tonsillectomy adenoidectomy

1. Tonsillectomy & Adenoidectomy See Exemplar Provided

2. Objectives Assess the anatomy, physiology, and pathophysiology of the tonsillectomy & adenoidectomy Analyze the diagnostic and surgical interventions for a patient undergoing a _______________. Plan the intraoperative course for a patient undergoing_____________. Assemble supplies, equipment, and instrumentation needed for the procedure.

3. Objectives Choose the appropriate patient position Identify the incision used for the procedure Analyze the procedural steps for_____________. Describe the care of the specimen Discuss the postoperative considerations for a patient undergoing _______________

4. Terms & Definitions A

5. Definition/Purpose of Procedure Removal of tonsils & adenoids by sharp or blunt dissection Adenoids are removed to facilitate breathing, prevent recurrent otitis media, and to restore hearing loss due to obstruction of the eustachian tube

6. Relevant A & P Pharynx (throat) p. 618 – 620 Begins at internal nares and ends posterior to the larynx at the level of the esophagus. It is divided into 3 regions according to location: the nasopharynx, oropharynx, and laryngopharynx. The lymphoid elements (pharngeal, palatine, and lingual tonsils, and the pharngeal band) contained with the pharynx are named Waldeyer’s ring. What is the difference between the palatine tonsils and the lingual tonsils? What are the pharyngeal tonsils? Palatine: (also called faucial)—two oval masses of lymphoid tissue which are located at each edge of the fauces withing the folds of two bands of tissue that descend from the soft palate to the base of the tongue, called the tonsillar pillars. Each tonsil has an anterior and posterior pillar. Behind each posterior posterior tonsillar pillar is a pink band of lymphoid tissue called the lateral pharyngeal band. The tonsils produce lymphocytes. Each of the palantine tonsils contains 10-20 crypts or dips that help trap bacteria. The lingual tonsils are a pair of lymphoid areas located on the posterior surface of the tongue near the base. The pharyngeal tonsils are are located on the posterior wall of the nasopharynx. When the pharyngeal tonsils are enlarged, they are referred to as adenoids. They are a single mass of lymphatic tissue embedded n the mucous membrane of the nasopharynx. These tonsils help to protect against pathogens entering the nose. After about age 7, this lymphatic tissue usually begins to shrink. Pharynx (throat) p. 618 – 620 Begins at internal nares and ends posterior to the larynx at the level of the esophagus. It is divided into 3 regions according to location: the nasopharynx, oropharynx, and laryngopharynx. The lymphoid elements (pharngeal, palatine, and lingual tonsils, and the pharngeal band) contained with the pharynx are named Waldeyer’s ring. What is the difference between the palatine tonsils and the lingual tonsils? What are the pharyngeal tonsils? Palatine: (also called faucial)—two oval masses of lymphoid tissue which are located at each edge of the fauces withing the folds of two bands of tissue that descend from the soft palate to the base of the tongue, called the tonsillar pillars. Each tonsil has an anterior and posterior pillar. Behind each posterior posterior tonsillar pillar is a pink band of lymphoid tissue called the lateral pharyngeal band. The tonsils produce lymphocytes. Each of the palantine tonsils contains 10-20 crypts or dips that help trap bacteria. The lingual tonsils are a pair of lymphoid areas located on the posterior surface of the tongue near the base. The pharyngeal tonsils are are located on the posterior wall of the nasopharynx. When the pharyngeal tonsils are enlarged, they are referred to as adenoids. They are a single mass of lymphatic tissue embedded n the mucous membrane of the nasopharynx. These tonsils help to protect against pathogens entering the nose. After about age 7, this lymphatic tissue usually begins to shrink.

