????????? ????? ??????? ? ???????? ?? Tonsillectomy

1
????????? ????? ??????? ? ???????? ??
Tonsillectomy AdenoidectomyDr.S
SohelipourDr.SHR Abtahi
2
Introduction

• In 1994 140,000 U.S. children under the age of
  15 had adenoidectomies and 286,000 had
  adenotonsillectomies
• This is down from a peak of over 1 million in the
  1970s
• These are the most common major surgical
  procedures in children.

3
Anatomy

• Tonsils
• Plica triangularis
• Gerlachs tonsil
• Adenoids
• Fossa of Rosenmüller
• Passavants ridge

4
(No Transcript)
5
Blood Supply

• Tonsils
• Ascending and descending palatine arteries
• Tonsillar artery
• 1 aberrant ICA just deep to superior constrictor
• Adenoids
• Ascending pharyngeal, sphenopalatine arteries

6
Histology

• Tonsils
• Specialized squamous
• Extrafollicular
• Mantle zone
• Germinal center
• Adenoids
• Ciliated pseudostratified columnar
• Stratified squamous
• Transitional

7
Common Diseases of the Tonsils and Adenoids

• Acute adenoiditis/tonsillitis
• Recurrent/chronic adenoiditis/tonsillitis
• Obstructive hyperplasia
• Malignancy

8
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

9
(No Transcript)
10
Microbiology of Adenotonsillitis

• Most common organisms cultured from patients with
  chronic tonsillar disease (recurrent/chronic
  infection, hyperplasia)
• Streptococcus pyogenes (Group A beta-hemolytic
  streptococcus)
• H.influenza
• S. aureus
• Streptococcus pneumoniae

11
Acute Adenotonsillitis

• Differential diagnosis
• Infectious mononucleosisMalignancy lymphoma,
  leukemia, carcinomaDiptheriaScarlet
  feverAgranulocytosis

12
Medical Management

• PCN is first line, even if throat culture is
  negative for GABHS
• For acute UAO NP airway, steroids, IV abx, and
  tonsillectomy for poor response
• Recurrent tonsillitis PCN injection if concerned
  about noncompliance or antibiotics aimed against
  BLPO and anaerobes
• For chronic tonsillitis or obstruction,
  antibiotics directed against BLPO and anaerobes
  for 3-6 weeks will eliminate need for surgery in
  17

13
Obstructive Hyperplasia

• Adenotonsillar hypertrophy most common cause of
  SDB in children
• Diagnosis
• Indications for polysomnography
• Interpretation of polysomnography
• Perioperative considerations

14
Unilateral Tonsillar Enlargement

• Apparent enlargement vs true enlargement
• Non-neoplastic
• Acute infective
• Chronic infective
• Hypertrophy
• Congenital
• Neoplastic

15
Peritonsillar Abscess
16
(No Transcript)
17
ICA Aneurysm
18
Pleomorphic Adenoma
19
Other Tonsillar Pathology

• Hyperkeratosis, mycosis leptothrica
• Tonsilloliths

20
Candidiasis
21
Syphilis
22
Retention Cysts
23
Supratonsillar Cleft
24
Indications for Tonsillectomy

• AAO-HNS
• 4 or more episodes/year
• Hypertrophy causing malocclusion, UAO
• PTA unresponsive to nonsurgical mgmt
• Halitosis, not responsive to medical therapy
• UTE, suspicious for malignancy
• Individual considerations

25
Indications for Adenoidectomy

• Obstruction
• Chronic nasal obstruction or obligate mouth
  breathing
• OSA with FTT, cor pulmonale
• Dysphagia
• Speech problems
• Severe orofacial/dental abnormalities
• Infection
• Recurrent/chronic adenoiditis (4 or more
  episodes/year)
• Recurrent/chronic OME

26
PreOp Evaluation of Adenoid Disease

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

27
PreOp Evaluation of Adenoid Disease

• Differential diagnoses
• Allergic rhinitis
• Sinusitis
• GERD
• For concomitant sinus disease, treat adenoids
  first

28
PreOp Evaluation of Adenoid Disease

• Evaluate palate
• Symptoms/FH of CP or VPI
• Midline diastases of muscles, bifid uvula
• CNS or neuromuscular disease
• Preexisting speech disorder?

29
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.

