Download Tonsillitis, Tonsillectomy and Adenoidectomy

Tonsillitis, Tonsillectomy and
Adenoidectomy
Steven T. Wright, M.D.
Faculty Advisor: Ronald Deskin, M.D.
The University of Texas Medical Branch
Department of Otolaryngology
Grand Rounds Presentation
November 5, 2003
Adenotonsillectomy
Most commonly performed procedure in the
history of surgery
 $500 million annually in healthcare
expenditures

History
Almost exclusively by Otolaryngologists
 Celsus in 50 A.D.
 Caque of Rheims
 Phillip Syng developed the tonsillotome

Anatomy
Anatomy
Histology
Clinical Evaluation
Acute Tonsillitis
 Chronic Tonsillitis
 Obstructive Tonsillar Hyperplasia

Clinical Evaluation


Odynophagia, fever,
tender cervical
lymphadenopathy.
Supporting
documents, 2 or more
 Fever> 38.5
 Tonsillar Exudate
 Tender cervical
LAD >2cm
 Positive throat
culture
Clinical evaluation
Viral
 Lower grade fever
 Lower WBC, Lymphocytic shift
 Less tonsillar exudate
 Bacterial
 Higher WBC, Granulocytic shift
 More exudative

Recurrent Acute Tonsillitis
Seven episodes in a single year
 Five or more episodes in 2 years
 Three or more episodes in 3 years

Chronic Tonsillitis
No true consensus on the definition.
 Symptoms greater than 4 weeks

Differential Diagnosis
Infectious Mononucleosis
 EBV
 Scarlet Fever
 Corynebacterium diptheriae
 Malignancy

Complications of Tonsillitis
Cervical Adenitis
 Neck Abscess
 Peritonsillar abscess
 Intratonsillar abscess
 Lemierre’s syndrome

Post Streptococcal
Glomerulonephritis
Joint Pain and oliguric renal failure 10 days
after the pharyngitis.
 Treatment aimed at eliminating the
infection and supportive therapy for renal
failure.
 Excellent prognosis in children.

Adenoid Hyperplasia
Triad
 Hyponasality
 Snoring
 Open mouth breathing
 Purulent rhinorrhea, post nasal drip, chronic
cough, and headache

Obstructive Airway Symptoms
Snoring
 Apneic episodes with gasping or choking
 Daytime hypersomnolence
 Nocturnal enuresis
 Behavioral disturbances
 Heart failure and Failure to thrive

Tonsil Size

Grade
1
2
3
4
%
<25
25-50
51-75
>75
Obstructive Sleep Apnea
Polysomnography is the gold standard of
diagnosis.
 Imperative in Adults
 In children, a convincing history is
adequate
 OSA: RDI > 5, SpO2<90%
 UARS: RDI <5, SpO2 >90%
 Primary Snoring: RDI <1, SpO2>90%

Medical Therapy
TCHP recommends confirming bacterial
pharyngitis before beginning antibiotics.
 Rapid Strep Test
 Throat Culture

Medical Therapy



First Line
 Penicillin/Cephalosporin for 10 days
 Injectable forms for noncompliance
BLPO, co pathogens
Macrolides
 Penicillin allergy
 Erythromycin/Clarithromycin 10 days
 Azithromycin (12mg/kg/day) 5 days
Medical Therapy
Patients with recurrent otitis media history
have higher bacterial concentrations with
BLPO.
 Initial treatment with anti-BLP antibiotic.
 Adenotonsillar size may respond to a one
month course of antibiotic therapy.
 Adenoid hyperplasia may respond to a 6-8
week course of intranasal steroid.

Surgical Indications

Adenoidectomy
 Absolute
 Airway obstruction w/ cor pulmonale
 Failure to thrive
 Relative
 Chronic Nasal Obstruction
 Recurrent/ Chronic Adenoiditis
 Recurrent/ Chronic Sinusitis
 Recurrent acute otitis media/ Recurrent
COME
Surgical Indications


Absolute
 Obstructive airway with cor pulmonale
 Severe dysphagia
 Failure to thrive
Relative
 Recurrent acute tonsillitis
 Chronic tonsillitis
 Obstructive Sleep Apnea
 Peritonsillar Abscess
 Halitosis
 Suspected Neoplasia/ Tonsillar hyperplasia
Preoperative evaluation
Most common lab test is a CBC
 Coagulation studies when the history or
physical examination suggests a bleeding
disorder.
 Lateral Neck/Adenoid films

