Adenotonsillar disease

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Adenotonsillar disease

• Shahin Bastaninejad, MD, ORL-HNS Surgeon
• Assistant professor of tehran university of
  medical sciences

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Anatomy

• Tonsil boundary
• Plica triangularis
• Adenoid boundary
• Posterior aspect of the nasal septum
• Fossa of Rosenmüller
• Passavants ridge

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Waldeyers Ring
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Presentation outlines

• Acute Infections
• Chronic diseases
• Obstructive hyperplasia
• Mass
• Surgery

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Acute Infections
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Acute Adenotonsillitis

• Etiology
• 85 of this problem is due to the viral infection
  (less in children)
• In bacterial infections there is about 40
  antibiotic resistancy (due to beta-lactamase-produ
  cing germs)
• GABHS is the most important pathogen because of
  potential sequelae

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Bacteriology of adenotonsillitis

• Group A beta-hemolytic is most recognized
  pathogen
• This organism is associated with a risk of
  rheumatic fever and glomerulonephritis
• Many other organisms are involved
• H.influenza
• S. aureus
• Streptococcus pneumoniae

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GABHS

• More common in 5 to 15 years old children
• Not seen in less than 3 years

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Diagnosis

• Viral pharyngitis symptoms
• Coryza
• Hoarseness
• Cough
• Conjunctivitis
• Centor criteria for GABHS
• Hx of fever more than 38
• Anterior cervical LAP
• Pharyngeal or Tonsillar exudate
• Absence of cough

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Approach to the Centor scoring

• 0-1 ? Abx not needed
• 2-4 ? perform Cx
• Clue when all 4 scores are present in 44 of
  the patients there is no GABHS

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Treatment Plan

• Delay in treatment up to 9 days can be
  acceptebale
• When empiric txy?
• Lack of Pt .f/u
• Lack of Lab. access
• Toxic presentation
• In some extends when all 4 measures present

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In parentheses!!!

• When culture is positive there are two
  possibilites
• True infection
• Carrier state
• In this scenario, serological evaluation with
  ASO(anti-streptolysin O) will be usefull (in true
  infection it will be more than 3 times than its
  usual range)

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Medical Management

• Penicillin is first line treatment ? oral
  medication is preferable (penicillin V)
• Other choices
• Amoxicillin (wide spectrum than Pencillin V)
• Macrolides
• Clindamycin

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• Recurrent or unresponsive infections require
  treatment with beta-lactamase resistant
  antibiotics such as
• Clindamycin
• Augmentin
• Penicillin plus rifampin (or Erythro Metro)

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• If no response after 48 hr, re-evaluate patient
  for the followings
• Sequelea
• Patients incompliance
• Other underlying disease
• Abx failure

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Peritonsillar abscess

• Abscess formation outside tonsillar capsule
• Signs and symptoms
• Fever
• Sore throat
• Dysphagia/odynophagia
• Drooling
• Trismus
• Unilateral swelling of soft palate/pharynx with
  uvula deviation

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Be aware of ICA Aneurysm!
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Peritonsillar abscess

• Thought to be extension of tonsillitis to involve
  surrounding tissue with abscess formation
• Recently described to be an infection of small
  salivary glands in the supratonsillar fossa
  called Webers glands
• Would explain superior pole involvement and the
  usual absence of tonsillar erythema/exudates

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Candidiasis
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Infectious Mononucleosis
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IMN

• Clinical diagnosis can be made from the
  characteristic triad of fever, pharyngitis, and
  lymphadenopathy lasting for 1 to 4 weeks
• Laboratory tests are needed for confirmation
• Serologic test results include a normal to
  moderately elevated white blood cell count, an
  increased total number of lymphocytes (more than
  50), greater than 10 atypical lymphocytes, and
  a positive reaction to a "mono spot" test

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IMN

• When "mono spot" or heterophile test results are
  negative, additional laboratory testing may be
  needed to differentiate EBV infections from a
  mononucleosis-like illness
• EBV-Specific Laboratory Tests
• IgM and IgG to the viral capsid antigen
• IgM to the early antigen
• antibody to EBNA