30
PreOp Evaluation of Adenoid Disease
31
PreOp Evaluation of Tonsillar Disease

• History
• Documentation of episodes by physician
• FTT
• Cor pulmonale
• Poststreptococcal GN
• Rheumatic fever

32
PreOp Evaluation of Tonsillar Disease

• TONSIL SIZE
• 0 in fossa
• 1 lt25 occupation of oropharynx
• 2 25-50
• 3 50-75
• 4 gt75

Avoid gagging the patient
33
Complications

• 0.1-8.1 Postoperative bleeding
• Other
• Sore throat, otalgia, uvular swelling
• Respiratory compromise
• Dehydration
• Burns and iatrogenic trauma

34
Rare Complications

• Velopharyngeal Insufficiency
• Nasopharyngeal stenosis
• Atlantoaxial subluxation/ Grisels syndrome
• Regrowth
• Eustachian tube injury
• Depression
• Laceration of ICA/ pseudoaneursym of ICA

35
Questions?
36
(No Transcript)
37
DEFINITION

• Adenoid pharyngeal tonsil Nasopharyngeal
• Mass of sub epithelial lympoid tissue situated
  posterior to the nasal cavity in the roof of the
  nasopharynx
• In children it forms a soft mound in the roof and
  posterior wall of the nasopharynx, above and
  behind the uvula.
• Age enlargement from less than a year old to 12
  years.

38
HISTOLOGY OF ADENOID

• Unlike other types of tonsils.
• Has pseudostratified columnar ciliated
  epithelium.
• Lack crypts (opening or outlet) but has a capsule
• It drains to the jugulodigastric lymph nodes
  below the angle of the mandible.

39
IMPORTANCE OF ADENOID AND TONSILLAR TISSUE.

• Part of lymphoid tissue of Waldeyers ring
• Its size increases progressively until puberty,
  then diminishes until about the age of 20 years
  and from this time onwards, maintains its adult
  size.

40

• Protective Functions
• Formation of lymphocytes
• Formation of antibodies
• Acquisition of immunity
• Localization of infection filters to the
  upper respiratory passages.

41
PATHOLOGY

• An enlarged adenoid or adenoid hypertrophy, can
  become nearly the size of a ping pong ball.
• Completely block airflow through the nasal
  passages or block the back of the nose.
• Breathing through the nose requiring an
  uncomfortable amount of work.
• Inhalation occurs instead through an open mouth.
• Affects voice mechanism (speech hyponasality)
• Recurrent upper respiratory tract infection.

42
CLINICAL FEATURES OF ADENOID FACES IN CHILDREN.

• It causes an atypical appearance of the face
  (adenoid face)
• Features of adenoid faces include
• Mouth breathing
• Elongated face
• Prominent incisors
• Hypoplastic maxilla
• Short upper lip
• Elevated nostril
• High Arched palate

43
TONSILLITIS ADENOID
44
Symptoms

• Bilateral Nasal
• discharge
• Mucoid or mucopurulent discharge WHY? Due to
  blockage of the choanae
• Excoriation of the nasal vestibule upper lip
• Post nasal discharge causing frequent nocturnal
  cough

• Bilateral Nasal Obstruction
• Mouth Breathing
• Snoring OSA
• Speech hyponasality
• Difficult suckling

Rhinolalia clausa (speech hyponasality)
45
Signs

• Posterior Rhinoscopy ? difficult
• Digital palpation? not pleasant
• Endoscopic examination? the best

46
Investigations

• Lateral soft tisue X ray of the nasopharynx
• It is not the size of the
• nasopharyngeal tonsil which is
• important but the size of the
• mass in relation to the
• nasopharyngeal space

47
Complications
Restless sleep, Night mare, Nocturnal eneuresis

• 1- OSAS
• During Sleep
• During day time
• 2- Descending infection
• 3-? Adenoid Facies

Morning headache Impaired concentration Excessive
day-time sleepiness
Recurrent OM Pharyngitis, Laryngitis, bronchitis
Idiot look Pinched nostril Short upper
lip Prominent incisor High arched palate
48
(No Transcript)
49
Removal

• Adenoidectomy procedure of surgical removal of
  the adenoid
• Studies have shown that adenoid regrowth occurs
  in as many as 20 of the cases after removal.
  Why?
• Adenoid tissue is not encompassed by a capsule
  like the tonsils. Complete removal of all adenoid
  tissue is nearly impossible and thus recurrent
  hypertrophy or infection is possible.

50
Indications for Adenoidectomy

• Paradise study (1984)
• 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 (1994)
• Recommend adenoidectomy with M T as the initial
  surgical treatment for children with MEE gt 90
  days and CHL gt 20 dB

51
Indications for Adenoidectomy

• Obstruction
• Chronic nasal obstruction or obligate mouth
  breathing
• OSA with FTT, cor pulmonale
• Dysphagia
• Speech problems
• Severe orofacial/dental abnormalities
• Infection
• Recurrent/chronic adenoiditis (3 or more
  episodes/year)
• Recurrent/chronic OME (/- previous BMT)

52
PreOp Evaluation of Adenoid Disease

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

53
PreOp Evaluation of Adenoid Disease

• Differential diagnoses
• Allergic rhinitis
• Sinusitis
• GERD
• For concomitant sinus disease, treat adenoids
  first

54
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?

