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Tons slides-2003-1105

  1. 1. Tonsillitis, Tonsillectomy andAdenoidectomySteven T. Wright, M.D.Steven T. Wright, M.D.Ronald Deskin, M.D.Ronald Deskin, M.D.November 5, 2003November 5, 2003
  2. 2. Adenotonsillectomy Most commonly performed procedure in theMost commonly performed procedure in thehistory of surgeryhistory of surgery $500 million annually in healthcare$500 million annually in healthcareexpendituresexpenditures
  3. 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
  4. 4. Anatomy
  5. 5. Anatomy
  6. 6. Histology
  7. 7. Clinical Evaluation Acute TonsillitisAcute Tonsillitis Chronic TonsillitisChronic Tonsillitis Obstructive Tonsillar HyperplasiaObstructive Tonsillar Hyperplasia
  8. 8. Clinical Evaluation Odynophagia, fever,Odynophagia, fever,tender cervicaltender cervicallymphadenopathy.lymphadenopathy. SupportingSupportingdocuments, 2 or moredocuments, 2 or more Fever> 38.5Fever> 38.5 Tonsillar ExudateTonsillar Exudate Tender cervicalTender cervicalLAD >2cmLAD >2cm Positive throatPositive throatcultureculture
  9. 9. Clinical evaluation ViralViral Lower grade feverLower grade fever Lower WBC, Lymphocytic shiftLower WBC, Lymphocytic shift Less tonsillar exudateLess tonsillar exudate BacterialBacterial Higher WBC, Granulocytic shiftHigher WBC, Granulocytic shift More exudativeMore exudative
  10. 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. 11. Chronic Tonsillitis No true consensus on the definition.No true consensus on the definition. Symptoms greater than 4 weeksSymptoms greater than 4 weeks
  12. 12. Differential Diagnosis Infectious MononucleosisInfectious Mononucleosis EBVEBV Scarlet FeverScarlet Fever Corynebacterium diptheriaeCorynebacterium diptheriae MalignancyMalignancy
  13. 13. Complications of Tonsillitis Cervical AdenitisCervical Adenitis Neck AbscessNeck Abscess Peritonsillar abscessPeritonsillar abscess Intratonsillar abscessIntratonsillar abscess Lemierre’s syndromeLemierre’s syndrome
  14. 14. Post StreptococcalGlomerulonephritis Joint Pain and oliguric renal failure 10 daysJoint Pain and oliguric renal failure 10 daysafter the pharyngitis.after the pharyngitis. Treatment aimed at eliminating theTreatment aimed at eliminating theinfection and supportive therapy for renalinfection and supportive therapy for renalfailure.failure. Excellent prognosis in children.Excellent prognosis in children.
  15. 15. Adenoid Hyperplasia TriadTriad HyponasalityHyponasality SnoringSnoring Open mouth breathingOpen mouth breathing Purulent rhinorrhea, post nasal drip, chronicPurulent rhinorrhea, post nasal drip, chroniccough, and headachecough, and headache
  16. 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
  17. 17. Tonsil Size GradeGrade %% 11 <25<25 22 25-5025-50 33 51-7551-75 44 >75>75
  18. 18. Obstructive Sleep Apnea Polysomnography is the gold standard ofPolysomnography is the gold standard ofdiagnosis.diagnosis. Imperative in AdultsImperative in Adults In children, a convincing history isIn children, a convincing history isadequateadequate 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. 19. Medical Therapy TCHP recommends confirming bacterialTCHP recommends confirming bacterialpharyngitis before beginning antibiotics.pharyngitis before beginning antibiotics. Rapid Strep TestRapid Strep Test Throat CultureThroat Culture
  20. 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. 21. Medical Therapy Patients with recurrent otitis media historyPatients with recurrent otitis media historyhave higher bacterial concentrations withhave higher bacterial concentrations withBLPO.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 onemonth course of antibiotic therapy.month course of antibiotic therapy. Adenoid hyperplasia may respond to a 6-8Adenoid hyperplasia may respond to a 6-8week course of intranasal steroid.week course of intranasal steroid.
