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Tonsillitis, Tonsillectomy and Adenoidectomy
Steven T. Wright, M.D.Steven T. Wright, M.D.
Ronald Deskin, M.D.Ronald Deskin, M.D.
November 5, 2003November 5, 2003
Adenotonsillectomy
Most commonly performed procedure in the Most commonly performed procedure in the history of surgeryhistory of surgery
$500 million annually in healthcare $500 million annually in healthcare expendituresexpenditures
History
Almost exclusively by OtolaryngologistsAlmost exclusively by Otolaryngologists Celsus in 50 A.D.Celsus in 50 A.D. Caque of RheimsCaque of Rheims Phillip Syng developed the tonsillotomePhillip Syng developed the tonsillotome
Anatomy
Anatomy
Histology
Clinical Evaluation
Acute TonsillitisAcute Tonsillitis Chronic TonsillitisChronic Tonsillitis Obstructive Tonsillar HyperplasiaObstructive Tonsillar Hyperplasia
Clinical Evaluation Odynophagia, fever, Odynophagia, fever,
tender cervical tender cervical lymphadenopathy.lymphadenopathy.
Supporting Supporting documents, 2 or moredocuments, 2 or more Fever> 38.5Fever> 38.5 Tonsillar ExudateTonsillar Exudate Tender cervical Tender cervical
LAD >2cmLAD >2cm Positive throat Positive throat
cultureculture
Clinical evaluation
ViralViral Lower grade feverLower grade fever Lower WBC, Lymphocytic shiftLower WBC, Lymphocytic shift Less tonsillar exudate Less tonsillar exudate
BacterialBacterial Higher WBC, Granulocytic shiftHigher WBC, Granulocytic shift More exudativeMore exudative
Recurrent Acute Tonsillitis
Seven episodes in a single yearSeven episodes in a single year Five or more episodes in 2 yearsFive or more episodes in 2 years Three or more episodes in 3 yearsThree or more episodes in 3 years
Chronic Tonsillitis
No true consensus on the definition.No true consensus on the definition. Symptoms greater than 4 weeksSymptoms greater than 4 weeks
Differential Diagnosis
Infectious MononucleosisInfectious Mononucleosis EBVEBV
Scarlet FeverScarlet Fever Corynebacterium diptheriaeCorynebacterium diptheriae MalignancyMalignancy
Complications of Tonsillitis
Cervical AdenitisCervical Adenitis Neck AbscessNeck Abscess Peritonsillar abscessPeritonsillar abscess Intratonsillar abscessIntratonsillar abscess Lemierre’s syndromeLemierre’s syndrome
Post Streptococcal Glomerulonephritis Joint Pain and oliguric renal failure 10 days Joint Pain and oliguric renal failure 10 days
after the pharyngitis.after the pharyngitis. Treatment aimed at eliminating the Treatment aimed at eliminating the
infection and supportive therapy for renal infection and supportive therapy for renal failure.failure.
Excellent prognosis in children.Excellent prognosis in children.
Adenoid Hyperplasia
TriadTriad HyponasalityHyponasality SnoringSnoring Open mouth breathingOpen mouth breathing
Purulent rhinorrhea, post nasal drip, chronic Purulent rhinorrhea, post nasal drip, chronic cough, and headachecough, and headache
Obstructive Airway Symptoms
SnoringSnoring Apneic episodes with gasping or chokingApneic episodes with gasping or choking Daytime hypersomnolenceDaytime hypersomnolence Nocturnal enuresisNocturnal enuresis Behavioral disturbancesBehavioral disturbances Heart failure and Failure to thriveHeart failure and Failure to thrive
Tonsil Size
GradeGrade % % 11 <25<25 22 25-5025-50 33 51-7551-75 44 >75>75
Obstructive Sleep Apnea
Polysomnography is the gold standard of Polysomnography is the gold standard of diagnosis.diagnosis. Imperative in AdultsImperative in Adults In children, a convincing history is In children, a convincing history is
adequateadequate OSA: RDI > 5, SpO2<90%OSA: RDI > 5, SpO2<90% UARS: RDI <5, SpO2 >90%UARS: RDI <5, SpO2 >90% Primary Snoring: RDI <1, SpO2>90%Primary Snoring: RDI <1, SpO2>90%
Medical Therapy
TCHP recommends confirming bacterial TCHP recommends confirming bacterial pharyngitis before beginning antibiotics.pharyngitis before beginning antibiotics.
