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Presentan : Desti Kusmardiani
Supervisor : dr. Agung Dinasti P, M.Kes, SpTHT-KL
Department of Otolaryngology - Head & Neck Surgery
Faculty of Medicine Padjadjaran Univerity
Haan Sadikin !eneral Hopital
"andung
#$%
- Literature Reading –
Tonsillitis,Tonsilletom! AndAdenoidetom!
%
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'ntroduction
2
Healt( pro)lem from dieae in t(e tonil and adenoid
*eyakumar + et al, +denotonilar Dieae in .(ildren 'n Head and Neck Surgery / Otolaryngology t( ed 0ditor1 "ailey "* & *o(non 2* 3olume one 4ippincot 5illiam & 5ilkin P(iladelp(ia, #$%6 p %67$-66David H Darro8, Diorder of t(e 2onil and +denoid 'n Pediatric Otolaryngology 0ditor1 Scott 9S & David HD +merican+cademy of Pediatric, US+ , #$%# p%:%-#%7
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A"AT#M$
3
PHAR$"%
Keith L. Moore. Clinically Oriented Anatomy
5th ed., 2006. p.953
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A"AT#M$
+tla of Human +natomy N02209 7rd ed #$$7
6
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&ALD'$'R R(")S
5
% +denoid;p(aryngeal<
# 2onil linguali
7 2onil palatina
6 4ateral faringeal)and
P(aryngeal!ranulation
= 2u)al 2onil;!erlac>(<
: 3entricel latlymp(oid tiue
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6Keith L. Moore. Clinically Oriented Anatomy
5 th ed., 2006. p.958
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AD'"#(D*PHAR$")'ALT#"S(LS
• 2riangular ma oflymp(oid on t(e
poterior apect oft(e )o?likenaop(aryn?
• Formed during t(e 7rd to :t( mont( ofem)ryogenei
7
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L(")+AL T#"S(LS
• Uncapulated
• Mot recentdevelopment adult
• Super@cial crypte8
Keith L. Moore. Clinically Oriented Anatomy 5th ed., 2006.
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PALAT("' T#"S(LS
Palatine Tonsils : 4ateral 8all of t(e orop(aryn?
+nterior 1 Pillar anterior
Poterior 1 Pillar poterior
4ateral 1 M contrictor p(aryngeu uperior
.ompoition 1 4ymp(oid tiue 9
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.OMPON0N2 +ND P9OP092'0S OF
5+4D0A09 9'N!
*eyakumar + et al, +denotonilar Dieae in .(ildren 'n Head and Neck Surgery / Otolaryngology t( ed 0ditor1"ailey "* & *o(non 2* 3olume one 4ippincot 5illiam & 5ilkin P(iladelp(ia, #$%6 p %67$-66 %$
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Arteries o Te Tonsils
11
o +cending palatine artery faciali artery poteroinferior
o 2onilar artery facialiartery antero inferior
o Doral lingual artery makilari interna anteromedia
o +cending p(aryngealartery e?ternal carotid
arterypotero uperior
o Palatine mayor & minorartery decendenpalatine artery anterouperior
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2onilar )ranc( of 4ingual vein- t(e main drainae ytem oft(e tonillar vein
2onilar acceoria vein ple?u p(aryngeali
Peritonilar vein uperior of tonillar )ed Main )leeding ourceafter tonillectomy
(nternal ugular/eins 12
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L!mpati Drainage # Te Tonsil
13
tream of 4imfe of tonilparenkim
eferen limfe in tra)ecula
gland of ervikali profunda
c(et area limfaticu nodulu
t(oraiku duktu
;No +Berent lymp(atic<
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"erves o te tonsil :
14
N IX
(Glossopharyngeal)the main nerve.
