tonsillectomy & adenoidectomy dr.s sohelipour dr.shr abtahi بيماريهاي لوزه،...
TRANSCRIPT
بيماريهاي لوزه، آدنوئيد و درمانهاي آن
Tonsillectomy Tonsillectomy & &
AdenoidectomyAdenoidectomy
Dr.S SohelipourDr.S SohelipourDr.SHR AbtahiDr.SHR Abtahi
Introduction
In 1994 140,000 U.S. children under the age of 15 had adenoidectomies and 286,000 had adenotonsillectomies
This is down from a peak of over 1 million in the 1970’s
These are the most common major surgical procedures in children.
AnatomyAnatomy
TonsilsTonsils Plica triangularis Gerlach’s tonsil
AdenoidsAdenoids Fossa of Rosenmüller Passavant’s ridge
Blood SupplyBlood SupplyTonsilsTonsils Ascending and
descending palatine arteries
Tonsillar artery 1% aberrant ICA just
deep to superior constrictor
AdenoidsAdenoids Ascending pharyngeal,
sphenopalatine arteries
HistologyHistology
TonsilsTonsils Specialized squamous Extrafollicular Mantle zone Germinal center
AdenoidsAdenoids Ciliated
pseudostratified columnar
Stratified squamous Transitional
Common Diseases of the Tonsils and Common Diseases of the Tonsils and AdenoidsAdenoids Acute adenoiditis/tonsillitis Recurrent/chronic
adenoiditis/tonsillitis Obstructive hyperplasia Malignancy
Acute AdenotonsillitisAcute Adenotonsillitis
Etiology 5-30% bacterial; of these
39% are beta-lactamase-producing (BLPO)
Anaerobic BLPO
GABHS most important pathogen because of potential sequelae
Throat culture
Microbiology of AdenotonsillitisMicrobiology of Adenotonsillitis
Most common organisms cultured from patients with chronic
tonsillar disease (recurrent/chronic infection, hyperplasia):
Streptococcus pyogenes (Group A beta-hemolytic
streptococcus)
H.influenza
S. aureus
Streptococcus pneumoniae
Acute AdenotonsillitisAcute Adenotonsillitis
Differential diagnosis
Infectious mononucleosis
Malignancy: lymphoma, leukemia, carcinoma
Diptheria
Scarlet fever
Agranulocytosis
Medical ManagementMedical Management
PCN is first line, even if throat culture is negative for GABHS
For acute UAO: NP airway, steroids, IV abx, and tonsillectomy for poor response
Recurrent tonsillitis: PCN injection if concerned about noncompliance or antibiotics aimed against BLPO and anaerobes
For chronic tonsillitis or obstruction, antibiotics directed against BLPO and anaerobes for 3-6 weeks will eliminate need for surgery in 17%
Obstructive HyperplasiaObstructive Hyperplasia
Adenotonsillar hypertrophy most common cause of SDB in children
Diagnosis Indications for polysomnography Interpretation of polysomnography Perioperative considerations
Unilateral Tonsillar EnlargementUnilateral Tonsillar Enlargement
Apparent enlargement vs true enlargement
Non-neoplastic: Acute infective Chronic infective Hypertrophy Congenital
Neoplastic
Peritonsillar AbscessPeritonsillar Abscess
ICA ICA AneurysmAneurysm
Pleomorphic Pleomorphic AdenomaAdenoma
Other Tonsillar PathologyOther Tonsillar Pathology
Hyperkeratosis, mycosis leptothrica
Tonsilloliths
CandidiasisCandidiasis
SyphilisSyphilis
Retention CystsRetention Cysts
Supratonsillar CleftSupratonsillar Cleft
Indications for TonsillectomyIndications for Tonsillectomy
AAO-HNS: 4 or more episodes/year Hypertrophy causing malocclusion, UAO PTA unresponsive to nonsurgical mgmt Halitosis, not responsive to medical therapy UTE, suspicious for malignancy Individual considerations
Indications for AdenoidectomyIndications for Adenoidectomy
Obstruction: Chronic nasal obstruction or obligate mouth breathing OSA with FTT, cor pulmonale Dysphagia Speech problems Severe orofacial/dental abnormalities
Infection: Recurrent/chronic adenoiditis (4 or more episodes/year) Recurrent/chronic OME
PreOp Evaluation ofPreOp Evaluation of Adenoid DiseaseAdenoid Disease
Triad of hyponasality, snoring, and mouth breathing
Rhinorrhea, nocturnal cough, post nasal drip
“Adenoid facies” “Milkman” & “Micky
Mouse” Overbite, long face,
crowded incisors
PreOp Evaluation of Adenoid DiseasePreOp Evaluation of Adenoid Disease
Differential diagnoses Allergic rhinitis Sinusitis GERD For concomitant sinus disease, treat adenoids
first
PreOp Evaluation of Adenoid DiseasePreOp Evaluation of Adenoid Disease
Evaluate palate Symptoms/FH of CP
or VPI Midline diastases of
muscles, bifid uvula CNS or
neuromuscular disease
Preexisting speech disorder?
