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Tonsillectomy, and

Adenoidectomy

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History
• Celsus 50 A.D.
• Caque of Rheims
• Philip Syng
• Wilhelm Meyer 1867
• Samuel Crowe

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Embryology
• 8 weeks: Tonsillar fossa and palatine tonsils
develop from the dorsal wing of the 1st
pharyngeal pouch and the ventral wing of
the 2nd pouch; tonsillar pillars originate
from 2nd/3rd arches
• Crypts 3-6 months; capsule 5th month;
germinal centers after birth
• 16 weeks: Adenoids develop as a
subepithelial infiltration of lymphocytes
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Anatomy
Tonsils
• Plica triangularis
• Gerlach’s tonsil
Adenoids
• Fossa of Rosenmüller
• Passavant’s ridge

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Blood Supply
Tonsils
• Ascending and descending
palatine arteries
• Tonsillar artery
• 1% aberrant ICA just deep
to superior constrictor
Adenoids
• Ascending pharyngeal,
sphenopalatine arteries
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Common Diseases of the Tonsils and Adenoids • Acute adenoiditis/tonsillitis • Recurrent/chronic adenoiditis/tonsillitis • Obstructive hyperplasia • Malignancy 2/12/2019 rhinoplastyman@yahoo.com 6 .

Acute Adenotonsillitis Etiology • 5-30% bacterial. of these 39% are beta-lactamase- producing (BLPO) • Anaerobic BLPO GABHS most important pathogen because of potential sequelae • Throat culture • Treatment 2/12/2019 rhinoplastyman@yahoo.com 7 .

2/12/2019 rhinoplastyman@yahoo. aureus • Streptococcus pneumoniae Tonsil weight is directly proportional to bacterial load.influenza • S. Microbiology of Adenotonsillitis Most common organisms cultured from patients with chronic tonsillar disease (recurrent/chronic infection.com 8 . hyperplasia): • Streptococcus pyogenes (Group A beta-hemolytic streptococcus) • H.

Acute Adenotonsillitis Differential diagnosis Infectious mononucleosis Malignancy: lymphoma. leukemia.com 9 . carcinoma Diptheria Scarlet fever Agranulocytosis 2/12/2019 rhinoplastyman@yahoo.

and immediate tonsillectomy for poor response • Recurrent tonsillitis: PCN injection if concerned about noncompliance or antibiotics aimed against BLPO and anaerobes • For chronic tonsillitis or obstruction.com 10 . Medical Management • PCN is first line. antibiotics directed against BLPO and anaerobes for 3-6 weeks will eliminate need for surgery in 17% • Co-amoxiclav or clindamycin or PCN+Rifampin 2/12/2019 rhinoplastyman@yahoo. even if throat culture is negative for GABHS • For acute UAO: NP airway. steroids. IV abx.

Obstructive Hyperplasia • Adenotonsillar hypertrophy most common cause of SDB in children • Diagnosis:snoring. FTT. nocturnal enuresis. daytime symptoms… poor mentation.com 11 . restless sleep. chronic mouth breathing • Indications for polysomnography • Interpretation of polysomnography • Perioperative considerations 2/12/2019 rhinoplastyman@yahoo. dysphagia. decreased attn span. poor scholastic performance.

com 12 .• Interpretation of polysomnography: Indications for surgical intervention >1 apnea in 1 hour Central apnea + o2sat<90% O2sat<92% CO2>53 CO2>45 in more than 60% of test time 2/12/2019 rhinoplastyman@yahoo.

Unilateral Tonsillar Enlargement Apparent enlargement vs true enlargement Non-neoplastic: • Acute infective • Chronic infective • Hypertrophy • Congenital Neoplastic 2/12/2019 rhinoplastyman@yahoo.com 13 .

com 14 . Peritonsillar Abscess 2/12/2019 rhinoplastyman@yahoo.

ICA Aneurysm 2/12/2019 rhinoplastyman@yahoo.com 15 .

com 16 . Pleomorphic Adenoma 2/12/2019 rhinoplastyman@yahoo.

mycosis leptothrica • Tonsilloliths 2/12/2019 rhinoplastyman@yahoo.com 17 . Other Tonsillar Pathology • Hyperkeratosis.

Candidiasis 2/12/2019 rhinoplastyman@yahoo.com 18 .

Retention Cysts 2/12/2019 rhinoplastyman@yahoo.com 19 .

com 20 . Supratonsillar Cleft 2/12/2019 rhinoplastyman@yahoo.

com 21 . Indications for Tonsillectomy. Historical Evolution 2/12/2019 rhinoplastyman@yahoo.

Indications for Tonsillectomy Paradise study • Frequency criteria: 7 episodes in 1 year or 5 episodes/year for 2 years or 3 episodes/year for 3 years • Clinical features (one or more): T 38. cervical LAD (>2cm) or tender LAD.com 22 . positive culture for GABHS. antibiotic treatment 2/12/2019 rhinoplastyman@yahoo. tonsillar/pharyngeal exudate.3.