Descenden branch of
N. palatine.
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Anatomi and P!siologi Di0erenes1et2een Te Adenoids and Tonsils
15Brodsy, L. !o"e, C. #onsilitis, #onsillectomyand Adenoidectomy. $n %ead and &ec '(r)ery*Otolaryn)olo)y, 5 th ed.Bailey, +ol. $, 2006. p. -
Adenoids Tonsils
+natomic4ocation
- Poterior 8allnaop(aryn?
- May e?tend intopoterior c(oane
- 4ateral 8all orofaring- Occaionaly e?tend
into naop(aryn? or(ypop(aryn?
!ro 2riangular (apeC invaginated)y deep fold,fe8 crypt
!enerally ovoid(ape,ometime )ilo)ed'nvaginated )y #$-7$)ranc(ing crypt
Microcopic 7 type of epit(elium 1.illiated peudotrati@edcolumnar
Suamou 2ranitional +g proceing
No aBerent limp(atic
SpecialiEed +g proceingNo aBerent limp(atic
P(yiologic Mucocilliary clearance+g proceing'mmune urveillance
+g proceing, immuneurveillance
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(MM+"#PH$S(#L#)$ 2(e tonil and adenoid involved
in /oth local immunity and in immuneurveillance for t(e development oft(e )ody> immunologic defeneytem
16
3#R'()"MAT'R(AL
4(")'ST'D*("HAL'D5
Ativation 1,T-
l!mpos
ite, AP6
Loall!presentedantigeni
stimuli
)eneratememor!
l!mposite to7e
disseminated tooter muosal
site *eyakumar + et al, +denotonilar Dieae in .(ildren 'n Head and Neck Surgery / Otolaryngology t( ed 0ditor1 "ailey "* & *o(non 2* 3olumeone 4ippincot 5illiam & 5ilkin P(iladelp(ia, #$%6 p %67$-66
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.linical Preentation
;3irue<• play an important rule a initiator ofmucoal inamation, crypt o)truction,ulceration leading to )acterial uperinfection
• r(inoviru, coronaviru, adenoviru, (erpeimple? viru, parainuenEa, eptein-)arrviru, cytomegaloviru
• ymptom1 ore t(roat, odynop(agia, otalgia,(eadac(e, fever
*eyakumar + et al, +denotonilar Dieae in .(ildren 'n Head and Neck Surgery / Otolaryngology t( ed 0ditor1 "ailey "* & *o(non 2* 3olumeone 4ippincot 5illiam & 5ilkin P(iladelp(ia, #$%6 p %67$-66
%:
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.linical Preentation;"acteriologyGMicro)iology<
• Mot infection can )e linked to t(e preence of )eta-lactamae producing organim t(at ditort t(e normalaerodigetive )acterial milieu and can caue
commenal organim to )ecome pat(ogenic
• 'nfection are often polymicro)ial in nature and ofteninclude anaero)ic pat(ogen
• O)truction of tonillar crypt can erve a a nidu for)acterial tai and can furt(er perpetuate a conditionof c(ronic infection, uppuration, and @tulae
*eyakumar + et al, +denotonilar Dieae in .(ildren 'n Head and Neck Surgery / Otolaryngology t( ed 0ditor1 "ailey "* & *o(non 2* 3olumeone 4ippincot 5illiam & 5ilkin P(iladelp(ia, #$%6 p %67$-66
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M(6R#1(#L#)$
19
1ateria
Aero/ic ro(p A Beta %emolytic 'treptococc(s 1AB%'ro(p B, C, 'treptococc(s%emophil(s in4(ena 1tipe B dan non tipe'treptococc(s pne(moniae, 'treptococc(s epidermidisMoraella catarrhalis, 'taphyllococc(s a(re(s%emophyll(s parain4(ena&eisseria sp.Mico/acteria sp., Lacto/acill(s sp.7. colli, %elico/acter pylori
Chlamydia pne(moniae+naero)ic Bacteroides sp., !eptococc(s sp.
Microaerophillic streptococci8eillonella par+(laBido/acteri(m adolescences7(/acteri(m sp., Lacto/acill(s sp.(so/acteri(m sp., Bacteroides sp.!orphyromonas asaccharolytica!re+otella sp.