PreOp Evaluation of Adenoid PreOp Evaluation of Adenoid DiseaseDiseaseLateral neck films are
useful only when history and physical exam are not in agreement.
Accuracy of lateral neck films is dependent on proper positioning and patient cooperation.
PreOp Evaluation of Adenoid PreOp Evaluation of Adenoid DiseaseDisease
PreOp Evaluation of Tonsillar DiseasePreOp Evaluation of Tonsillar Disease
History Documentation of episodes by physician FTT Cor pulmonale Poststreptococcal GN Rheumatic fever
PreOp Evaluation of Tonsillar DiseasePreOp Evaluation of Tonsillar Disease
TONSIL SIZE 0 in fossa +1 <25%
occupation of oropharynx
+2 25-50% +3 50-75% +4 >75%
Avoid gagging the patient
ComplicationsComplications
0.1-8.1% Postoperative bleeding
Other: Sore throat, otalgia, uvular swelling Respiratory compromise Dehydration Burns and iatrogenic trauma
Rare ComplicationsRare Complications
Velopharyngeal Insufficiency Nasopharyngeal stenosis Atlantoaxial subluxation/ Grisel’s syndrome Regrowth Eustachian tube injury Depression Laceration of ICA/ pseudoaneursym of ICA
Questions?
DEFINITIONDEFINITION Adenoid =pharyngeal tonsil = Nasopharyngeal Mass of sub – epithelial lympoid tissue situated
posterior to the nasal cavity in the roof of the nasopharynx
In children it forms a soft mound in the roof and posterior wall of the nasopharynx, above and behind the uvula.
Age – enlargement from less than a year old to 12 years.
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HISTOLOGY OF ADENOIDHISTOLOGY OF ADENOIDUnlike other types of tonsils.Has pseudostratified columnar
ciliated epithelium.Lack crypts (opening or outlet) but
has a capsuleIt drains to the jugulodigastric
lymph nodes below the angle of the mandible.
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IMPORTANCE OF ADENOID AND IMPORTANCE OF ADENOID AND TONSILLAR TISSUE.TONSILLAR TISSUE.
Part of lymphoid tissue of Waldeyer’s ring
Its size increases progressively until puberty, then diminishes until about the age of 20 years and from this time onwards, maintains its adult size.
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Protective FunctionsFormation of lymphocytesFormation of antibodiesAcquisition of immunityLocalization of infection – “filters” to
the upper respiratory passages.
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PATHOLOGYPATHOLOGY An enlarged adenoid or adenoid
hypertrophy, can become nearly the size of a ping pong ball. Completely block airflow through the nasal
passages or block the back of the nose.1. Breathing through the nose requiring an
uncomfortable amount of work.
2. Inhalation occurs instead through an open mouth.
3. Affects voice mechanism (speech hyponasality)
4. Recurrent upper respiratory tract infection.
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CLINICAL FEATURES OF ADENOID FACES IN CHILDREN. It causes an atypical appearance of the face
(adenoid face)Features of adenoid faces includeMouth breathingElongated faceProminent incisorsHypoplastic maxillaShort upper lipElevated nostrilHigh Arched palate
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Symptoms
- Bilateral Nasal Obstruction
- Mouth Breathing- Snoring & OSA- Speech hyponasality- Difficult suckling
Bilateral Nasal discharge- Mucoid or mucopurulent
discharge WHY? Due to blockage of the choanae
- Excoriation of the nasal vestibule & upper lip
- Post nasal discharge causing frequent nocturnal cough
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Rhinolalia clausa(speech hyponasality)
Signs
Posterior Rhinoscopy difficult Digital palpation not pleasant Endoscopic examination the best
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InvestigationsInvestigations
Lateral soft tisue X ray of the nasopharynx
It is not the size of the
nasopharyngeal tonsil which is
important but the size of the
mass in relation to the
nasopharyngeal space
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ComplicationsComplications1- OSAS:- During Sleep:- During day time
2- Descending infection
3- ِ Adenoid Facies
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Morning headacheImpaired concentrationExcessive day-time sleepinessRecurrent OMPharyngitis, Laryngitis,
bronchitis
Restless sleep, Night mare, Nocturnal
eneuresis
Idiot lookPinched nostrilShort upper lipProminent incisorHigh arched
palate
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RemovalRemoval
Adenoidectomy – procedure of surgical removal of the adenoidStudies have shown that adenoid regrowth
occurs in as many as 20% of the cases after removal. Why?