Rapid Strep TestRapid Strep Test Throat CultureThroat Culture
Medical Therapy
First LineFirst Line Penicillin/Cephalosporin for 10 daysPenicillin/Cephalosporin for 10 days Injectable forms for noncomplianceInjectable forms for noncompliance
BLPO, co pathogensBLPO, co pathogens MacrolidesMacrolides
Penicillin allergyPenicillin allergy Erythromycin/Clarithromycin 10 daysErythromycin/Clarithromycin 10 days Azithromycin (12mg/kg/day) 5 daysAzithromycin (12mg/kg/day) 5 days
Medical Therapy
Patients with recurrent otitis media history Patients with recurrent otitis media history have higher bacterial concentrations with have higher bacterial concentrations with BLPO.BLPO. Initial treatment with anti-BLP antibiotic.Initial treatment with anti-BLP antibiotic.
Adenotonsillar size may respond to a one Adenotonsillar size may respond to a one month course of antibiotic therapy.month course of antibiotic therapy.
Adenoid hyperplasia may respond to a 6-8 Adenoid hyperplasia may respond to a 6-8 week course of intranasal steroid. week course of intranasal steroid.
Surgical Indications
AdenoidectomyAdenoidectomy AbsoluteAbsolute
Airway obstruction w/ cor pulmonaleAirway obstruction w/ cor pulmonaleFailure to thriveFailure to thrive
RelativeRelativeChronic Nasal Obstruction Chronic Nasal Obstruction Recurrent/ Chronic AdenoiditisRecurrent/ Chronic AdenoiditisRecurrent/ Chronic SinusitisRecurrent/ Chronic SinusitisRecurrent acute otitis media/ Recurrent Recurrent acute otitis media/ Recurrent
COME COME
Surgical Indications AbsoluteAbsolute
Obstructive airway with cor pulmonaleObstructive airway with cor pulmonale Severe dysphagiaSevere dysphagia Failure to thriveFailure to thrive
RelativeRelative Recurrent acute tonsillitisRecurrent acute tonsillitis Chronic tonsillitisChronic tonsillitis Obstructive Sleep ApneaObstructive Sleep Apnea Peritonsillar AbscessPeritonsillar Abscess HalitosisHalitosis Suspected Neoplasia/ Tonsillar hyperplasiaSuspected Neoplasia/ Tonsillar hyperplasia
Preoperative evaluation
Most common lab test is a CBCMost common lab test is a CBC Coagulation studies when the history or Coagulation studies when the history or
physical examination suggests a bleeding physical examination suggests a bleeding disorder.disorder.
Lateral Neck/Adenoid filmsLateral Neck/Adenoid films
Von Willebrand’s Disease
Autosomal dominant bleeding disorderAutosomal dominant bleeding disorder Increased bleeding time and prolonged Increased bleeding time and prolonged
aPTT.aPTT. Perioperative managementPerioperative management
IV Desmopressin (0.3ugm/kg)IV Desmopressin (0.3ugm/kg) Serum SodiumSerum Sodium
Idiopathic Thrombocytopenic Purpura Most common thrombocytopenia of Most common thrombocytopenia of
childhood.childhood. 90% resolution by 9-12 months90% resolution by 9-12 months SplenectomySplenectomy IVIG preoperativelyIVIG preoperatively
Innovative Surgical Techniques
Cold DissectionCold Dissection ElectrosurgeryElectrosurgery Intracapsular partial tonsillectomyIntracapsular partial tonsillectomy Harmonic ScalpelHarmonic Scalpel Radiofrequency tonsillar ablation and Radiofrequency tonsillar ablation and
coblation.coblation.
Electrosurgery
Most popular technique for tonsillectomyMost popular technique for tonsillectomy Equivalent or superior to the other methods Equivalent or superior to the other methods
of tonsillectomy.of tonsillectomy.
Intracapsular Partial Tonsillectomy 45 degree Microdebrider (1500rpm).45 degree Microdebrider (1500rpm). AdvantagesAdvantages
As effective as standard tonsillectomy in As effective as standard tonsillectomy in relieving obstruction.relieving obstruction.
Less pain, quicker return to normal dietLess pain, quicker return to normal diet Disadvantages:Disadvantages:
Tonsillar regrowthTonsillar regrowth Greater intraoperative blood loss Greater intraoperative blood loss
Harmonic Scalpel
Advantages:Advantages: Better visibilityBetter visibility Smaller risk of stray energy shocksSmaller risk of stray energy shocks Improved post operative painImproved post operative pain
Disadvantages:Disadvantages: Must use alternate device for adenoidectomyMust use alternate device for adenoidectomy Similar intraoperative blood loss.Similar intraoperative blood loss.
