diabetes
     • Hypertension
     • Bleeding diathesis
   • Complications are
     • Infection
     • Bleeding
     • Septal hematoma and abscess
     • Septal perforation
     • Toxic shock syndrome
     • Saddle nose deformity
3. Functional Endoscopic Sinus Surgery (FESS) - It is performed to remove the diseased mucosa and the normal mucosa remains intact.
   • Indications are-
     • Chronic bacterial sinusitis unresponsive to adequate medical treatment.
     • Recurrent acute bacterial sinusitis.
     • Fungal sinusitis with fungal ball polyp
     • Removal of foreign body from nose or sinus
     • Endoscopic septoplasty with a repair of the lateral wall
   • Contraindications are
     • Inexperience and lack of proper instrumentation
     • Osteomyelitis
     • Threatened intracranial or infraorbital complication
   • Complications
     • Major complications are-
       • Orbital Hemorrhage
       • Loss of vision/blindness
       • CSF leak
       • Meningitis
       • Brain abscess
       • Anosmia
       • Death
     • Minor complications
       • Periorbital echymosis
       • Periorbital emphysema
       • Postoperative epistaxis
       • Exacerbation of asthma
       • Hyposmia
4. Cortical Mastoidectomy- Exenteration of all the air cells in the mastoid.
   • Indications-
     • Acute coalescent mastoiditis: Because of loss of septation, the mastoid air cells communicate with each other. This, along with the presence of pus, is an indication for cortical mastoidectomy.
     • Incompletely resolved acute otitis media with reservoir sign
     • Masked Mastoiditis 
   • Complications-
     • Injury to the facial nerve (most important)
     • Dislocation of incus
     • The sigmoid sinus is present near the posterior wall of the mastoid and injury to the sigmoid sinus during surgery causes profuse bleeding.
     • Postoperative wound infection
5. Radical Mastoidectomy
   • It involves the MRM + Removal of the mucosa of middle ear and mastoid + Removal of Ossciles + Removal of muscles like Tensor tympani and Stapedius + Plugging of eustachian tube with fat.
   • Indications -
     • When the cholesteatoma cannot be removed safely, i.e., cholesteatoma invading the Eustachian tube.
     • Removal of glomus tumour
     • If previous attempts to eradicate cholesteatoma failed.
   • Containdications-
     • Facial paralysis
     • Perichondritis of pinna
     • Injury to the dura or sigmoid sinus
     • Cavity problems
6. Tympanoplasty 
   • It is performed to repair the middle ear. A perforation in the tympanic membrane causing recurrent middle ear disease needs repair.

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