Tonsillitis Tonsillectomy and Adenoidectomy Steven T Wright M

Tonsillitis, Tonsillectomy and Adenoidectomy Steven T. Wright, M. D. Ronald Deskin, M. D. November 5, 2003

Adenotonsillectomy Most commonly performed procedure in the history of surgery n $500 million annually in healthcare expenditures n

History Almost exclusively by Otolaryngologists n Celsus in 50 A. D. n Caque of Rheims n Phillip Syng developed the tonsillotome n

Anatomy

Anatomy

Histology

Clinical Evaluation Acute Tonsillitis n Chronic Tonsillitis n Obstructive Tonsillar Hyperplasia n

Clinical Evaluation n n Odynophagia, fever, tender cervical lymphadenopathy. Supporting documents, 2 or more u Fever> 38. 5 u Tonsillar Exudate u Tender cervical LAD >2 cm u Positive throat culture

Clinical evaluation Viral u Lower grade fever u Lower WBC, Lymphocytic shift u Less tonsillar exudate n Bacterial u Higher WBC, Granulocytic shift u More exudative n

Recurrent Acute Tonsillitis Seven episodes in a single year n Five or more episodes in 2 years n Three or more episodes in 3 years n

Chronic Tonsillitis No true consensus on the definition. n Symptoms greater than 4 weeks n

Differential Diagnosis Infectious Mononucleosis u EBV n Scarlet Fever n Corynebacterium diptheriae n Malignancy n

Complications of Tonsillitis Cervical Adenitis n Neck Abscess n Peritonsillar abscess n Intratonsillar abscess n Lemierre’s syndrome n

Post Streptococcal Glomerulonephritis Joint Pain and oliguric renal failure 10 days after the pharyngitis. n Treatment aimed at eliminating the infection and supportive therapy for renal failure. n Excellent prognosis in children. n

Adenoid Hyperplasia Triad u Hyponasality u Snoring u Open mouth breathing n Purulent rhinorrhea, post nasal drip, chronic cough, and headache n

Obstructive Airway Symptoms Snoring n Apneic episodes with gasping or choking n Daytime hypersomnolence n Nocturnal enuresis n Behavioral disturbances n Heart failure and Failure to thrive n

Tonsil Size n Grade u 1 u 2 u 3 u 4 % <25 25 -50 51 -75 >75

Obstructive Sleep Apnea Polysomnography is the gold standard of diagnosis. u Imperative in Adults u In children, a convincing history is adequate n OSA: RDI > 5, Sp. O 2<90% n UARS: RDI <5, Sp. O 2 >90% n Primary Snoring: RDI <1, Sp. O 2>90% n

Medical Therapy TCHP recommends confirming bacterial pharyngitis before beginning antibiotics. n Rapid Strep Test n Throat Culture n

Medical Therapy n n n First Line u Penicillin/Cephalosporin for 10 days u Injectable forms for noncompliance BLPO, co pathogens Macrolides u Penicillin allergy u Erythromycin/Clarithromycin 10 days u Azithromycin (12 mg/kg/day) 5 days

Medical Therapy Patients with recurrent otitis media history have higher bacterial concentrations with BLPO. u Initial treatment with anti-BLP antibiotic. n Adenotonsillar size may respond to a one month course of antibiotic therapy. n Adenoid hyperplasia may respond to a 6 -8 week course of intranasal steroid. n

Surgical Indications n Adenoidectomy u Absolute t Airway obstruction w/ cor pulmonale t Failure to thrive u Relative t Chronic Nasal Obstruction t Recurrent/ Chronic Adenoiditis t Recurrent/ Chronic Sinusitis t Recurrent acute otitis media/ Recurrent COME

Surgical Indications n n Absolute u Obstructive airway with cor pulmonale u Severe dysphagia u Failure to thrive Relative u Recurrent acute tonsillitis u Chronic tonsillitis u Obstructive Sleep Apnea u Peritonsillar Abscess u Halitosis u Suspected Neoplasia/ Tonsillar hyperplasia

Preoperative evaluation Most common lab test is a CBC n Coagulation studies when the history or physical examination suggests a bleeding disorder. n Lateral Neck/Adenoid films n

Von Willebrand’s Disease Autosomal dominant bleeding disorder n Increased bleeding time and prolonged a. PTT. n Perioperative management u IV Desmopressin (0. 3 ugm/kg) u Serum Sodium n

Idiopathic Thrombocytopenic Purpura Most common thrombocytopenia of childhood. n 90% resolution by 9 -12 months n Splenectomy n IVIG preoperatively n

Innovative Surgical Techniques Cold Dissection n Electrosurgery n Intracapsular partial tonsillectomy n Harmonic Scalpel n Radiofrequency tonsillar ablation and coblation. n

Electrosurgery Most popular technique for tonsillectomy n Equivalent or superior to the other methods of tonsillectomy. n

Intracapsular Partial Tonsillectomy n n n 45 degree Microdebrider (1500 rpm). Advantages u As effective as standard tonsillectomy in relieving obstruction. u Less pain, quicker return to normal diet Disadvantages: u Tonsillar regrowth u Greater intraoperative blood loss

Harmonic Scalpel n n Advantages: u Better visibility u Smaller risk of stray energy shocks u Improved post operative pain Disadvantages: u Must use alternate device for adenoidectomy u Similar intraoperative blood loss.

Radiofrequency tonsillar coblation Coblation is superior to ablation. n Early elimination of pain and reduced pain medicine usage. n Early resumption of normal diet. n Currently inadequate for adenoidectomy n

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 n Perioperative antibiotics u Fewer episodes of fever, offensive odor, improved oral intake, less pain, fewer days to return to normal activity u Cardiac abnormality

Adjuvant Therapies n Perioperative Steroids u Dexamethasone (0. 15 -1. 0 mg/kg) u Two times less likely to have an episode of postoperative emesis, and more likely to advance to eating a soft diet. u Reducing postoperative pulmonary distress, subglottic edema, pain reduction.

Adjuvant Therapies n Pain control u Tylenol and Tylenol w/ codeine are the most commonly used. u Similar pain control, less oral intake with codeine versus Tylenol alone. u NSAIDS still controversial.

Complications Mortality rate is 1 in 16000 -35000. n Anesthetic complications n Eustachian tube injury n VPI n Nasopharyngeal stenosis n Pulmonary Edema n Atlantoaxial subluxation n

23 hour observation Age younger than 3. n Obstructive sleep apnea/craniofacial syndromes involving the airway. n Systemic disorders n Poor socioeconomic situation n Peritonsillar abscess n Emesis or Hemorrhage n

Post Operative Hemorrhage The best treatment is prevention. n Early vs. Delayed hemorrhage. n Overnight observation and venous access n Surgical intervention. n Carotid angiography if any suspicion of carotid artery injury. n

Case Study n 8 yo 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. n Loud snoring, frequent pauses up to 5 seconds terminated with gasps of breath. n

Physical Examination Normal facies, open mouth breathing, tonsils 3+, no cleft deformities. n Remainder of exam is normal. n

Case Study Undergoes uneventful tonsillectomy and adenoidectomy with 23 hour observation. n 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”. n Decreased perception of taste with no smell abnormalities. n

Diagnosis Dysgeusia n Unknown mechanism- thought to be due to prolonged pressure on the tongue by the mouth retractor. n Treatment is reassurance. n

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