Adenoid tissue is not encompassed by a capsule like the tonsils. Complete removal of all adenoid tissue is nearly impossible and thus recurrent hypertrophy or infection is possible.
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Indications for AdenoidectomyIndications for Adenoidectomy
Paradise study (1984) 28-35% fewer acute episodes of OM with adenoidectomy
in kids with previous tube placement Adenoidectomy or T & A not indicated in children with
recurrent OM who had not undergone previous tube placement
Gates et al (1994) Recommend adenoidectomy with M & T as the initial
surgical treatment for children with MEE > 90 days and CHL > 20 dB
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Indications for AdenoidectomyIndications for AdenoidectomyObstruction: Chronic nasal obstruction or obligate mouth breathing OSA with FTT, cor pulmonale Dysphagia Speech problems Severe orofacial/dental abnormalities
Infection: Recurrent/chronic adenoiditis (3 or more episodes/year) Recurrent/chronic OME (+/- previous BMT)
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PreOp Evaluation ofPreOp Evaluation of Adenoid DiseaseAdenoid Disease
Triad of hyponasality, snoring, and mouth breathing
Rhinorrhea, nocturnal cough, post nasal drip
“Adenoid facies” “Milkman” & “Micky
Mouse” Overbite, long face,
crowded incisors
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PreOp Evaluation of Adenoid DiseasePreOp Evaluation of Adenoid Disease
Differential diagnosesDifferential diagnoses• Allergic rhinitis• Sinusitis• GERD• For concomitant sinus disease, treat adenoids
first
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PreOp Evaluation of Adenoid DiseasePreOp Evaluation of Adenoid Disease
Evaluate palateEvaluate palate• Symptoms/FH of CP or
VPI• Midline diastasis of
muscles, bifid uvula• CNS or neuromuscular
disease
• Preexisting speech disorder?
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PreOp Evaluation of Adenoid DiseasePreOp Evaluation of Adenoid Disease
Lateral neck films are useful only when history and physical exam are not in agreement.
Accuracy of lateral neck films is dependent on proper
positioning and patient cooperation.
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PreOp Evaluation of Adenoid DiseasePreOp Evaluation of Adenoid Disease
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Treatment Treatment
Adenoidectomy operation
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Adenoidectomy with great careAdenoidectomy with great care
Adenoidectomy for speech problemsLook for short palate, submucous cleft of the short or hard palate to avoid velopharyngeal insufficiency after the procedure as the voice may become hypernasal.
Should be avoided in patients with cleft palate.
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Acute tonillitisAcue inflammation of the palatine tonsils
Age: Any age but common in
children
Etiology :- Beta hemolyic streptococci
- Streptococcus pneumonia
- Hemophylus influenza
Mode of transmissiondroplet infection
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EmbryologyEmbryology
• 8 weeks: Tonsillar fossa and palatine tonsils develop from the dorsal wing of the 1st pharyngeal pouch and the ventral wing of the 2nd pouch; tonsillar pillars originate from 2nd/3rd arches
• Crypts 3-6 months; capsule 5th month; germinal centers after birth
• 16 weeks: Adenoids develop as a subepithelial infiltration of lymphocytes
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AnatomyAnatomy
TonsilsTonsils• Plica triangularis• Gerlach’s tonsil
AdenoidsAdenoids• Fossa of
Rosenmüller• Passavant’s ridge
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Blood SupplyBlood Supply
TonsilsTonsils• Ascending and
descending palatine arteries
• Tonsillar artery• 1% aberrant ICA just
deep to superior constrictor
AdenoidsAdenoids• Ascending pharyngeal,
sphenopalatine arteries
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HistologyHistology
TonsilsTonsils• Specialized squamous• Extrafollicular• Mantle zone• Germinal center
AdenoidsAdenoids• Ciliated pseudostratified
columnar• Stratified squamous• Transitional
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SymptomsRapid onset of - Fever, Headache, Anorrhexia, Malaise- Severe sore throat ± referred otagia- Halitosis
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SignsGeneral :High Fever with flushed face
PharyngealAcute follicular tonsillitisAcute membranous tonsillitisAcute parynchymatous tonsillitis
CervicalEnlarged tender jugulo-digastric
lymph nodes
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The crypts of the tonsils are full of purulent exudateGiving yellow spots on the tonsils
The yellow spots may Coalease to form a Yellow membrane
