Tonsillitis, Tonsillectomy and Adenoidectomy | PPT
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Tonsillitis, Tonsillectomy and Adenoidectomy
Most commonly performed procedure in the history of surgery
$500 million annually in healthcare expenditures
Almost exclusively by Otolaryngologists
Celsus in 50 A.D.
Caque of Rheims
Phillip Syng developed the tonsillotome
Obstructive Tonsillar Hyperplasia
Odynophagia, fever, tender cervical lymphadenopathy.
Supporting documents, 2 or more
Tender cervical LAD >2cm
Positive throat culture
Lower grade fever
Lower WBC, Lymphocytic shift
Less tonsillar exudate
Higher WBC, Granulocytic shift
Recurrent Acute Tonsillitis
Seven episodes in a single year
Five or more episodes in 2 years
Three or more episodes in 3 years
No true consensus on the definition.
Symptoms greater than 4 weeks
Complications of Tonsillitis
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.
Open mouth breathing
Purulent rhinorrhea, post nasal drip, chronic cough, and headache
Obstructive Airway Symptoms
Apneic episodes with gasping or choking
Heart failure and Failure to thrive
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%
TCHP recommends confirming bacterial pharyngitis before beginning antibiotics.
Rapid Strep Test
Penicillin/Cephalosporin for 10 days
Injectable forms for noncompliance
BLPO, co pathogens
Erythromycin/Clarithromycin 10 days
Azithromycin (12mg/kg/day) 5 days
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.
Airway obstruction w/ cor pulmonale
Failure to thrive
Chronic Nasal Obstruction
Recurrent/ Chronic Adenoiditis
Recurrent/ Chronic Sinusitis
Recurrent acute otitis media/ Recurrent COME
Obstructive airway with cor pulmonale
Failure to thrive
Recurrent acute tonsillitis
Obstructive Sleep Apnea
Suspected Neoplasia/ Tonsillar hyperplasia
Most common lab test is a CBC
Coagulation studies when the history or physical examination suggests a bleeding disorder.
Lateral Neck/Adenoid films
Von Willebrand’s Disease
Autosomal dominant bleeding disorder
Increased bleeding time and prolonged aPTT.
IV Desmopressin (0.3ugm/kg)
Idiopathic Thrombocytopenic Purpura
Most common thrombocytopenia of childhood.
90% resolution by 9-12 months
Innovative Surgical Techniques
Intracapsular partial tonsillectomy
Radiofrequency tonsillar ablation and coblation.
Most popular technique for tonsillectomy
Equivalent or superior to the other methods of tonsillectomy.
Intracapsular Partial Tonsillectomy
45 degree Microdebrider (1500rpm).
As effective as standard tonsillectomy in relieving obstruction.
Less pain, quicker return to normal diet
Greater intraoperative blood loss
Smaller risk of stray energy shocks
Improved post operative pain
Must use alternate device for adenoidectomy
Similar intraoperative blood loss.
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
Perioperative local anesthetic
0.25% bupivicaine w/ 1:100,000 Epinephrine
ease of dissection, postoperative pain
Airway obstruction, cardiac dysrrhythmias, seizures
Fewer episodes of fever, offensive odor, improved oral intake, less pain, fewer days to return to normal activity
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.
Tylenol and Tylenol w/ codeine are the most commonly used.
Similar pain control, less oral intake with codeine versus Tylenol alone.
NSAIDS still controversial.
Mortality rate is 1 in 16000-35000.
Eustachian tube injury
23 hour observation
Age younger than 3.
Obstructive sleep apnea/craniofacial syndromes involving the airway.
Poor socioeconomic situation
Emesis or Hemorrhage
Post Operative Hemorrhage
The best treatment is prevention.
Early vs. Delayed hemorrhage.
Overnight observation and venous access
Carotid angiography if any suspicion of carotid artery injury.
8yo male referred to the Pediatric clinic for evaluation and treatment of recurrent tonsillitis.
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.
Normal facies, open mouth breathing, tonsils 3+, no cleft deformities.
Remainder of exam is normal.
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.
Unknown mechanism- thought to be due to prolonged pressure on the tongue by the mouth retractor.
Treatment is reassurance.