3iru 7pstein*Barr, Adeno+ir(s$n4(ena A, B%erpes simple, :espiratoy syncytial!arain4(ena
Ot(er Myco/acteri(m 1atypical nont(/erc(losisCandida al/icans
Brodsky !. "o#e $. %onsilitis %onsillectomy and &denoidectomy. In 'ead and Neck rgery*+tolaryngology , th ed. Bailey vol. I -/. p. 001/
D(33'R'"T(AL #3 AD'"#T#"S(L
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D(33'R'"T(AL #3 AD'"#T#"S(L
#%
#$
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T#"S(LS
21
'tiolog! : !+"HS, pneumococcu,tap(ylococcu, (aemop(yllu inuenEa,and 0ptein-"arr viru
Patolog! : Hyperplaia and inammaiellular tiue, leukoit, de)ri and)acteria patogen at t(e crypta
6linial Signs : Sore t(roat, dyp(agia, 8eakne, fever, tender cervical nodein t(e preence of tonil t(at are erymatou and (ave e?udate, mallodorou)reat(, otalgia
P!sial e8amination : Hypertrop(i and inamai, 8(ite ekudat, o)tructionof air8ay and muIe ign
Diagnosis : 2(roat culture or rapid trep antigen tet for !+"HS
Terap! : )edret, (ydration, diet, +nalgetik and +nti)iotik
Aute Tonsilitis
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90.U990N2 +cute 2oniliti
9ecurrent acute infection (a )eenvaria)ly
de@ned a 1
% Four to even epiode of acutetonilliti in one year
# Five epiode for t8o conecutive
year7 2(ree epiode per year for 7
conecutive year
22
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.H9ON'. P09S'S20N2 2oniliti
6linial Signs :
.(ronic ore t(roat, malodorou )reat(, e?ceive tonillarde)ri ;tonillolit(<, peritonillar eryt(ema, and peritent,tender cervical adenopat(y, foreign )ody enation
P!sial '8amination :
Hypertrop(i
.icatric of t(e tonil
Stenoi of t(e crypta
Purulent e?udat
Terap! :
Hydration, +nti)iotik and 2onillectomy
23
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O"S29U.2'30 2ONS'44+9HAP09P4+S'+
6linial Signs : Snoring 8it( o)tructive ditur)ance ;aleep anda8ake<, dyp(agia, voice c(ange ;muIing or (yponaality<,c(ange )e(aviour and emotion
P!sial e8amination : Hyperplaia tonil 8it( (ealt(y crypta
Terap! :
Paliatif, Preventif and 2onillectomy
24
"ull, 92 .olot +tla of 0N2 Diagnoi
6t( ed, 2(ieme, #$$7 p %J=-#%$
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AD'"#(DS
DiKcult to diBerentiate from a generaliEed virallyinduce U9' or a true )acterial r(inoinuiti
6linial Signs :
Purulent r(inorr(ea
Naal o)truction
Fever
Otiti media
4oud noring
25
Aute Adenoiditis
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26
“Presence of four or greater discrete episodesof acute adenoiditis during of a 6-month
period”• Treatment :
+ntimicro)ial prop(yla?i
aymptomatic )et8eeninfection, epecially ifcomor)idity occur ;reactiveair8ay dieae, recurrent otiti<
daily lo8 doe ;one (alf to
one t(ird t(e full doe< epiodic prop(yla?i ;(ortcoure of +" 8it( t(e onetof U9'<
• Di0erential Diagnosis:
9ecurrent acute inuiti
0?traeop(ageal reu?;009<-induced
adenoiditi
Reurrent Aute Adenoiditis
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.H9ON'. ;P09S'S20N2< +denoiditi
Often aociated 8it( c(ronic inuiti and otiti media 6linial Signs :
Peritent naal dic(arge,
malodorou )reat(,
potnaal drip, and
c(ronic congetion
27
- 2(e role of 009 a contri)utory to c(ronic adenoidinammation, epecially in younger c(ildren
