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Tonsillectomy and PRP

By July 25, 2024No Comments

In the United States, tonsillectomy is the most performed surgical procedure on children. Over the years, the number of these surgeries has dramatically declined. However, surgeons still perform over 500,000 annually on children under 15 years old.

According to the American Academy of Otolaryngology, the definition of tonsillectomy is a surgical procedure with or without adenoidectomy that completely removes the tonsil including the capsule. Surgeons accomplish this by dissecting the peritonsillar space between the tonsil capsule and the muscular wall.

The palatine tonsils are a ring of lymphoid tissue. The demarcation of this lymphoid tissue from the surrounding muscular wall is by a fibrous capsule. We call the space between the capsule and the muscular wall the peritonsillar space. The three muscles about this space are the palatoglossus, palatopharyngeal and the superior constrictor. Immediately deep to these muscles is the glossopharyngeal nerve and this nerve is very susceptible to injury during this surgery. Even transient swelling around this nerve can result in alteration of taste and referred pain in the ear. Also, the arterial blood supply to this area is very rich. The main vessels come from branches of the external carotid artery. These branches are the lingual, facial, pharyngeal and internal maxillary arteries. The facial artery and internal maxillary artery supply the tonsil directly.

Therefore, surgeons can easily injure the tonsil’s extensive and rich blood and nerve supply during this procedure.

Indications

There are two main indications for tonsillectomy.

  • Sleep disordered breathing.
  • Recurrent tonsillitis

Other additional indications include tonsillar asymmetry to rule out malignancy. The cancers in this area are squamous cell carcinoma and lymphoma. The most common neoplasms in children are lymphomas.

Sleep disordered breathing is the recurrent partial of complete upper airway obstruction during sleep. This results in the disruption of the normal ventilation and sleep patterns such as REM sleep. This diagnosis can be made easily on history and physical by the medical professional. Symptoms of this condition include hyperactivity, daytime fatigue and aggression. Parents report loud snoring, witnessed apnea and restlessness, poor growth, poor academic performance and nocturnal enuresis.

Children with sleep disordered breathing have higher than normal antibiotic use and 40% higher hospital visits. Consequently, their overall healthcare usage is 215% higher than that of children without this condition.

In sleep disordered breathing, both the tonsils and adenoids are commonly affected. However, tonsillar size does not always correlate with the severity of SDB; therefore, testing may be necessary. Polysomnography can evaluate these uncommon cases.

Recurrent tonsillitis was and is, the most common reason for removal of this tissue. Years ago, two or more infections in the tonsils was enough justification to remove them. Today, the governing bodies of pediatrics and otolaryngology has modified the criteria. Patients with fewer than 7 episodes in the past year or fewer than 5 episodes annually in the past 2 years or fewer than 3 episodes annually in the past 3 years can be watched and do not need surgery by this criterion. If the frequency is higher than this criterion, then tonsillectomy is an option for treatment.

Documentation of each infection should include:

  • Temperature
  • Cervical adenopathy
  • Tonsillar exudate
  • Positive Group A Beta Hemolytic Streptococcal Cultures

Modifying factors include:

  • Antibiotic allergies or intolerance
  • Periodic fever
  • Peritonsillar abscess

Surgery

There are no absolute contraindications to tonsillectomy. The major risk factors are related to bleeding and the risks of anesthesia. Therefore, if there is a history of bleeding disorders or family history of malignant hyperthermia, they should be addressed preoperatively.

Types of surgery
  • Hot extracapsular technique is accomplished with a monopolar cautery and is the most popular technique in the US. The upper pole is grabbed, and the tonsil and capsule are dissected. Maintenance of hemostasis is by suction, cautery, packing or ties.
  • Cold tonsillectomy is performed by sharp dissection. This is accomplished by scalpel and snare. Hemostasis is by pressure, suction and cautery or tie.
  • Coblation utilizes saline irrigation that converts to ionized plasma and breaks down the tissue. Minimal heat is generated.
Post Operative Complications

The leading cause of post operative complications after tonsillectomy is pain. This can cause inadequate intake and lead to dehydration, dysphagia and weight loss. Adequate intake is paramount and oral analgesia is administered when needed.

Postoperative nausea and vomiting are another common complication. It occurs in approximately 70% of the cases. Surgeons now commonly administer intraoperative antiemetics and dexamethasone immediately after surgery. PONV is associated with increased admission rates, dehydration, a higher need for intravenous fluids and analgesia, and overall patient dissatisfaction.