Radiofrequency tonsillar coblation Coblation is superior to ablation.Coblation is superior to ablation. Early elimination of pain and reduced pain Early elimination of pain and reduced pain
medicine usage.medicine usage. Early resumption of normal diet.Early resumption of normal diet. Currently inadequate for adenoidectomyCurrently inadequate for adenoidectomy
Adjuvant Therapies
Perioperative local anestheticPerioperative local anesthetic0.25% bupivicaine w/ 1:100,000 0.25% bupivicaine w/ 1:100,000 EpinephrineEpinephrine
Advantages:Advantages:ease of dissection, postoperative painease of dissection, postoperative pain
Disadvantages:Disadvantages:Airway obstruction, cardiac dysrrhythmias, Airway obstruction, cardiac dysrrhythmias, seizuresseizures
Adjuvant Therapies
Perioperative antibioticsPerioperative antibiotics Fewer episodes of fever, offensive odor, Fewer episodes of fever, offensive odor,
improved oral intake, less pain, fewer improved oral intake, less pain, fewer days to return to normal activitydays to return to normal activity
Cardiac abnormalityCardiac abnormality
Adjuvant Therapies
Perioperative SteroidsPerioperative Steroids Dexamethasone (0.15-1.0mg/kg)Dexamethasone (0.15-1.0mg/kg) Two times less likely to have an episode Two times less likely to have an episode
of postoperative emesis, and more likely of postoperative emesis, and more likely to advance to eating a soft diet.to advance to eating a soft diet.
Reducing postoperative pulmonary Reducing postoperative pulmonary distress, subglottic edema, pain distress, subglottic edema, pain reduction.reduction.
Adjuvant Therapies
Pain controlPain control Tylenol and Tylenol w/ codeine are the Tylenol and Tylenol w/ codeine are the
most commonly used.most commonly used. Similar pain control, less oral intake with Similar pain control, less oral intake with
codeine versus Tylenol alone.codeine versus Tylenol alone. NSAIDS still controversial.NSAIDS still controversial.
Complications
Mortality rate is 1 in 16000-35000.Mortality rate is 1 in 16000-35000. Anesthetic complicationsAnesthetic complications Eustachian tube injuryEustachian tube injury VPIVPI Nasopharyngeal stenosisNasopharyngeal stenosis Pulmonary EdemaPulmonary Edema Atlantoaxial subluxationAtlantoaxial subluxation
23 hour observation
Age younger than 3.Age younger than 3. Obstructive sleep apnea/craniofacial Obstructive sleep apnea/craniofacial
syndromes involving the airway.syndromes involving the airway. Systemic disordersSystemic disorders Poor socioeconomic situationPoor socioeconomic situation Peritonsillar abscessPeritonsillar abscess Emesis or HemorrhageEmesis or Hemorrhage
Post Operative Hemorrhage
The best treatment is prevention.The best treatment is prevention. Early vs. Delayed hemorrhage.Early vs. Delayed hemorrhage. Overnight observation and venous accessOvernight observation and venous access Surgical intervention.Surgical intervention. Carotid angiography if any suspicion of Carotid angiography if any suspicion of
carotid artery injury.carotid artery injury.
Case Study
8yo male referred to the Pediatric clinic for 8yo male referred to the Pediatric clinic for evaluation and treatment of recurrent evaluation and treatment of recurrent tonsillitis.tonsillitis.
History
Only 2 episodes of documented pharyngitis Only 2 episodes of documented pharyngitis in the past 12 months, strep negative, only in the past 12 months, strep negative, only missed 5 days of school total last year.missed 5 days of school total last year.
Loud snoring, frequent pauses up to 5 Loud snoring, frequent pauses up to 5 seconds terminated with gasps of breath.seconds terminated with gasps of breath.
Physical Examination
Normal facies, open mouth breathing, Normal facies, open mouth breathing, tonsils 3+, no cleft deformities.tonsils 3+, no cleft deformities.
Remainder of exam is normal.Remainder of exam is normal.
Case Study
Undergoes uneventful tonsillectomy and Undergoes uneventful tonsillectomy and adenoidectomy with 23 hour observation.adenoidectomy with 23 hour observation.
On follow up visit 2 weeks postoperatively, On follow up visit 2 weeks postoperatively, his mom complains that he doesn’t like his mom complains that he doesn’t like some of his favorite foods. He says they some of his favorite foods. He says they taste “yucky”.taste “yucky”.
Decreased perception of taste with no smell Decreased perception of taste with no smell abnormalities.abnormalities.
Diagnosis
DysgeusiaDysgeusia Unknown mechanism- thought to be due to Unknown mechanism- thought to be due to
prolonged pressure on the tongue by the prolonged pressure on the tongue by the mouth retractor.mouth retractor.
Treatment is reassurance.Treatment is reassurance.
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