- +lt(oug( initially adenoidectomy may )e c(oen fortreatment of adenoiditi andGor inuiti, prognoi forimprovement after t(e urgery could diBerigni@cantly ;unpu)li(ed data<
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O"S29U.2'30 +denoidHAP09P4+S'+
-'tiolog! :0nlarge adenoid
Naop(aryngeal o)truction
-Te triad os!mptoms :c(ronic naal o)truction
;aociated 8it( noring ando)ligate mout( )reat(ing<,
r(inorr(ea, and
a (yponaal voice
28
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6linial 'valuation• P(yical e?amination (ould )e performed 8it(
t(e c(ildL mout( open and t(e tongue on t(eoor of t(e mout( 8it(in t(e oral cavity
• Having t(e c(ild ay aa( 8ill allo8 aement
of palatal integrity and motion
• 2onillar (ypertrop(y i uually de@ned a falling8it(in t(e 7 to 6 range
• 2(e otolaryngologit mut )e cogniEant of ign ofc(ronic dieae, uc( a peritonillar eryt(ema,tender cervical lymp(adenopat(y, tonillolit(,moot( glitening tonil, or e?ceively ayptic
tonil 29 *eyakumar + et al, +denotonilar Dieae in .(ildren 'n Head and Neck Surgery / Otolaryngology t( ed 0ditor1 "ailey "* & *o(non 2* 3olumeone 4ippincot 5illiam & 5ilkin P(iladelp(ia, #$%6 p %67$-66
•
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1rods9! gradingo tonsil sie
- !rade $urglcally a)ent ;+<
- !rade %8it(in t(e tonillar pillar ;"< ;$to # air8ay o)truction<
-!rade # jut toG)eyond t(e tonillar pillar;.< ;# to $ air8ayo)truction<
-!rade 7
)eyond t(e tonillar pillar, )ut notto midline ;D< ;$ to : air8ayo)truction<
-!rade 6touc(lng 'n t(e midline ;0< ;: to%$$ air8ay o)truction<
*eyakumar + et al, +denotonilar Dieae in .(ildren 'n Head and Neck Surgery / Otolaryngology t( ed 0ditor1 "ailey "* & *o(non 2* 3olumeone 4ippincot 5illiam & 5ilkin P(iladelp(ia, #$%6 p %67$-66
7$
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6linial 'valuation
31
AD'"#(D
Histor! r(inorr(ea c(ronic coug(
potnaal drip o)ligate mout( )reat(ing noring (yponaal peec(
P!sial '8amination•
open mout( appearance•attened mid face claic “adenoid facies”• dark circle under t(e eye
Assessed "asalit! Spee
emp(aiEe naal emiion milman or micey mo(se pinc( t(e noe during anaality tranmitted p(rae anterior and poteriorr(inocopy direct e?i)le @)eropticnaop(aryngocopy ;QQ 7yo<•a)normalitie in t(e
ma?illary- mandi)ularrelation(ip palate evaluation
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32
T#"S(LS
2(e Firt-line anti)iotic in acute tonilliti due to !+"HS peniciillin
+nti)iotic eBective againt R-lactamae-producing mo orencapulated anaero)e ;7-= 8eek< in c(ronic tonilliti oro)tructive (yperplaia +mo?-clavulanat orclyndamicin
+cute upper air8ay o)truction 1 Naop(aryngeal air8ay
'mmediate tonillectomy 1-P2+ coe?it 8it( infection of mononucleoi-c(ild 8it( poor clinical repone to medical t(erapy
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'ndication of 2onillectomy
33
#7strution 2onillar (yperplaia 8it( c(ronico)tructionSleep-related diordered )reat(ing
O)tructive leep apnea yndrome
Upper air8ay reitance yndrome O)tructive (ypoventilationyndrome Failure to t(rive .or pulmonale S8allo8ing a)normalitie Speec( a)normalitie
OrofacialGdental a)normalitie 4ymp(oproliferative diorder