Von Willebrand’s Disease
Autosomal dominant bleeding disorder
 Increased bleeding time and prolonged
aPTT.
 Perioperative management
 IV Desmopressin (0.3ugm/kg)
 Serum Sodium

Idiopathic Thrombocytopenic
Purpura
Most common thrombocytopenia of
childhood.
 90% resolution by 9-12 months
 Splenectomy
 IVIG preoperatively

Innovative Surgical Techniques
Cold Dissection
 Electrosurgery
 Intracapsular partial tonsillectomy
 Harmonic Scalpel
 Radiofrequency tonsillar ablation and
coblation.

Electrosurgery
Most popular technique for tonsillectomy
 Equivalent or superior to the other methods
of tonsillectomy.

Intracapsular Partial
Tonsillectomy



45 degree Microdebrider (1500rpm).
Advantages
 As effective as standard tonsillectomy in
relieving obstruction.
 Less pain, quicker return to normal diet
Disadvantages:
 Tonsillar regrowth
 Greater intraoperative blood loss
Harmonic Scalpel


Advantages:
 Better visibility
 Smaller risk of stray energy shocks
 Improved post operative pain
Disadvantages:
 Must use alternate device for adenoidectomy
 Similar intraoperative blood loss.
Radiofrequency tonsillar
coblation
Coblation is superior to ablation.
 Early elimination of pain and reduced pain
medicine usage.
 Early resumption of normal diet.
 Currently inadequate for adenoidectomy

Adjuvant Therapies
Perioperative local anesthetic
0.25% bupivicaine w/ 1:100,000
Epinephrine
Advantages:
ease of dissection, postoperative pain
Disadvantages:
Airway obstruction, cardiac dysrrhythmias,
seizures
Adjuvant Therapies

Perioperative antibiotics
 Fewer episodes of fever, offensive odor,
improved oral intake, less pain, fewer
days to return to normal activity
 Cardiac abnormality
Adjuvant Therapies

Perioperative Steroids
 Dexamethasone (0.15-1.0mg/kg)
 Two times less likely to have an episode
of postoperative emesis, and more likely
to advance to eating a soft diet.
 Reducing postoperative pulmonary
distress, subglottic edema, pain reduction.
Adjuvant Therapies

Pain control
 Tylenol and Tylenol w/ codeine are the
most commonly used.
 Similar pain control, less oral intake with
codeine versus Tylenol alone.
 NSAIDS still controversial.
Complications
Mortality rate is 1 in 16000-35000.
 Anesthetic complications
 Eustachian tube injury
 VPI
 Nasopharyngeal stenosis
 Pulmonary Edema
 Atlantoaxial subluxation

23 hour observation
Age younger than 3.
 Obstructive sleep apnea/craniofacial
syndromes involving the airway.
 Systemic disorders
 Poor socioeconomic situation
 Peritonsillar abscess
 Emesis or Hemorrhage

Post Operative Hemorrhage
The best treatment is prevention.
 Early vs. Delayed hemorrhage.
 Overnight observation and venous access
 Surgical intervention.
 Carotid angiography if any suspicion of
carotid artery injury.

Case Study

8yo male referred to the Pediatric clinic for
evaluation and treatment of recurrent
tonsillitis.
History
Only 2 episodes of documented pharyngitis
in the past 12 months, strep negative, only
missed 5 days of school total last year.
 Loud snoring, frequent pauses up to 5
seconds terminated with gasps of breath.

Physical Examination
Normal facies, open mouth breathing,
tonsils 3+, no cleft deformities.
 Remainder of exam is normal.

Case Study
Undergoes uneventful tonsillectomy and
adenoidectomy with 23 hour observation.
 On follow up visit 2 weeks postoperatively,
his mom complains that he doesn’t like
some of his favorite foods. He says they
taste “yucky”.
 Decreased perception of taste with no smell
abnormalities.

Diagnosis
Dysgeusia
 Unknown mechanism- thought to be due to
prolonged pressure on the tongue by the
mouth retractor.
 Treatment is reassurance.
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Bibliography
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