Download GLENELG COMMUNITY HOSPITAL INC Adenotonsillectomy

GLENELG COMMUNITY HOSPITAL INC
Adenotonsillectomy
Learning Package
Name_____________________________________________RN/EN
Date___________________________
Department_____________________
Return this Learning Package to Staff Educator for marking and a certificate
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INTRODUCTION
This self directed package is designed to assist nurses to become proficient in the care of an
infant, child or adolescent and adult, who has had an Adenotonsillectomy.
This package enables you to work through the skills at your own pace.
OBJECTIVES
On completion of the learning package you will be able to:
KNOWLEDGE
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Describe the Paediatric airway anatomy and physiology
Outline the definition of Adenotonsillectomy
Describe the indications for Adenotonsillectomy
Identify complications following an Adenotonsillectomy and state the actions required
if these occur
SKILLS
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Give total care for an infant, child or adolescent, or adult who has had an
Adenotonsillectomy in a safe environment
Evaluate respiratory status
ATTITUDE
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Appreciate the need for staff to be competent in airway management before giving
care to an infant, child or adolescent or adult who has had an Adenotonsillectomy
Provide education to staff, patients and their families on care following
Adenotonsillectomy.
RELATED CONCEPTS
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Paediatric growth and development
Paediatric respiratory assessment
Respiratory anatomy and physiology
Oxygen therapy
Cardiopulmonary Resuscitation
Infection Control practices
Surgical nursing
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ANATOMY AND PHYSIOLOGY
The pharynx can be considered to be a muscular tube that connects the oral and nasal
cavities with the oesophagus and larynx. While rather simple at first glance, the action of
swallowing is considerably complex, requiring closure of the nasopharynx, closure of larynx
propulsion of liquids and solids into the proximal oesophagus without aspiration into the
tracheas and lungs. The pharynx can be divided into three parts:
The boundaries of the nasopharynx are the skull base (basisphenoid) above and the soft
palate below. The adenoid tissue is positioned in the midline of the posterior nasopharyngeal
wall and is not visible through the mouth. Along with the tonsils, it makes up the major
portion of the pharyngeal lymphoid tissue termed Waldeyers ring. The blood supply to the
adenoid tissue arises from the ascending pharyngeal and sphenopalatine arteries. Branches
of IX and X provide sensory innervation and are responsible for the referred pain to the
ear/throat with adenoid infection.
The oropharynx runs from the soft palate and palatal folds to the epiglottis.
Tonsils (palatine and lingual) and adenoids are a collection of lymphoid tissue that helps the
body fight infection. The palatine tonsils (commonly and from herein referred to as the”
tonsils”) are located on either side of the oropharnyx. The palatine tonsils are visible at the
back of the throat. The lingual tonsil lies over the posterior base of the tongue.
The tonsillar branch of the facial artery provides the majority of the blood supply to the
tonsils. In most people, the internal carotid artery lays two centimeters posterolateral to the
deep surface of the tonsil. The nerve supply of the tonsils arises from IX and some branches
of lesser palatine nerve via sphenopalatine ganglion.
The hypopharynx begins at the epiglottis and extends to the level of the cricoid cartilage or
the beginning of the oesophagus. At this point there is a muscle (cricopharyngeous) that
closes off the pharynx form the oesophagus. The trachea projects upwards and backwards,
to open into the front wall of the hypopharynx. At this junction the trachea forms the larynx.
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Image of lateral view of the pharyngeal structures
(Reference http://health.bwmc.umms.org/imagepages)
Image of location of the tonsils and adenoids
(Reference www.picsearch.com)
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ADENOTONSILECTOMY DEFINITION
Adenoidectomy and tonsillectomy, or Adenotonsillectomy (the removal of both the adenoids
and the tonsils) is one of the most frequently performed surgical procedures in children.
Studies have shown the greatest frequency of these operations lies between the ages of 4
and 8 years and between the ages of 13 and 23 years.
INDICATIONS
ADENOID
Symptoms that indicate enlarged, obstructing adenoids that may benefit from an
adenoidectomy include:
 The triad of hypo-nasality, snoring and mouth breathing
 Recurrent purulent rhinorrhea
 Post-nasal drip
 Chronic sinusitis
 Chronic middle ear effusions
 Persisting symptoms following medical therapy e.g. antibiotics
 Dental malocclusion or oro-facial growth disturbance
Adenoid size may be graded. This grading refers to the observed size of the adenoid with
respect to obstruction of the choanae.