(netion 9ecurrentGc(ronic tonilliti 2onilliti 8it( 1 +)ceed cervical node +cute air8ay o)truction
.ardiac valve dieae Peritent tonilliti 8it( 1
Peritent ore t(roat 2ender cervical node Halitoi 2onilolit(iai
Streptococcal carrier tateunreponive
to medical t(erapy in a c(ild of(oue(old
at rik Peritonillar a)ce unreponive to medical t(erapy or in a patient 8it(
recurrent tonilliti or recurrent
"rodky, 4 Poje, . 2oniliti, 2onillectomy and+denoidectomy 'n Head and Neck Surgery-Otolaryngology, t( ed "ailey, vol ', #$$= p
%%
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P+9+D'S0 .9'209'+ FO9
2ONS'440.2OMA
*eyakumar + et al, +denotonilar Dieae in .(ildren 'n Head and Neck Surgery / Otolaryngology t( ed 0ditor1 "ailey "* & *o(non 2* 3olumeone 4ippincot 5illiam & 5ilkin P(iladelp(ia, #$%6 p %67$-66
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Tonsilletom!
Teni;ue o Tonsilletom! :
% Diection and Snare Met(od# 2onil !uillotine ;Sluder< 2ec(niue
7 2onillectomy 8it( 4ocal +net(eia
6 .ryogenic 2onillectomy 0lectroteriliEation of 2(e 2onil
= 4aer 2onillectomy
35
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36
2ec(niue of 2onillectomy
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2ec(niue of 2onillectomy
37
etode Dissetion-Snare
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Pot Operative .are
% Maintain air8ay
# .ontrolled of )leeding
7 Maintenance in general
6 Diet tage1
- %-# day1 liuid food and cold
- 7- day1 train porridge or train
food- =- day1 regular porridge
- J-%$ day1 2eam rice
- %% day 1 9iceGregular food38
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39
AD'"#(D+ntimicro)ial eBective againt R-lactamae-producingmo 1 recurrent G c(ronic adenoiditi
'ntra naal teroid ;=-to- 8eek< 1 adenoid (yperplaia
Surgical tec(niue 1 mirror viualiEation of t(enaop(aryn? and removal of t(e tiue 8it( (arpcurette, adenotome, po8ered microde)rider, or 8it(cauter
Hemotai 1 'ntraoperative packing, application of
)imut( u)galleate, electrocoagulation of adenoi )ed
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Management
40
#7strution +denoid (yperplaia 8it( c(ronic naalo)truction or o)ligate mout( )reat(ing Sleep-related diordered )reat(ing O)tructive leep apnea yndrome Upper air8ay reitance yndrome O)tructive (ypoventilationyndrome Failure to t(rive .or pulmonale
S8allo8ing a)normalitie Speec( a)normalitie OrofacialGdental a)normalitie 4ymp(oproliferative diorder(netion 9ecurrentGc(ronic adenoiditi 9ecurrentGc(ronic otiti media 8it(
eBuion .(ronic otiti media .(ronic inuiti"eoplasia Supected neoplaia, )enign ormalignant
"rodky, 4 Poje, . 2oniliti, 2onillectomy and+denoidectomy 'n Head and Neck Surgery-Otolaryngology, t( ed "ailey, vol ', #$$= p%%
'ND'.+2'ONSOF
+D0NO'D0.2OMA
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6ompliations
• Naop(aryngealtenoi
• "leeding
• 2orticolli
• .-pine lu?ation;rare<
41
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Teni;ue o Adenoidetom!
% .uretae adenoidectomy
- Prepare of curetae
- .uretae
- 0?amination
42
a +denoidectomy 8it( (eade?tenion poition
) "eckmann> ring curette
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Teni;ue oAdenoidetom!
