2. Adenotonsillectomy
Most commonly performed procedure in theMost commonly performed procedure in the
history of surgeryhistory of surgery
$500 million annually in healthcare$500 million annually in healthcare
expendituresexpenditures
3. 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
10. 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
11. Chronic Tonsillitis
No true consensus on the definition.No true consensus on the definition.
Symptoms greater than 4 weeksSymptoms greater than 4 weeks
14. Post Streptococcal
Glomerulonephritis
Joint Pain and oliguric renal failure 10 daysJoint Pain and oliguric renal failure 10 days
after the pharyngitis.after the pharyngitis.
Treatment aimed at eliminating theTreatment aimed at eliminating the
infection and supportive therapy for renalinfection and supportive therapy for renal
failure.failure.
Excellent prognosis in children.Excellent prognosis in children.
15. Adenoid Hyperplasia
TriadTriad
HyponasalityHyponasality
SnoringSnoring
Open mouth breathingOpen mouth breathing
Purulent rhinorrhea, post nasal drip, chronicPurulent rhinorrhea, post nasal drip, chronic
cough, and headachecough, and headache
16. 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
18. Obstructive Sleep Apnea
Polysomnography is the gold standard ofPolysomnography is the gold standard of
diagnosis.diagnosis.
Imperative in AdultsImperative in Adults
In children, a convincing history isIn 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%
19. Medical Therapy
TCHP recommends confirming bacterialTCHP recommends confirming bacterial
pharyngitis before beginning antibiotics.pharyngitis before beginning antibiotics.
Rapid Strep TestRapid Strep Test
Throat CultureThroat Culture
20. 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
21. Medical Therapy
Patients with recurrent otitis media historyPatients with recurrent otitis media history
have higher bacterial concentrations withhave higher bacterial concentrations with
BLPO.BLPO.
Initial treatment with anti-BLP antibiotic.Initial treatment with anti-BLP antibiotic.
Adenotonsillar size may respond to a oneAdenotonsillar size may respond to a one
month course of antibiotic therapy.month course of antibiotic therapy.
Adenoid hyperplasia may respond to a 6-8Adenoid hyperplasia may respond to a 6-8
week course of intranasal steroid.week course of intranasal steroid.
24. Preoperative evaluation
Most common lab test is a CBCMost common lab test is a CBC
Coagulation studies when the history orCoagulation studies when the history or
physical examination suggests a bleedingphysical examination suggests a bleeding
disorder.disorder.
Lateral Neck/Adenoid filmsLateral Neck/Adenoid films
25. Von Willebrand’s Disease
Autosomal dominant bleeding disorderAutosomal dominant bleeding disorder
Increased bleeding time and prolongedIncreased bleeding time and prolonged
aPTT.aPTT.
Perioperative managementPerioperative management
IV Desmopressin (0.3ugm/kg)IV Desmopressin (0.3ugm/kg)
Serum SodiumSerum Sodium
26. Idiopathic Thrombocytopenic
Purpura
Most common thrombocytopenia ofMost common thrombocytopenia of
childhood.childhood.
90% resolution by 9-12 months90% resolution by 9-12 months
SplenectomySplenectomy
IVIG preoperativelyIVIG preoperatively
28. Electrosurgery
Most popular technique for tonsillectomyMost popular technique for tonsillectomy
Equivalent or superior to the other methodsEquivalent or superior to the other methods
of tonsillectomy.of tonsillectomy.
29. Intracapsular Partial
Tonsillectomy
45 degree Microdebrider (1500rpm).45 degree Microdebrider (1500rpm).
AdvantagesAdvantages
As effective as standard tonsillectomy inAs 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 lossGreater intraoperative blood loss
30. 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.
31. Radiofrequency tonsillar
coblation
Coblation is superior to ablation.Coblation is superior to ablation.
Early elimination of pain and reduced painEarly 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
32. Adjuvant Therapies
Perioperative local anestheticPerioperative local anesthetic
0.25% bupivicaine w/ 1:100,0000.25% 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
33. Adjuvant Therapies
Perioperative antibioticsPerioperative antibiotics
Fewer episodes of fever, offensive odor,Fewer episodes of fever, offensive odor,
improved oral intake, less pain, fewerimproved oral intake, less pain, fewer
days to return to normal activitydays to return to normal activity
Cardiac abnormalityCardiac abnormality
34. Adjuvant Therapies
Perioperative SteroidsPerioperative Steroids
Dexamethasone (0.15-1.0mg/kg)Dexamethasone (0.15-1.0mg/kg)
Two times less likely to have an episodeTwo times less likely to have an episode
of postoperative emesis, and more likelyof postoperative emesis, and more likely
to advance to eating a soft diet.to advance to eating a soft diet.
Reducing postoperative pulmonaryReducing postoperative pulmonary
distress, subglottic edema, paindistress, subglottic edema, pain
reduction.reduction.
35. Adjuvant Therapies
Pain controlPain control
Tylenol and Tylenol w/ codeine are theTylenol and Tylenol w/ codeine are the
most commonly used.most commonly used.
Similar pain control, less oral intake withSimilar pain control, less oral intake with
codeine versus Tylenol alone.codeine versus Tylenol alone.
NSAIDS still controversial.NSAIDS still controversial.
36. 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
37. 23 hour observation
Age younger than 3.Age younger than 3.
Obstructive sleep apnea/craniofacialObstructive 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
38. 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 ofCarotid angiography if any suspicion of
carotid artery injury.carotid artery injury.
39. Case Study
8yo male referred to the Pediatric clinic for8yo male referred to the Pediatric clinic for
evaluation and treatment of recurrentevaluation and treatment of recurrent
tonsillitis.tonsillitis.
40. History
Only 2 episodes of documented pharyngitisOnly 2 episodes of documented pharyngitis
in the past 12 months, strep negative, onlyin 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 5Loud snoring, frequent pauses up to 5
seconds terminated with gasps of breath.seconds terminated with gasps of breath.
41. 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.
42. Case Study
Undergoes uneventful tonsillectomy andUndergoes 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 likehis mom complains that he doesn’t like
some of his favorite foods. He says theysome of his favorite foods. He says they
taste “yucky”.taste “yucky”.
Decreased perception of taste with no smellDecreased perception of taste with no smell
abnormalities.abnormalities.
43. Diagnosis
DysgeusiaDysgeusia
Unknown mechanism- thought to be due toUnknown mechanism- thought to be due to
prolonged pressure on the tongue by theprolonged pressure on the tongue by the
mouth retractor.mouth retractor.
Treatment is reassurance.Treatment is reassurance.
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