Velopharyngeal insufficiency is an uncommon post operative complication following tonsillectomy. Symptoms include altered speech (very nasal) and food regurgitation through the nasal passages.

Bleeding is the most feared complication following tonsillectomy with or without adenoidectomy. In a large multi-year study involving greater than 100,000 children, 2.8% had unscheduled visits to the emergency facilities and 0.8% required a procedure to stop the bleeding.

Frequency is higher at night with 50% of cases occurring between 10PM and 1AM. Experts believe this is due to changes in circadian rhythm and drying of the mucosa from mouth breathing or snoring.

Platelet Rich Plasma is an autologous blood concentrate that is rich in cytokines, growth factors and bioactive proteins. Doctors have used Platelet Rich Plasma in all fields of medicine and dentistry to repair and regenerate damaged tissues. Recently, researchers have published many articles on using Platelet Rich Plasma post-tonsillectomy to reduce postoperative side effects and complications.

Studies

Eur Arch Otorhinolaryngol 2019 Feb;276(2):489-496 PMID 30460402

Introduction: To compare the short- term outcomes of pediatric patients who underwent tonsillectomy alone vs. tonsillectomy plus platelet rich plasma therapy in terms of postoperative pain, appetite status, analgesia requirement and bleeding complications.

Conclusion: In conclusion, this study of pediatric tonsillectomy patients reveled the superiority of tonsillectomy with PRP over tonsillectomy alone in terms of effectiveness in reducing postoperative pain and improving appetite status, together with a lower requirement for analgesia and a reduced risk of post-tonsillectomy bleeding during the first 10 postoperative days.

J Laryngol Otol 2019 Jul;133(7):615-621 PMID 31296273

Objective: Researchers conducted a single-center, single-blind experimental study to determine the effectiveness of autologous platelet-rich plasma applied to the tonsillar bed postoperatively in reducing pain and hemorrhage.

Conclusion: This pilot study, conducted in India, reveled valid positive results for a promising new technology. The pain score and hemorrhage grade on the test side were lower than on the control side. These findings were statistically significant.

J Laryngol Otol 2021 Jun;135(^):539-544 PMID 33988093

Objective: Surgeons perform tonsillectomy, a painful surgery, in cases of recurrent tonsillitis. Application of platelet rich plasma to diminish the pain and morbidity post-tonsillectomy is gaining importance. This study evaluated post-operative pain and morbidity after autologous platelet rich plasma application on the tonsil beds during tonsillectomy.

Conclusion: Platelet Rich Plasma application was effective in accentuating healing and reducing post-tonsillectomy pain and morbidity.

Author notes- Discuss with your healthcare professional about the use of platelet rich plasma post operative tonsillectomy. Insist on an FDA cleared PRP kit and approved device for concentration and activation. There is a difference with platelet rich plasma and every one of the 500,000 cases done yearly in the US deserves the best kits for concentration and activation.

More About Juventix

Juventix Regenerative Medical is an industry leader in the regenerative medical field. We design our FDA-cleared Platelet Rich Plasma Kits for safety, sterility, and effectiveness. We scientifically manufacture our kits to provide a platelet concentrate devoid of red blood cells and containing a minimal number of leukocytes, which are critical to the regenerative process.

Juventix Regenerative Medical offers a LED Activator to activate the platelets and begin the regenerative process. We accomplish the critical step of activating the release of cytokines, growth factors, and bioactive proteins from the alpha granules on the platelets using LED light. This negates the use of chemical additives such as Calcium Chloride, Thrombin, or Collagen. Furthermore, this mode of activation by LED light provides sustained growth factor release compared to older methods while adhering to the minimal manipulation guidelines of the FDA.

Juventix Regenerative Medical supplies a Bio-Incubator to transform the Platelet Rich Plasma into an Injectable Platelet Rich Fibrin. The Platelet Rich Fibrin, commonly called the “second generation of platelet products” has different cytokines and growth factors than the original PRP. These different cytokines create an anti-inflammatory microenvironment, making them suitable for use in inflammatory conditions.

Juventix Regenerative Medical has an array of services, devices and products for the regenerative professional. Juventix continually strives to offer the best, cost-effective products that the FDA has cleared, approved, or registered. Safety and efficacy are always primary goals for Juventix. When choosing regenerative therapies, consider Juventix.

RESTORE, REVIVE, REGENERATE- JUVENTIX REGENERATIVE MEDICAL

Regenerative Regards,

Dr. Robert McGrath

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