TONSIL
The indications for a tonsillectomy are:
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Tonsillar hyperplasia causing upper airway obstruction and obstructive sleep apnoea
Recurrent acute tonsillitis
Recurrent peritonsillar abscess (there is a 10-20% chance of recurrence within 12
months, so most advocate removal of the tonsils after two episodes)
 Chronic tonsillitis (characterized by the triad of tonsilloliths, erythema of the tonsillar
fauces, and enlarged cervical lymph nodes)
 Dysphasia due to tonsillar hyperplasia
 Dental malocclusion due to adversely affected orofacial growth
 Unilateral tonsil enlargement, presumed neoplastic)
Brodsky, Moore and Stanievich describe as assessment scale for tonsillar hyperplasia. This
scale is based on a percentage of obstruction. Another less frequently used method of
grading is;
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grade 1- tonsils were those lying lateral to the tonsillar fauces
grade 2- at the level of the fauces
grade 3- medial to the fauces but not to midline
grade 4 –touching at the midline
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Image of hyperplasia of tonsils
Image of hyperplasia of tonsils
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Image of mononucleosis
Image of streptococcus infection
(Reference Google images 2013)
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CONTRAINDICATIONS
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Bleeding diatheses such as haemophilia A and B and Von Willebrand disease affect
blood clotting. Haemophilia A, or Classical Haemophilia, is the most common form,
and is due to the deficiency of clotting factor VII (8). Haemophilia B, or Christmas
disease, is due to the deficiency of clotting factor IX (9). Haemophilia is rarely seen in
females, as it is X-linked. Von Willebrand disease affects 1% of the general
population and is transmitted in an autosomal dominant fashion, and affects both
clotting factors and platelet function. Children with known clotting diatheses will be
referred to WCH to have any ENT surgery carried out in conjunction with a
haematologist.
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Poor anaesthetic risk or uncontrolled medical illness (e.g. diabetes) which can result
in intra and post-operative complications.
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Acute infection. Intraoperative bleeding is greater during acute infection, and there is
also the risk of spreading the infection to other structures. Some studies have
reported that the risk of bleeding is high following a tonsillectomy where there is a
peritonsillar abscess (a “quinsy tonsillectomy” than in an elective tonsillectomy.
COMPLICATIONS POSTOPERATIVELY INCLUDE
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Respiratory compromise. It is also important to keep in mind that in any patient
who has upper airway obstruction, removal of that obstruction can lead to post
obstructive pulmonary oedema (the sudden loss of negative intrathoracic pressure
leads to fluid flowing from capillaries into the lungs).
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Haemorrhage. Reactionary haemorrhage, which occurs in the first 24 hours and
secondary haemorrhage, which occurs after 24hours and up to 10 days later.
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Pain is the most common complication of the operation. It can also lead to
dehydration which results in prolonged hospitalisation.
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Poor oral intake resulting in dehydration.
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Injury to lips or teeth is a potential complication of any oral or Oropharyngeal
surgery
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Temporo-mandibular joint subluxation from excessive mouth opening or a weak
joint capsule, can lead to severe muscle spasm and inability to open the mouth, until
the subluxation is corrected..
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Atlanto-axial joint subluxation may be due to patient positioning for
Adenotonsillectomy in predisposed individuals (Down’s syndrome, achondroplasia,
and rheumatoid arthritis). Newer techniques safeguard against this in such
predisposed patients. Grisel’s syndrome is the occurrence of atlantoaxial subluxation
in association with inflammation of adjacent soft tissues (usually infection), and is
extremely rare.
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THE PROCEDURE
Tonsillectomy is one of the oldest surgical procedures. It was first described by Clesus (first
century A.D.) who used a hook to grasp the tonsil then used his finger to incise it.
In the 6th century, physicians began to use a knife to remove the tonsil as well as beginning
to recognize that being in the correct plane was important for successful outcome.
In the 17th century, physicians began to recognize that exposure was important; they
recommended having an assistant to hold the patient steady while doing the procedure.