# +denoidectomy 8it( endocopy
43
Helal, =-0ndocopic Po8ered+denoidectomy(ttp1GG888googleerar(GimageGendocopicadenoidectomy
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.ON29+'ND'.+2'ON
• .ontraindication to 2&+ includecoagulation a)normalitie t(at (ould )eaddreed prior to urgery, and often reuirea multidiciplinary approac( including(ematology involvement and coordination
• .(ildren 8it( acute illnee t(at mig(timpair t(e a)ility to maintain adeuate
potoperative (ydration or afely undergogeneral anet(eia (ould defer electiveurgery
*eyakumar + et al, +denotonilar Dieae in .(ildren 'n Head and Neck Surgery / Otolaryngology t( ed 0ditor1 "ailey "* & *o(non 2* 3olumeone 4ippincot 5illiam & 5ilkin P(iladelp(ia, #$%6 p %67$-66
66
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45
Peritonillar a)ce Sore t(roatGdyp(agia +nti)iotic ;iv<
P(aryngotonillar )ulge Needle apirationG' & D in O9
2rimu
Drooling 'mmediate tonillectomy+cute air8ay o)truction Stridor Naop(aryngeal air8ay
econdary to 2 & + MuIedG(yponaal voice Steroid ;iv<
(yperplaia Drooling +nti)iotic ;iv<
0nlarged tonil ;and adenoid<
Hemorr(age pot- "leeding from mout( or noe 4ocal control ;cauteryor
tonillectomy Freuent 8allo8ing vaocontriction<
.ontrol in O9
0valuate for coagulopat(y in
elected cae
6ompliations o adenotonsillar disease
and adenoidetom! and tonsilletom!
6ompliation Presentation Management
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46
Pot 2 & + air8ay o)truction Occur in @rt 6/#6 ( Naop(aryngeal air8ay
Palatal 8elling Suction gently
Hypop(aryngeal ecretion Steroid ;iv<
De(ydration pot 2 & + Poor oral intake .ontrol emei if preent
Dry mucou mem)rane iv Hydration
4et(argy Parental education
Pain control prn
Peritent 3P' after Hypernaal peec( ;lating Speec( t(erapy
+denoidectomy )eyond # mo potop< Palate urgery
Naal regurgitation of uid
Pulmonary edema after DiKculty 8it( o?ygenation Poitive and e?piratoryventilation
relief of air8ay o)truction noted
)y anet(eiologit
Frot(y pink ecretion from 4ai?
endotrac(eal tu)e Morp(ine
Hitory of o)tructiona
ManagementPresentation6ompliation
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*eyakumar + et al, +denotonilar Dieae in .(ildren 'n Head and Neck Surgery / Otolaryngology t( ed 0ditor1 "ailey "* & *o(non 2* 3olumeone 4ippincot 5illiam & 5ilkin P(iladelp(ia, #$%6 p %67$-66
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#$%$ .4'N'.+4 P9+.2'.0 !U'D04'N0S
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H()HL()HT
• +denotonillar dieae uually preent inc(ildren 8it( eit(er recurrent t(roatinfection or SD" Preently t(e motcommon indication for 2&+ i SD"
• +ppro?imately 7$ of )acterial cae ofacute tonillop(aryngiti are caued )y!+"+, 8it( a varying contri)ution from
ot(er pat(ogen, including group . )eta-(emolytic treptococci, N g$%%$%2(oeae,. dip(t(eria, . pneumoniae, and Mpneumuniae
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H'!H4'!H2
• 2(e +merican +cademy of Otolaryngology-Head and Neck Surgery pu)li(ed a.linical Practice !uideline on t(e
indication for tonillectomy )aed on ane?tenive literature revie8 and an e?pertpanel t(at included )ot( otolaryngologitand nonotolaryngologit 2(ey made
recommendation to addre t(e t8o motcommon indication for tonillectomy1recurrent tonilliti and SD"
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