  22. 22. Surgical Indications AdenoidectomyAdenoidectomy AbsoluteAbsoluteAirway obstruction w/ cor pulmonaleAirway obstruction w/ cor pulmonaleFailure to thriveFailure to thrive RelativeRelativeChronic Nasal ObstructionChronic Nasal ObstructionRecurrent/ Chronic AdenoiditisRecurrent/ Chronic AdenoiditisRecurrent/ Chronic SinusitisRecurrent/ Chronic SinusitisRecurrent acute otitis media/ RecurrentRecurrent acute otitis media/ RecurrentCOMECOME
  23. 23. 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
  24. 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 orphysical examination suggests a bleedingphysical examination suggests a bleedingdisorder.disorder. Lateral Neck/Adenoid filmsLateral Neck/Adenoid films
  25. 25. Von Willebrand’s Disease Autosomal dominant bleeding disorderAutosomal dominant bleeding disorder Increased bleeding time and prolongedIncreased bleeding time and prolongedaPTT.aPTT. Perioperative managementPerioperative management IV Desmopressin (0.3ugm/kg)IV Desmopressin (0.3ugm/kg) Serum SodiumSerum Sodium
  26. 26. Idiopathic ThrombocytopenicPurpura Most common thrombocytopenia ofMost common thrombocytopenia ofchildhood.childhood. 90% resolution by 9-12 months90% resolution by 9-12 months SplenectomySplenectomy IVIG preoperativelyIVIG preoperatively
  27. 27. Innovative Surgical Techniques Cold DissectionCold Dissection ElectrosurgeryElectrosurgery Intracapsular partial tonsillectomyIntracapsular partial tonsillectomy Harmonic ScalpelHarmonic Scalpel Radiofrequency tonsillar ablation andRadiofrequency tonsillar ablation andcoblation.coblation.
  28. 28. Electrosurgery Most popular technique for tonsillectomyMost popular technique for tonsillectomy Equivalent or superior to the other methodsEquivalent or superior to the other methodsof tonsillectomy.of tonsillectomy.
  29. 29. Intracapsular PartialTonsillectomy 45 degree Microdebrider (1500rpm).45 degree Microdebrider (1500rpm). AdvantagesAdvantages As effective as standard tonsillectomy inAs effective as standard tonsillectomy inrelieving 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. 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. 31. Radiofrequency tonsillarcoblation Coblation is superior to ablation.Coblation is superior to ablation. Early elimination of pain and reduced painEarly elimination of pain and reduced painmedicine usage.medicine usage. Early resumption of normal diet.Early resumption of normal diet. Currently inadequate for adenoidectomyCurrently inadequate for adenoidectomy
  32. 32. Adjuvant TherapiesPerioperative local anestheticPerioperative local anesthetic0.25% bupivicaine w/ 1:100,0000.25% bupivicaine w/ 1:100,000EpinephrineEpinephrineAdvantages:Advantages:ease of dissection, postoperative painease of dissection, postoperative painDisadvantages:Disadvantages:Airway obstruction, cardiac dysrrhythmias,Airway obstruction, cardiac dysrrhythmias,seizuresseizures
  33. 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, fewerdays to return to normal activitydays to return to normal activity Cardiac abnormalityCardiac abnormality
  34. 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 episodeof postoperative emesis, and more likelyof postoperative emesis, and more likelyto advance to eating a soft diet.to advance to eating a soft diet. Reducing postoperative pulmonaryReducing postoperative pulmonarydistress, subglottic edema, paindistress, subglottic edema, painreduction.reduction.
  35. 35. Adjuvant Therapies Pain controlPain control Tylenol and Tylenol w/ codeine are theTylenol and Tylenol w/ codeine are themost commonly used.most commonly used. Similar pain control, less oral intake withSimilar pain control, less oral intake withcodeine versus Tylenol alone.codeine versus Tylenol alone. NSAIDS still controversial.NSAIDS still controversial.
  36. 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. 37. 23 hour observation Age younger than 3.Age younger than 3. Obstructive sleep apnea/craniofacialObstructive sleep apnea/craniofacialsyndromes involving the airway.syndromes involving the airway. Systemic disordersSystemic disorders Poor socioeconomic situationPoor socioeconomic situation Peritonsillar abscessPeritonsillar abscess Emesis or HemorrhageEmesis or Hemorrhage
  38. 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 ofcarotid artery injury.carotid artery injury.
  39. 39. Case Study 8yo male referred to the Pediatric clinic for8yo male referred to the Pediatric clinic forevaluation and treatment of recurrentevaluation and treatment of recurrenttonsillitis.tonsillitis.
  40. 40. History Only 2 episodes of documented pharyngitisOnly 2 episodes of documented pharyngitisin the past 12 months, strep negative, onlyin the past 12 months, strep negative, onlymissed 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 5seconds terminated with gasps of breath.seconds terminated with gasps of breath.
  41. 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. 42. Case Study Undergoes uneventful tonsillectomy andUndergoes uneventful tonsillectomy andadenoidectomy 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 likesome of his favorite foods. He says theysome of his favorite foods. He says theytaste “yucky”.taste “yucky”. Decreased perception of taste with no smellDecreased perception of taste with no smellabnormalities.abnormalities.
  43. 43. Diagnosis DysgeusiaDysgeusia Unknown mechanism- thought to be due toUnknown mechanism- thought to be due toprolonged pressure on the tongue by theprolonged pressure on the tongue by themouth retractor.mouth retractor. Treatment is reassurance.Treatment is reassurance.
