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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