As the procedure was painful and difficult for patients to endure further development of
“tools” (tonsillotome) enabled the surgeon to grasp and remove the tonsil in one swift move.
McKenzie further developed it into the tonsil guillotine.
There are many surgical techniques available today including;
 Cold steel
This is the traditional method which involves removal of the tonsils by blunt dissection
followed by haemostasis using ligatures.
 Diathermy
This uses electrical energy (alternating current) applied directly to the tissue. It can be
bipolar (current passes between the two tips of the forceps) or monopolar (current passes
between instrument and a plate attached to the patient’s skin). As current arcs between the
instrument tips (bipolar) or instrument and the patient) monopolar), the heat generated may
be used to separate and dissect tissues, thus peeling the tonsils away from the pharyngeal
wall, and also to promote haemostasis. Diathermy is sometimes used as an adjunct to cold
steel surgery to achieve haemostasis.
 Coblation
This involves passing a radiofrequency bipolar electric current through N/Saline. The
resulting plasma field of sodium ions c can be used to dissect tissue by disrupting
intercellular bonds and causing tissue vaporization. This method generates less heat than
diathermy. The Argon plasma coagulator can also be used. This involves a high-voltage
monopolar current transmitted to the tissue by a fine jet of ionized Argon gas resulting in the
same tissue coagulation or vaporisation
MEDICATIONS
Paracetamol
 Pre-operative:
□ Oral if documented
 Intraoperative:
□ IV Paracetamol 15mg/kg if not given preoperatively
 Post-operative:
□ Regular Paracetamol 15-20mg/kg 6 hourly
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Oxycodone
 Is given post-operatively as a first option for uncontrolled pain at 0.1-0.2mg/kg orally
4 hourly PRN
Morphine/Fentanyl
 Intra-operative
□ IV morphine 0.1mg/kg
PROCEDURE
Preparation for surgery
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Usual Preparation for surgery as per Glenelg Community Hospital procedure
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Admission to Day Surgery
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Most important is inquiry on admission to any recent use of ant-platelet
agents such as aspirin and non-steroidal and anti-inflammatory drugs.
(NSAIDS).
Post operative care
Post operative management for ENT patients who have increased potential for airway
problems
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A nurse may be requested particularly where patients have a history
suggestive of obstructive sleep apnoea. These patients must have a nurse
present at all times as 1:1 nursing dependency with close monitoring of the
patients airway, vital signs and continuous oximetry.
Post operative management for ENT patients who do not have an increased risk for
airway problems.
The patients will be nursed as a ration 1:4 for early and late shifts and 1:5 ratio for night
shifts with the usual close monitoring of the patients airway and monitoring of vital signs as
well as oximetry as per Clinical Pathway for Adenotonsillectomy
Equipment
Collect equipment and allocate bed space according to clinical assessment and the need for
observation.
Airway
Monitor closely for early signs of airway obstruction/aspiration especially while patient is still
under the effects of sedation or sleeping.
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Trouble shooting:
 On arrival to the ward, position the patient on their side to maintain the airway. Do not
place a pillow under the head until fully awake and encourage patient to rest in bed
until next morning
Vital Signs
Vital signs are an important component of monitoring the patient’s progress and allows for
prompt detection of adverse effects. This constitutes the monitoring of temperature, pulse,
respirations and blood pressure (not in children under 12 years of age unless otherwise
indicated) as well as oximetry in postoperative patients. Assess and document patient’s
status and notify Medical Officer of signs of impaired consciousness.
Trouble shooting:
 A sudden increase in pulse rate does not necessarily mean the child is
haemorrhaging it may be they are going to vomit. However, a gradually increasing
heart rate is the earliest sign of occult haemorrhage.
 Pallor also needs to be assessed keeping in mind that some children will be pale
after the operation.
Hydration
Blood and secretions swallowed during the procedure frequently lead to some postoperative nausea and vomiting. Administer IV fluids for the first 24hours or until a
satisfactory oral intake resumes. Notify a medical Officer of the amount of vomiting is
concerning, or if further intravenous fluids are required to maintain adequate hydration.
Trouble shooting:
 Encourage thin, non-irritant drinks; frozen icy poles often work well.