Marked hyperemia and enlargement of the tonsils
Acute follicular T. Acute membranous T Acute parynchymatous T
ComplicationsLocal:- Peritonsillar abscess
- Parapharyngeal abscess
- Retropharyngeal abscess
Systemic- Rheumatic fever
(carditis and arthritis)
- Acute glomerulonephritis
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Quinzy
PreOp Evaluation of Tonsillar DiseasePreOp Evaluation of Tonsillar Disease
History Documentation of episodes by physician FTT Cor pulmonale Poststreptococcal GN Rheumatic fever
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PreOp PreOp EvaluationEvaluation of Tonsillar Disease of Tonsillar Disease
TONSIL SIZE 0 in fossa +1 <25% occupation
of oropharynx +2 25-50% +3 50-75% +4 >75%
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Avoid gagging the patient
PreOp Evaluation of Tonsillar DiseasePreOp Evaluation of Tonsillar Disease
Down syndrome 10% have AA laxity Obtain lateral cervical films (flexion/extension)
when positive findings on history, PE If unstable, need neurosurgical evaluation
preoperatively Large tongue and small mandible… difficult
intubation Prone to cardiac arrhythmias/hypotension during
induction
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Treatment
Antibiotics: 10 days
Rest
Ample fluid intake
Cold compresses
Analgesic Antipyretics
Gargles
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Chronic TonsillitisChronic TonsillitisChronic inflammation of the palatine tonsilsChronic inflammation of the palatine tonsils
Etiology :
Repeated attacks of acute tonsillitis
Symptoms: one or more of the following- History of repeated attacks of AT- Irritation in the throat- Foetor oris
If hypertrophic- Difficult swallowing- Obsrtuctive sleep apnea
Signs:Pharyngeal - Asymmetry of the size of the
tonsils- Hypertrophy of the tonsils- The crypts ooze pus on
pressure by tongue depressor- Hyperaemia of the anterior
pillars
Cervical Persistent enlargement of
jagulodigastric lymph nodes
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Acute AdenotonsillitisAcute AdenotonsillitisEtiology 5-30% bacterial; of
these 39% are beta-lactamase-producing (BLPO)
Anaerobic BLPO
GABHS most important pathogen because of potential sequelae
Throat culture Treatment
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Microbiology of AdenotonsillitisMicrobiology of Adenotonsillitis
Most common organisms cultured from patients with chronic tonsillar disease (recurrent/chronic infection, hyperplasia): Streptococcus pyogenes (Group A beta-hemolytic
streptococcus) H.influenza S. aureus Streptococcus pneumoniae
Tonsil weight is directly proportional to bacterial load.
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Acute AdenotonsillitisAcute Adenotonsillitis
Differential diagnosisInfectious mononucleosisMalignancy: lymphoma, leukemia, carcinomaDiptheriaScarlet feverAgranulocytosis
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Medical ManagementMedical Management
PCN is first line, even if throat culture is negative for GABHS
For acute UAO: NP airway, steroids, IV abx, and immediate tonsillectomy for poor response
Recurrent tonsillitis: PCN injection if concerned about noncompliance or antibiotics aimed against BLPO and anaerobes
For chronic tonsillitis or obstruction, antibiotics directed against BLPO and anaerobes for 3-6 weeks will eliminate need for surgery in 17%
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PreOp Evaluation for Adenotonsillar DiseasePreOp Evaluation for Adenotonsillar Disease
Coagulation disordersCoagulation disorders• Historical screening• CBC, PT/PTT, BT, vWF activity• Hematology consult• von Willebrand’s disease• ITP• Sickle cell anemia
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Principles of Surgical ManagementPrinciples of Surgical Management
Numerous techniques: Guillotine Tonsillotome Beck’s snare Dissection with snare (Scissor dissection, Fisher’s
knife dissection, Finger dissection Electrodissection Laser dissection (CO2, KTP)
… Surgeon’s preference
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Post Operative ManagmentPost Operative Managment
Criteria for Overnight Observation Poor oral intake, vomiting, hemorrhage Age < 3 Home > 45 minutes away Poor socioeconomic condition Comorbid medical problems Surgery for OSA or PTA Abnormal coagulation values (+/- identified
disorder) in patient or family member
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ComplicationsComplications#1 Postoperative bleeding
Other: Sore throat, otalgia, uvular swelling Respiratory compromise Dehydration Burns and iatrogenic trauma
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Rare ComplicationsRare Complications Velopharyngeal Insufficiency Nasopharyngeal stenosis Atlantoaxial subluxation/ Grisel’s syndrome Regrowth Eustachian tube injury Depression Laceration of ICA/ pseudoaneursym of ICA