Indications for Tonsillectomy AAO-HNS: • 3 or more episodes/year • Hypertrophy causing malocclusion. UAO • PTA unresponsive to nonsurgical mgmt • Halitosis. not responsive to medical therapy • UTE.com 23 . suspicious for malignancy • Individual considerations 2/12/2019 rhinoplastyman@yahoo.

Also: 1. OSAS 8. Suspicious malignancy 2/12/2019 rhinoplastyman@yahoo. phonation disorders 11. Unresponsive carrier 4. Obstructive IMN unresponsive to medical therapy 5. Disphagia 10. Chronic tonsillitis with never-ending sore throat 7. FTT 9. Recurrent tonsillitis in patient with heart valve dis 2. Craniofacial growth abnormalities 13. In patient with febrile convulsion 3.com 24 . Malocclusion 12. Corpulmonale 14. Carrier of diphtheria 6.

Respiratory acidosis 5. Chronic hypoxia and hypercapnea 4. Corpulmonale and CHF 2/12/2019 rhinoplastyman@yahoo. Pulmonary hypertension 8. Alveolar hypovantilation 3. Right atrial dilatation 7. URT obstruction 2. Pathophysiology of corpulmonale in OSA: 1. Vasoconstriction of alveolar capillaries 6.com 25 .

com 26 . Irregularities in ADH secretion Pathophysiology of FTT: 1. SDB 2.Pathophysiology of enuresis: 1. may sometimes stop totally Both return to normal following A&T 2/12/2019 rhinoplastyman@yahoo. REM abnormalities 3. SDB 2. Irregularities in GH secretion. REM abnormalities 3.

ADHD (Attention Deficit Hyperactivity Disorder) is the most Common psychiatric diagnosis in children. Maybe due to abnormal sleep pattern Neurocognitive development delays: Healthy sleeping pattern: important component of brain growth Frontal cortex growth continues up to puberty Most critical age: 3-7 2/12/2019 rhinoplastyman@yahoo. In direct correlation with Sleep Disordered Breathing(SDB) Pathophysiology uncertain.com 27 .

Indications for Adenoidectomy Paradise study • 28-35% fewer acute episodes of OM with adenoidectomy in kids with previous tube placement • Adenoidectomy or T & A not indicated in children with recurrent OM who had not undergone previous tube placement Gates et al • Recommend adenoidectomy with M & T as the initial surgical treatment for children with MEE > 90 days and CHL > 20 dB 2/12/2019 rhinoplastyman@yahoo.com 28 .

previous BMT) 2/12/2019 rhinoplastyman@yahoo. Indications for Adenoidectomy Obstruction: • Chronic nasal obstruction or obligate mouth breathing • SDB with FTT. cor pulmonale • Dysphagia • Speech problems • Severe orofacial/dental abnormalities Infection: • Recurrent/chronic adenoiditis (3 or more episodes/year) • Recurrent/chronic OME (+/.com 29 .

com 30 . 2% in SDB • Chronic recurrent AOM • COM • Chronic otorrhea • VT and persistent discharge • Suspecious malignancy 2/12/2019 rhinoplastyman@yahoo. Also: • Chronic sinusitis: first step biofilm in 95% adenoid specimen vs.

crowded incisorsrhinoplastyman@yahoo. and mouth breathing • Rhinorrhea. post nasal drip • “Adenoid facies” • “Milkman” & “Micky Mouse” • Overbite. snoring.com 2/12/2019 31 . nocturnal cough. PreOp Evaluation of Adenoid Disease • Triad of hyponasality. long face.

treat adenoids first 2/12/2019 rhinoplastyman@yahoo.com 32 . PreOp Evaluation of Adenoid Disease Differential diagnoses • Allergic rhinitis • Sinusitis • GERD • For concomitant sinus disease.

PreOp Evaluation of Adenoid Disease Evaluate palate • Symptoms/FH of CP or VPI • Midline diastasis of muscles. bifid uvula • CNS or neuromuscular disease • Preexisting speech disorder? 2/12/2019 rhinoplastyman@yahoo.com 33 .

PreOp Evaluation of Adenoid Disease Lateral neck films are useful only when history and physical exam are not in agreement. Accuracy of lateral neck films is dependent on proper positioning and patient cooperation.com 34 . 2/12/2019 rhinoplastyman@yahoo.

PreOp Evaluation of Adenoid Disease 2/12/2019 rhinoplastyman@yahoo.com 35 .

com 36 . PreOp Evaluation of Tonsillar Disease History • Documentation of episodes by physician • FTT • Cor pulmonale • Poststreptococcal GN • Rheumatic fever 2/12/2019 rhinoplastyman@yahoo.

com 37 . PreOp Evaluation of Tonsillar Disease TONSIL SIZE • 0 in fossa • +1 <25% occupation of oropharynx • +2 25-50% • +3 50-75% • +4 >75% 2/12/2019 Avoid gagging the patient rhinoplastyman@yahoo.

com 38 . PreOp Evaluation of Tonsillar Disease Down syndrome • 10% have AtlantoAxial laxity • Obtain lateral cervical films (flexion/extension) when positive findings on history. need neurosurgical evaluation preoperatively • Large tongue and small mandible… difficult intubation • Prone to cardiac arrhythmias/hypotension during induction 2/12/2019 rhinoplastyman@yahoo. PE • If unstable.