 Soft food such as jellies, ice-cream, custard and mashed foods can be helpful but
there needs to be some solid food such as toast to encourage gentle removal of the
eschar
 Avoid foods which may irritate or sting the tonsil fossa such as citric juices, salt and
vinegar.
 Encourage small amounts frequently and offer their “favourite” foods.
 Older children who are finding it difficult to chew can be offered chewing gum to
assist in chewing.
 Good mouth care is required as there can be “bad breath” or “change in taste”
following the surgery which can decrease appetite. Encourage the child to brush their
teeth and use mouth wash as tolerated.
 An antiemetic may be administered to alleviate nausea which will assist with eating
.DO NOT GIVE AN ANTIEMETIC IF THE CHILD IS HAEMORRHAGING.
Pain relief
Inadequate pain relief is associated with children’s refusal to eat, which results in
dehydration, weight loss and local infection. Aspirin based drugs are not given as pain relief
as there is an increased risk of post tonsillectomy haemorrhage. Referred pain can be
encountered postoperatively due to inflammation, disruption to oral mucosa, nerve irritation
and spam of the exposed pharyngeal muscles.
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Trouble shooting:
 Administer regular analgesic especially before meals and at bedtime.
 Adolescents may need stronger pain relief
 If Opioids are used in children and adolescents with obstructive sleep apnoea, they
must be closely monitored with continuous oximetry
 Referred pain to the ear or neck is common but watch for signs of trismus or
torticollis.
Haemorrhage
Post operative haemorrhage is the most common serious complication after
Adenotonsillectomy surgery. Bleeding can be defined as reactionary haemorrhage or
secondary.
Complications from a post operative tonsil haemorrhage include;
 Severe respiratory insult requiring resuscitation (Code Blue)
 Hypovolemic shock requiring fluid resuscitation and/or blood product
 Respiratory distress that requires re-positioning to maximize airway support and
administration of oxygen to maintain saturation above 95%
Primary bleeding occurs intraoperatively. Reactionary bleeding occurs within the first 24
hours postoperatively. A significant primary haemorrhage is treated in the theatre with
cautery, ligation or packing in the tonsillar fossa. If any reactionary haemorrhage occurs on
the ward, collect the ENT box and notify the ENT Surgeon with the estimated blood loss and
vital signs, and call for assistance as necessary. A Nurse must remain in attendance at the
bedside at all times.
Secondary bleeding can occur after 24 hours up to 14 days with the most frequent time
being 6 days post-operatively.
If bleeding is not active
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Monitor and document pulse and respirations and blood pressure ½ hourly with
continuous oximetry or as determined by the ENT Surgeon
Measure/ estimate all blood vomits. Observe vomit for fresh blood and clots. Do not
empty vomit bowls until seen by the ENT surgeon. Document all on fluid balance
chart
Report immediately to ENT Surgeon any sign of bleeding.
If bleeding is active
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Follow procedure as above
Trouble shooting
Look for signs of haemorrhage which may include:
- excessive swallowing
- pallor and sweating
- increased pulse rate
- excessive blood loss from nose and mouth
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excessive fresh blood or clots in any vomits
blood seen in the back of the throat, or clots on the tonsil bed
Initial signs of post-adenoidectomy bleeding may be controlled using topical
nasal decongestants
Hydrogen peroxide mouthwash can be effective in settling secondary posttonsillectomy haemorrhage in paediatric patients. It also allows better visibility
due to its foaming action removing debris from the tonsillar fossa. if ordered,
dilute the peroxide with two parts cold water to make a slightly more palatable
mixture encourage older children and adolescents to gargle hydrogen
peroxide mouth wash 1% until frothing action occurs and then spit into the r
receiver. Do not swallow.
The ENT box contains items required to immediately control any post operative bleeding
e.g. adenoid, tonsils or epistaxis.
It is important to be familiar with the items and their use.
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Silver Nitrate Sticks-cauterising identified bleeding site
DIRECTIONS: The healthcare professional moistens the applicator tip with distilled water
and applies it to the affected area. The strength of the action is controlled by the dilution
with distilled water. One Grafco® Silver Nitrate applicator is generally sufficient for each
application.