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Management of HemorrhageManagement of Hemorrhage
Ice water gargle, afrin Overnight observation and IV fluids Dangerous induction ECA ligation Arteriography
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Obstructive HyperplasiaObstructive Hyperplasia
Adenotonsillar hypertrophy most common cause of SDB in children
Diagnosis Indications for polysomnography Interpretation of polysomnography Perioperative considerations
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Unilateral Tonsillar EnlargementUnilateral Tonsillar EnlargementApparent enlargement vs true enlargement
Non-neoplastic: Acute infective Chronic infective Hypertrophy Congenital
Neoplastic
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Peritonsillar Abscess
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Pleomorphic AdenomaPleomorphic Adenoma86
Other Tonsillar PathologyOther Tonsillar Pathology
Hyperkeratosis, mycosis leptothrica
Tonsilloliths
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Candidiasis88
SyphilisSyphilis89
Retention Retention CystsCysts 90
Supratonsillar Supratonsillar CleftCleft 91
Indications for Tonsillectomy; Historical Indications for Tonsillectomy; Historical EvolutionEvolution
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Indications for TonsillectomyIndications for Tonsillectomy
Paradise study Frequency criteria: 7 episodes in 1 year
or 5 episodes/year for 2 years or 3 episodes/year for 3 years
Clinical features (one or more): T 38.3, cervical LAD (>2cm) or tender LAD; tonsillar/pharyngeal exudate; positive culture for GABHS; antibiotic treatment
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Indications for TonsillectomyIndications for Tonsillectomy
AAO-HNS: 3 or more episodes/year Hypertrophy causing malocclusion, UAO PTA unresponsive to nonsurgical mgmt Halitosis, not responsive to medical therapy UTE, suspicious for malignancy Individual considerations
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Case studyCase study 13 year old female referred by PCP
for frequent throat infections “She’s always sick. She’s been on
four different antibiotics this year.” You call her pediatrician… he is out
of town and his nurse can’t find the chart
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Case studyCase study No known medical problems, no prior
surgical procedures Takes motrin for menustrual cramps No personal history of bleeding other than
occasional nose bleeds and extremely heavy periods.
Family history unknown. Patient is adopted.
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Case studyCase study Physical exam is unremarkable. Mom breaks down in tears when you tell her you
do not have enough documentation of illness to warrant T & A. “I had to go on welfare because I’ve missed so much work from her being out sick.”
You hesitate. She adds, “Her grades have dropped from all A’s to all F’s. If she misses any more school, she’ll be held back.”
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Case studyCase study You confirm with her pediatrician that she has
had 4 episodes of tonsillitis this year and agree to T & A.
Because of her history of epistaxis and menorrhagia, you order a PT, PTT, CBC, BT.
She has a mild microcytic anemia and prolonged bleeding time.
You order vWF activity level and consult hematology
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Case studyCase study
She has a subnormal level of vWF, which responds to a DDAVP challenge (rise in vWF and Factor VII greater than 100%).
You advise her to stop taking motrin. Before surgery, she receives
desmopressin 0.3 microg/kg IV over 30 min and amicar 200mg/kg.
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Case studyCase study She receives the same dose of DDVAP 12
hours postoperatively and every morning. Amicar is given 100mg/kg PO q 6 hr. Before each dose of DDAVP, serum
sodium is drawn. Sodium levels drop to 130.
Desmopressin is discontinued and substituted with cryoprecipitate.
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Case studyCase study
Patient presents to the ER on POD # 7 complaining of intermittent bleeding from her mouth.
You order cryoprecipitate, draw a Factor VII level and CBC, and call her hematologist.
Hemoglobin has dropped from 11.9 to 9.6.
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Case studyCase study PE reveals no active bleeding; an old clot
is present You establish IV access, admit the patient
for overnight observation, have her gargle with ice water, and administer crypoprecipitate
No further bleeding occurs, patient is discharged the next day
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