Tonsillitis, Tonsillectomy and Adenoidectomy

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

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

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

4. Anatomy

5. Anatomy

6. Histology

7. Clinical Evaluation • Acute Tonsillitis • Chronic Tonsillitis • Obstructive Tonsillar Hyperplasia

8. Clinical Evaluation • Odynophagia, fever, tender cervical lymphadenopathy. • Supporting documents, 2 or more • Fever> 38.5 • Tonsillar Exudate • Tender cervical LAD >2cm • Positive throat culture

9. Clinical evaluation • Viral • Lower grade fever • Lower WBC, Lymphocytic shift • Less tonsillar exudate • Bacterial • Higher WBC, Granulocytic shift • More exudative

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

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

12. Differential Diagnosis • Infectious Mononucleosis • EBV • Scarlet Fever • Corynebacterium diptheriae • Malignancy

13. Complications of Tonsillitis • Cervical Adenitis • Neck Abscess • Peritonsillar abscess • Intratonsillar abscess • Lemierre’s syndrome

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

15. Adenoid Hyperplasia • Triad • Hyponasality • Snoring • Open mouth breathing • Purulent rhinorrhea, post nasal drip, chronic cough, and headache

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

17. Tonsil Size • Grade % • 1 <25 • 2 25-50 • 3 51-75 • 4 >75

18. Obstructive Sleep Apnea • Polysomnography is the gold standard of diagnosis. • Imperative in Adults • In children, a convincing history is adequate • OSA: RDI > 5, SpO2<90% • UARS: RDI <5, SpO2 >90% • Primary Snoring: RDI <1, SpO2>90%

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

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

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

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

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

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

25. Von Willebrand’s Disease • Autosomal dominant bleeding disorder • Increased bleeding time and prolonged aPTT. • Perioperative management • IV Desmopressin (0.3ugm/kg) • Serum Sodium

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

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

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

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

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

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

32. 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

33. Adjuvant Therapies • Perioperative antibiotics • Fewer episodes of fever, offensive odor, improved oral intake, less pain, fewer days to return to normal activity • Cardiac abnormality

34. Adjuvant Therapies • Perioperative Steroids • Dexamethasone (0.15-1.0mg/kg) • Two times less likely to have an episode of postoperative emesis, and more likely to advance to eating a soft diet. • Reducing postoperative pulmonary distress, subglottic edema, pain reduction.

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

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

37. 23 hour observation • Age younger than 3. • Obstructive sleep apnea/craniofacial syndromes involving the airway. • Systemic disorders • Poor socioeconomic situation • Peritonsillar abscess • Emesis or Hemorrhage

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

39. Case Study • 8yo male referred to the Pediatric clinic for evaluation and treatment of recurrent tonsillitis.

40. History • Only 2 episodes of documented pharyngitis in the past 12 months, strep negative, only missed 5 days of school total last year. • Loud snoring, frequent pauses up to 5 seconds terminated with gasps of breath.

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

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

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

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