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Cophenylcaine Spray and nozzles
□ Local anaesthetic with vasoconstrictor/nasal decongestant
Onset of action is rapid and may last for one hour. The Anaesthetic can impair
swallowing, so must be used with caution in patients who are bleeding from the
pharynx
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Nasal Drops junior (Otrivin)
□ Used in the nose, thus constricts the nasal blood vessels, thereby decongesting
the mucosa of the nose and neighbouring regions of the pharynx
□ For patients suffering from a stuffy nose to breathe more easily. The effect of
Otrivin begins within a few minutes and persists for four to eight hours and
sometimes as long as twelve hours. Can also be useful for bleeding from the
adenoid bed, and avoids the local anesthetic in Cophenylcaine.
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Hydrogen Peroxide 3% solution
□ May settle minor bleeds by promoting clotting in vessels, and allows better visibility
due to its foaming action which cleans the tonsillar fossa
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3 Tongue depressors
Discharge
Prior to discharge ensure the patient meets the following criteria:
 Stable vital signs
 Able to ambulate without dizziness
 Nil signs of haemorrhage
 Afebrile
 Tolerating oral intake
Discharge education and written information for home management prior to discharge needs
to include:
 Pain management as pain can last up to 10 days and inadequate pain relief is
associated with children’s refusal to eat, which results in dehydration, weight loss,
and local infection
 When to call a doctor or return to hospital if signs of bleeding which may be delayed
haemorrhage-the most common time being one week post surgery
 infection
 limitation of activity can induce bleeding through dislodgement of possible clots
 Follow up appointment
Trouble shooting:
 It is normal to see white Eschar on the fossa as seen in the illustration above. These
are temporary scabs which occur as part of the healing process. They are not a sign
of infection and will be replaced with normal mucosa within two weeks of surgery. No
attempt should be made to remove them.
 Often, at around 5-6 days, there is a period of increased pain, which may include
pain in the ears, particularly while swallowing. there is often an acceleration of
healing response at this time, with- formation of some granulation tissues
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GLENELG COMMUNITY HOSPITAL
Adenotonsillectomy
Worksheet
Name_____________________________________________RN/EN
Date___________________________
Department_____________________
All completed worksheets to be forwarded to the Staff Educator
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1. Describe how enlarged adenoids and tonsils can alter normal respiratory function.
2. Name 3 indications for an adenoidectomy and 3 for a tonsillectomy
3. What nursing measures would you use to prevent airway obstruction in the immediate
postoperative period?
4. You are looking after a three year old patient who has had an Adenotonsillectomy. Identify
all of the postoperative observations you are going to do to provide a safe recovery for that
child and provide a rationale for each.
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5. Your four year old patient is refusing to eat or drink. What actions can you take to
encourage this child to eat and drink?
6. What would be your actions and where would you access the ENT box in the event of a
primary haemorrhage on the ward following an Adenotonsillectomy?
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7. A five year old child post tonsillectomy is spitting bright blood and saliva, approximately
10-20mls hourly, for the past two hours. Explain what immediate actions you are going to
take and why.
8. Henry (15 year old tonsillectomy patient) has eaten half a piece of toast and one cup of
cordial. He is complaining it hurts to eat. his mother has come to pick him up. What
discharge education are you going to give?
Comments:
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REFERENCES
Brown K Morin I, et al Urgent Adenotonsillectomy-An analysis of Risk Factors Associated
with Postoperative Respiratory Morbidity, Anaesthesiology 2003; 99; 586-95
Cummings. Otolaryngology: head and Neck Surgery 4th edition 2005 Mosby Inc
Does Hydrogen Peroxide Mouthwash Improve the outcome of Secondary PostTonsillectomy Bleed? A 10 year Review, Otolaryngology-head and neck Surgery, Volume
133, Issue 2, August 2005, pages 202-205
Driscolo, C. Darrow D, Kolai PJ Infectious indications for tonsillectomy paediatric Clinics of
North America 50 (2003) 445-58
Modbury Hospital Adenotonsillectomy learning Package (S.A. health S.A. Government of
South Australia
Potter P, Perry A, (2003) Fundamentals of Nursing. The CV Mosby Company, Australia
Tabae A, Lin J, Dupiton V, Jones J. The Role of Oral Fluid Intake Following Adenotonsillectomy International Journal Pediatric O2006) 70, (2006)
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