PT/PTT. BT.com 39 . PreOp Evaluation for Adenotonsillar Disease Coagulation disorders • Historical screening • CBC. vWF activity • Hematology consult • von Willebrand’s disease • ITP • Sickle cell anemia 2/12/2019 rhinoplastyman@yahoo.

com 40 . Principles of Surgical Management Numerous techniques: • Guillotine • Tonsillotome • Beck’s snare • Dissection with snare (Scissor dissection. Fisher’s knife dissection. KTP) • Coblation • RadioFrequency … Surgeon’s preference 2/12/2019 rhinoplastyman@yahoo. Finger dissection • Electrodissection • Laser dissection (CO2.

vomiting.identified disorder) in patient 2/12/2019 or family member rhinoplastyman@yahoo. Post Operative Managment Criteria for Overnight Observation • Poor oral intake.com 41 . hemorrhage • Age < 3 • Home > 45 minutes away • Poor socioeconomic condition • Comorbid medical problems • Surgery for OSA or PTA • Abnormal coagulation values (+/.

com 42 . uvular swelling • Respiratory compromise • Dehydration • Burns and iatrogenic trauma • Dental problems and trauma 2/12/2019 rhinoplastyman@yahoo. otalgia. Complications #1 Postoperative bleeding Other: • Sore throat.

com 43 . Rare Complications • Velopharyngeal Insufficiency • Nasopharyngeal stenosis • Atlantoaxial subluxation/ Grisel’s syndrome • Regrowth • Eustachian tube injury • Depression • Laceration of ICA/ pseudoaneursym of ICA 2/12/2019 rhinoplastyman@yahoo.

afrin • Overnight observation and IV fluids • Dangerous induction • ECA ligation • Arteriography 2/12/2019 rhinoplastyman@yahoo.com 44 . Management of Hemorrhage • Ice water gargle.

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She’s been on four different antibiotics this year.com 47 .” • You call her pediatrician… he is out of town and his nurse can’t find the chart 2/12/2019 rhinoplastyman@yahoo. Case study • 13 year old female referred by PCP for frequent throat infections • “She’s always sick.

Patient is adopted. 2/12/2019 rhinoplastyman@yahoo. Case study • No known medical problems. • Family history unknown.com 48 . no prior surgical procedures • Takes motrin for menustrual cramps • No personal history of bleeding other than occasional nose bleeds and extremely heavy periods.

If she misses any more school.” 2/12/2019 rhinoplastyman@yahoo. she’ll be held back.” • You hesitate.com 49 . • Mom breaks down in tears when you tell her you do not have enough documentation of illness to warrant T & A. “I had to go on welfare because I’ve missed so much work from her being out sick. Case study • Physical exam is unremarkable. She adds. “Her grades have dropped from all A’s to all F’s.

• She has a mild microcytic anemia and prolonged bleeding time. • Because of her history of epistaxis and menorrhagia. • You order vWF activity level and consult 2/12/2019 rhinoplastyman@yahoo. PTT. you order a PT. CBC. BT.com 50 hematology . Case study • You confirm with her pediatrician that she has had 4 episodes of tonsillitis this year and agree to T & A.

which responds to a DDAVP challenge (rise in vWF and Factor VII greater than 100%). • You advise her to stop taking motrin. 2/12/2019 rhinoplastyman@yahoo.3 microg/kg IV over 30 min and amicar 200mg/kg.com 51 . she receives desmopressin 0. • Before surgery. Case study • She has a subnormal level of vWF.

Case study • She receives the same dose of DDVAP 12 hours postoperatively and every morning. • Desmopressin is discontinued and substituted with cryoprecipitate. Sodium levels drop to 130.com 52 . 2/12/2019 rhinoplastyman@yahoo. • Amicar is given 100mg/kg PO q 6 hr. serum sodium is drawn. • Before each dose of DDAVP.

draw a Factor VII level and CBC.6. and call her hematologist.9 to 9. 2/12/2019 rhinoplastyman@yahoo. • Hemoglobin has dropped from 11. • You order cryoprecipitate. Case study • Patient presents to the ER on POD # 7 complaining of intermittent bleeding from her mouth.com 53 .

patient is discharged the next day 2/12/2019 rhinoplastyman@yahoo. and administer crypoprecipitate • No further bleeding occurs. an old clot is present • You establish IV access. have her gargle with ice water. Case study • PE reveals no active bleeding.com 54 . admit the patient for overnight observation.