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IMN Test interpretation

• Primary Infection Primary EBV infection is
  indicated if IgM antibody to the viral capsid
  antigen is present and antibody to EBNA is absent
• Past Infection If antibodies to both the viral
  capsid antigen and EBNA are present, then past
  infection (from 4 to 6 months to years earlier)
  is indicated

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IMN Test interpretation

• Reactivation In the presence of antibodies to
  EBNA, an elevation of antibodies to early antigen
  suggests reactivation
• Chronic EBV Infection Reliable laboratory
  evidence for continued active EBV infection is
  very seldom found in patients who have been ill
  for more than 4 months

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Diphtheria
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Chronic disease
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Chronic Tonsillitis

• Chronic sore throat
• Malodorous breath
• Presence of tonsilliths
• Persistent tender cervical lymphadenopathy
• Lasting at least 3 months
• Be aware of Anaerobic infections

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Cryptic tonsils

• Hyperkeratosis, mycosis leptothrica
• Tonsilloliths

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Obstructive Hyperplasia
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Obstructive Adenoid Hyperplasia

• Signs and Symptoms
• Obligate mouth breathing
• Hyponasal voice
• Snoring and other signs of sleep disturbance

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Obstructive Tonsillar Hyperplasia

• Snoring and other symptoms of sleep disturbance
• Muffled voice
• Dysphagia

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Tonsillar Mass
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Malignant Neoplasms

• Most common is lymphoma
• Non-Hodgkins lymphoma
• Rapid unilateral tonsillar enlargement associated
  with cervical lymphadenopathy and systemic
  symptoms

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Lymphoma
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SCC
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Congenital tonsillar masses

• Teratoma
• Hemangioma
• Lymphangioma
• Cystic hygroma

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Surgery
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Tonsillectomy(2010-AAOHNS)

• Infection indications
• Pharyngitis more than 7 / yr in 1 yr
• More than 5 / yr for 2yrs
• More than 3 / yr for 3yrs
• Recurrent infections with modifying factors
• Multiple Abx allergy / intolerance
• PF.ASP.A periodic fever/aphthous stomatitis and
  pharyngitis/adenitis
• History of peritonsillar abscess

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Tnosillectomy Cont

• Persistent foul taste or breath due to chronic
  tonsillitis not responsive to medical therapy
• Chronic or recurrent tonsillitis associated with
  streptococcal carrier state and not responding to
  beta-lactamase resistant antibiotics
• Unilateral tonsil hypertrophy presumed to be
  neoplastic

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Adenotonsillectomy

• ATH and Sleep disordered breathing (SDB)
• Severity of the SDB depends on adenotonsillar
  size and/or Craniofacial anatomy and/or
  neuromuscular tone
• Ask for comorbid conditions Growth retardation /
  poor school performance / enuresis / behavioral
  problems (ADHD,)
• Polysomnography indications (PaO2 less than 85
  and/or AHIgt5) ? check PSG in obese patient/down
  syndrome/craniofacial anomaly

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Adenoidectomy

• Infection
• Purulent adenoiditis
• Adenoid hypertrophy associated with
• Chronic otitis media with effusion
• Chronic recurrent acute otitis media
• Chronic otitis media with perforation
• Otorrhea or chronic tube otorrhea
• Obstruction (next slide)
• Other
• Suspected neoplasia
• Adenoid hypertrophy associated with chronic
  sinusitis

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Adenoidectomy Cont

• Obstruction
• Adenoid hypertrophy associated with excessive
  snoring and chronic mouth-breathing
• Sleep apnea or sleep disturbances
• Adenoid hypertrophy associated with
• Cor pulmonale
• Failure to thrive
• Dysphagia
• Speech abnormalities
• Craniofacial growth abnormalities
• Occlusion abnormalities
• Speech abnormalities

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Pre-Op Evaluation of Adenoid Disease

• Triad of hyponasality, snoring, and mouth
  breathing
• Rhinorrhea, nocturnal cough, post nasal drip
• Adenoid facies
• long face, crowded incisors

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Pre-Op Evaluation of Adenoid Disease

• Evaluate palate
• Symptoms/FH of CP or VPI
• Bifid uvula
• CNS or neuromuscular disease
• Preexisting speech disorder?

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Pre-Op 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.

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Any questions !?