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Steven T. Wright, M.D. Ronald Deskin, M.D. November 5, 2003
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
Clinical Evaluation Acute Tonsillitis Chronic Tonsillitis Obstructive Tonsillar Hyperplasia .
5 Tonsillar Exudate Tender cervical LAD >2cm Positive throat culture . tender cervical lymphadenopathy. Supporting documents. fever.Clinical Evaluation Odynophagia. 2 or more Fever> 38.
Granulocytic shift More exudative .Clinical evaluation Viral Lower grade fever Lower WBC. Lymphocytic shift Less tonsillar exudate Bacterial Higher WBC.
Recurrent Acute Tonsillitis Seven episodes in a single year Five or more episodes in 2 years Three or more episodes in 3 years .
Chronic Tonsillitis No true consensus on the definition. Symptoms greater than 4 weeks .
Differential Diagnosis Infectious Mononucleosis EBV Scarlet Fever Corynebacterium diptheriae Malignancy .
Complications of Tonsillitis Cervical Adenitis Neck Abscess Peritonsillar abscess Intratonsillar abscess Lemierre’s syndrome .
Treatment aimed at eliminating the infection and supportive therapy for renal failure. . Excellent prognosis in children.Post Streptococcal Glomerulonephritis Joint Pain and oliguric renal failure 10 days after the pharyngitis.
Adenoid Hyperplasia Triad Hyponasality Snoring Open mouth breathing Purulent rhinorrhea. chronic cough. and headache . post nasal drip.
Obstructive Airway Symptoms Snoring Apneic episodes with gasping or choking Daytime hypersomnolence Nocturnal enuresis Behavioral disturbances Heart failure and Failure to thrive .
Tonsil Size Grade 1 2 3 4 % <25 25-50 51-75 >75 .
SpO2 >90% Primary Snoring: RDI <1. SpO2<90% UARS: RDI <5. Imperative in Adults In children.Obstructive Sleep Apnea Polysomnography is the gold standard of diagnosis. a convincing history is adequate OSA: RDI > 5. SpO2>90% .
Rapid Strep Test Throat Culture .Medical Therapy TCHP recommends confirming bacterial pharyngitis before beginning antibiotics.
co pathogens Macrolides Penicillin allergy Erythromycin/Clarithromycin 10 days Azithromycin (12mg/kg/day) 5 days .Medical Therapy First Line Penicillin/Cephalosporin for 10 days Injectable forms for noncompliance BLPO.
Adenoid hyperplasia may respond to a 6-8 week course of intranasal steroid. Adenotonsillar size may respond to a one month course of antibiotic therapy.Medical Therapy Patients with recurrent otitis media history have higher bacterial concentrations with BLPO. . Initial treatment with anti-BLP antibiotic.
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 .
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 .
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 .
3ugm/kg) Serum Sodium .Von Willebrand’s Disease Autosomal dominant bleeding disorder Increased bleeding time and prolonged aPTT. Perioperative management IV Desmopressin (0.
Idiopathic Thrombocytopenic Purpura Most common thrombocytopenia of childhood. 90% resolution by 9-12 months Splenectomy IVIG preoperatively .
.Innovative Surgical Techniques Cold Dissection Electrosurgery Intracapsular partial tonsillectomy Harmonic Scalpel Radiofrequency tonsillar ablation and coblation.
Electrosurgery Most popular technique for tonsillectomy Equivalent or superior to the other methods of tonsillectomy. .
Advantages As effective as standard tonsillectomy in relieving obstruction. Less pain.Intracapsular Partial Tonsillectomy 45 degree Microdebrider (1500rpm). quicker return to normal diet Disadvantages: Tonsillar regrowth Greater intraoperative blood loss .
.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.
Early elimination of pain and reduced pain medicine usage. Early resumption of normal diet. Currently inadequate for adenoidectomy .Radiofrequency tonsillar coblation Coblation is superior to ablation.
seizures . postoperative pain Disadvantages: Airway obstruction.25% bupivicaine w/ 1:100. cardiac dysrrhythmias.Adjuvant Therapies Perioperative local anesthetic 0.000 Epinephrine Advantages: ease of dissection.
offensive odor. fewer days to return to normal activity Cardiac abnormality . less pain. improved oral intake.Adjuvant Therapies Perioperative antibiotics Fewer episodes of fever.
. Reducing postoperative pulmonary distress.0mg/kg) Two times less likely to have an episode of postoperative emesis. and more likely to advance to eating a soft diet.15-1. pain reduction. subglottic edema.Adjuvant Therapies Perioperative Steroids Dexamethasone (0.
NSAIDS still controversial.Adjuvant Therapies Pain control Tylenol and Tylenol w/ codeine are the most commonly used. less oral intake with codeine versus Tylenol alone. Similar pain control. .
Complications Mortality rate is 1 in 16000-35000. Anesthetic complications Eustachian tube injury VPI Nasopharyngeal stenosis Pulmonary Edema Atlantoaxial subluxation .
Obstructive sleep apnea/craniofacial syndromes involving the airway. Systemic disorders Poor socioeconomic situation Peritonsillar abscess Emesis or Hemorrhage .23 hour observation Age younger than 3.
. Overnight observation and venous access Surgical intervention. Carotid angiography if any suspicion of carotid artery injury. Delayed hemorrhage. Early vs.Post Operative Hemorrhage The best treatment is prevention.
Case Study 8yo male referred to the Pediatric clinic for evaluation and treatment of recurrent tonsillitis. .
Loud snoring. . only missed 5 days of school total last year. strep negative.History Only 2 episodes of documented pharyngitis in the past 12 months. frequent pauses up to 5 seconds terminated with gasps of breath.
no cleft deformities. . tonsils 3+. open mouth breathing.Physical Examination Normal facies. Remainder of exam is normal.
his mom complains that he doesn’t like some of his favorite foods. On follow up visit 2 weeks postoperatively. He says they taste “yucky”. Decreased perception of taste with no smell abnormalities.Case Study Undergoes uneventful tonsillectomy and adenoidectomy with 23 hour observation. .
thought to be due to prolonged pressure on the tongue by the mouth retractor. Treatment is reassurance.Diagnosis Dysgeusia Unknown mechanism. .
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