  44. 44.  BibliographyBibliography Allen GC, et al. “Adenotonsillectomy in Children with von Willebrand Disease.” Archives of Otolaryngology 1999, May; 125(5) pp547-551.Allen GC, et al. “Adenotonsillectomy in Children with von Willebrand Disease.” Archives of Otolaryngology 1999, May; 125(5) pp547-551. Bailey BJ: Head and Neck Surgery- Otolaryngology, 3rd ed. Philadelphia, Lippincott-Raven, 2001, pp 979- 1006.Bailey BJ: Head and Neck Surgery- Otolaryngology, 3rd ed. Philadelphia, Lippincott-Raven, 2001, pp 979- 1006. Brook I, et al. “Microbiology of Healthy and Diseased Adenoids.” Laryngoscope 2000, June; 110(6): pp994-999.Brook I, et al. “Microbiology of Healthy and Diseased Adenoids.” Laryngoscope 2000, June; 110(6): pp994-999. Darrow D, Siemens C. “Indications for Tonsillectomy and Adenoidectomy.” Laryngoscope 2002, August; 112(8 part 2): pp6-10.Darrow D, Siemens C. “Indications for Tonsillectomy and Adenoidectomy.” Laryngoscope 2002, August; 112(8 part 2): pp6-10. Derkay C, Maddern B. “Innovative Techniques for Adenotonsillar Surgery in Children: Introduction and Commentary.” Laryngoscope 2002, August; 112(8Derkay C, Maddern B. “Innovative Techniques for Adenotonsillar Surgery in Children: Introduction and Commentary.” Laryngoscope 2002, August; 112(8part 2): p2.part 2): p2. Friedman M, et al. “Radiofrequency Tonsil Reduction: Safety, Morbidity, and Efficacy.” Laryngoscope 2003, May; 113(5): pp882-887.Friedman M, et al. “Radiofrequency Tonsil Reduction: Safety, Morbidity, and Efficacy.” Laryngoscope 2003, May; 113(5): pp882-887. Goldstein N. “Child Behavior and Quality of Life Before and After Tonsillectomy and Adenoidectomy.” Archives of Otolaryngology 2002, July; 128(7):Goldstein N. “Child Behavior and Quality of Life Before and After Tonsillectomy and Adenoidectomy.” Archives of Otolaryngology 2002, July; 128(7):pp770-775.pp770-775. Harley E. “Asymmetric Tonsil Size in Children.” Archives of Otolaryngology 2002, July; 128(7): pp767-769.Harley E. “Asymmetric Tonsil Size in Children.” Archives of Otolaryngology 2002, July; 128(7): pp767-769. Johnson L, et al. “Complications of Adenotonsillectomy.” Laryngoscope 2002, August; 112: pp35-36.Johnson L, et al. “Complications of Adenotonsillectomy.” Laryngoscope 2002, August; 112: pp35-36. Kay D, et al. “Perioperative Adenotonsillectomy Management in Children: Current practices.” Laryngoscope 2003, April: 113(4): pp 592-597.Kay D, et al. “Perioperative Adenotonsillectomy Management in Children: Current practices.” Laryngoscope 2003, April: 113(4): pp 592-597. Koempel J. “On the Origin of Tonsillectomy and the Dissection Method.” Laryngoscope 2002, September; 112(9): pp1583-1586.Koempel J. “On the Origin of Tonsillectomy and the Dissection Method.” Laryngoscope 2002, September; 112(9): pp1583-1586. Koltai P, et al. “Intracapsular Partial Tonsillectomy for Tonsillar Hypertrophy in Children.” Laryngoscope 2002, August; 112 (8 part 2): pp 17-19.Koltai P, et al. “Intracapsular Partial Tonsillectomy for Tonsillar Hypertrophy in Children.” Laryngoscope 2002, August; 112 (8 part 2): pp 17-19. Leinbach R, et al. “Hot versus Cold Tonsillectomy: A systematic review of the literature.” Otolaryngology-Head and Neck Surgery 2003, October; 129 (4):Leinbach R, et al. “Hot versus Cold Tonsillectomy: A systematic review of the literature.” Otolaryngology-Head and Neck Surgery 2003, October; 129 (4):pp360-364.pp360-364. Maddern B. “Electrosurgery for tonsillectomy.” Laryngoscope 2002, August; 112(8 part 2): pp11-13.Maddern B. “Electrosurgery for tonsillectomy.” Laryngoscope 2002, August; 112(8 part 2): pp11-13. Mui S, et al. “Efficacy of Tonsillectomy for Recurrent Throat Infection in Adults.” Laryngoscope 1998, September; 108(9): pp1325-1328.Mui S, et al. “Efficacy of Tonsillectomy for Recurrent Throat Infection in Adults.” Laryngoscope 1998, September; 108(9): pp1325-1328. Plant R. “Radiofrequency Treatment of Tonsillar Hypertrophy.” Laryngoscope 2002, August; 112(8 part 2): pp20-22.Plant R. “Radiofrequency Treatment of Tonsillar Hypertrophy.” Laryngoscope 2002, August; 112(8 part 2): pp20-22. Steward D, et al. “Do Steroids Reduce Morbidity of Tonsillectomy? 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