7. Relevant A & P See Video clip www.nucleusinc.com

8. Pathophysiology Upper aerodigestive tract Tonsillitis of the palatine tonsils STST p. 619, -622. Located in the Oropharynx Common preop diagnosis is “tonsillar hypertrophy” or ‘Recurrent tonsillitis.” Other problems which can occur in that region are peritonsillar abscess and cancer. Tonsillitis may affect any or all of the tonsillar regions—but it is usually of the palatine tonsils. The problem can be acute or chronic. Usually it’s caused by strepotococcal organism. Acute:enlarged and dusky and purulence of tonsillar crypts. Chronic: persistent sore throat, foul breat, enlarged cervical lymph nodes. Failure to treat chronic tonsillitis can lead to a peritonsillar abscess—or if treated and antibiotics failed. (Fig 17-28 p. 622) S & S: extreme pain, difficulty breathing, referred pain to the ear on the affected side. Surgery is called an I & D (incision and drainage). This is an emergency due to potential airway obstruction AND the infection can spread quickly to neck and chest, causing complications like pericarditis (fatal). Adenoiditis—inflammation of pharyngeal tonsils—usually bacterial, but may be viral or due to allergies. Recurrent adenoiditis can lead to hypertrophy (snoring is a symptom) or hearing impairment due to eustachian tube blockage. STST p. 619, -622. Located in the Oropharynx Common preop diagnosis is “tonsillar hypertrophy” or ‘Recurrent tonsillitis.” Other problems which can occur in that region are peritonsillar abscess and cancer. Tonsillitis may affect any or all of the tonsillar regions—but it is usually of the palatine tonsils. The problem can be acute or chronic. Usually it’s caused by strepotococcal organism. Acute:enlarged and dusky and purulence of tonsillar crypts. Chronic: persistent sore throat, foul breat, enlarged cervical lymph nodes. Failure to treat chronic tonsillitis can lead to a peritonsillar abscess—or if treated and antibiotics failed. (Fig 17-28 p. 622) S & S: extreme pain, difficulty breathing, referred pain to the ear on the affected side. Surgery is called an I & D (incision and drainage). This is an emergency due to potential airway obstruction AND the infection can spread quickly to neck and chest, causing complications like pericarditis (fatal). Adenoiditis—inflammation of pharyngeal tonsils—usually bacterial, but may be viral or due to allergies. Recurrent adenoiditis can lead to hypertrophy (snoring is a symptom) or hearing impairment due to eustachian tube blockage.

9. Terms & Definitions Hypertrophy Hypertrophy is enlargement of a structure due to the increase in the size of the cellsHypertrophy is enlargement of a structure due to the increase in the size of the cells

10. Diagnostics Exams H & P Visual exam C & S Preop testing CBC: PTT-7 minutes Preoperative testing which should be reported for the patient undergoing tonsillectomy would be PTT-7 minutes. This would be abnormal and indicates bleeding problems. This should be reported to the surgeon because one of the major complications of tonsillectomy is postop bleeding. Preoperative testing which should be reported for the patient undergoing tonsillectomy would be PTT-7 minutes. This would be abnormal and indicates bleeding problems. This should be reported to the surgeon because one of the major complications of tonsillectomy is postop bleeding.

11. Surgical Intervention:Special Considerations OR table position Order of extraction varies Best technique (not sterile) Surgeon may prefer to stand or sit Typical peds Adults: under local and sitting up

12. Surgical Intervention: Anesthesia General Peds mask induction Oral ET tube Lubricate and protect eyes

13. Surgical Intervention: Positioning Supine, neck hyperextended Supplies and equipment Neck roll Arm sleds or draw sheet Safety strap Foam headrest or donut Move patient to edge for ease of access Special considerations: high risk areas

14. Surgical Intervention: Skin Prep N/A

15. Surgical Intervention: Draping/Incision Head wrap or cover sheet Peritonsillar incision

16. Surgical Intervention: Supplies General ½ sheet x 2; raytex; towels; gowns & gloves, suction tubing, ESU w/extension; small basin Specific Suture: 2-0 plain heavy, tapered 5/8 in needle Meds: local of choice (marcaine or lidocaine w/epinephrine) Tonsil sponges # 12 knife blade Insulated suction cautery Syringe for irrigation Supplies for local (needle, syringe)

17. Surgical Intervention: Instruments T & A set

18. Surgical Intervention: Equipment Sitting stool Headlamp ? Harmonic scalpel Suction apparatus

19. Surgical Intervention: Procedure Steps See Exemplar and Procedure 17-6 STST

20. Counts Initial: sponges and sharps First closing Final closing Sponges Sharps

21. Specimen & Care Rt and left tonsils and adenoids Ask about separating—may “tag rt w/safety pin”

22. Postoperative Care Destination PACU—outpatient Position pt on side once extubated Elevate HOB Cold fluids Expected prognosis Return to normal activities within 2 wks Reduced incident of sore throat & ear infections

23. Postop Care Complications Hemorrhage up to 10 days post op Infection Wound Classification : II—increased for inflammation or infection

24. Resources STST Procedure 17-6 STST pp. 618