55
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.

56
PreOp Evaluation of Adenoid Disease
57
Treatment

• Adenoidectomy operation

58
Adenoidectomy with great care

• Adenoidectomy for speech problems
• Look for short palate, submucous cleft of the
  short or hard palate to avoid velopharyngeal
  insufficiency after the procedure as the voice
  may become hypernasal.
• Should be avoided in patients with cleft palate.

59
Acute tonillitisAcue inflammation of the
palatine tonsils

• Age Any age but common in children
• Etiology
• Beta hemolyic streptococci
• Streptococcus pneumonia
• Hemophylus influenza
• Mode of transmission
• droplet infection

60
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

61
Anatomy

• Tonsils
• Plica triangularis
• Gerlachs tonsil
• Adenoids
• Fossa of Rosenmüller
• Passavants ridge

62
Blood Supply

• Tonsils
• Ascending and descending palatine arteries
• Tonsillar artery
• 1 aberrant ICA just deep to superior constrictor
• Adenoids
• Ascending pharyngeal, sphenopalatine arteries

63
Histology

• Tonsils
• Specialized squamous
• Extrafollicular
• Mantle zone
• Germinal center
• Adenoids
• Ciliated pseudostratified columnar
• Stratified squamous
• Transitional

64

• Symptoms
• Rapid onset of
• - Fever, Headache, Anorrhexia, Malaise
• - Severe sore throat referred otagia
• - Halitosis

65

• Signs
• General
• High Fever with flushed face
• Pharyngeal
• Acute follicular tonsillitis
• Acute membranous tonsillitis
• Acute parynchymatous tonsillitis
• Cervical
• Enlarged tender jugulo-digastric lymph nodes

The crypts of the tonsils are full of purulent
exudate Giving yellow spots on the tonsils
Marked hyperemia and enlargement of the tonsils
The yellow spots may Coalease to form a Yellow
membrane
Acute parynchymatous T
Acute follicular T.
Acute membranous T
66

• Complications
• Local
• Peritonsillar abscess
• Parapharyngeal abscess
• Retropharyngeal abscess
• Systemic
• Rheumatic fever (carditis and arthritis)
• Acute glomerulonephritis

Quinzy
67
PreOp Evaluation of Tonsillar Disease

• History
• Documentation of episodes by physician
• FTT
• Cor pulmonale
• Poststreptococcal GN
• Rheumatic fever

68
PreOp Evaluation of Tonsillar Disease

• TONSIL SIZE
• 0 in fossa
• 1 lt25 occupation of oropharynx
• 2 25-50
• 3 50-75
• 4 gt75

Avoid gagging the patient
69
PreOp Evaluation of Tonsillar Disease

• Down syndrome
• 10 have AA laxity
• Obtain lateral cervical films (flexion/extension)
  when positive findings on history, PE
• If unstable, need neurosurgical evaluation
  preoperatively
• Large tongue and small mandible difficult
  intubation
• Prone to cardiac arrhythmias/hypotension during
  induction

70
Treatment

• Antibiotics 10 days
• Rest
• Ample fluid intake
• Cold compresses
• Analgesic Antipyretics
• Gargles

71
Chronic TonsillitisChronic inflammation of the
palatine tonsils

• Etiology
• Repeated attacks of acute tonsillitis
• Symptoms one or more of the following
• History of repeated attacks of AT
• Irritation in the throat
• Foetor oris
• If hypertrophic?
• Difficult swallowing
• Obsrtuctive sleep apnea

72

• Signs
• Pharyngeal
• Asymmetry of the size of the tonsils
• Hypertrophy of the tonsils
• The crypts ooze pus on pressure by tongue
  depressor
• Hyperaemia of the anterior pillars
• Cervical
• Persistent enlargement of jagulodigastric lymph
  nodes

73
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

74
Microbiology of Adenotonsillitis

• Most common organisms cultured from patients
  with chronic tonsillar disease (recurrent/chronic
  infection, hyperplasia)
• Streptococcus pyogenes (Group A beta-hemolytic
  streptococcus)
• H.influenza
• S. aureus
• Streptococcus pneumoniae
• Tonsil weight is directly proportional to
  bacterial load.

75
Acute Adenotonsillitis

• Differential diagnosis
• Infectious mononucleosisMalignancy lymphoma,
  leukemia, carcinomaDiptheriaScarlet
  feverAgranulocytosis

76
Medical Management

• PCN is first line, even if throat culture is
  negative for GABHS
• For acute UAO NP airway, steroids, IV abx, 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,
  antibiotics directed against BLPO and anaerobes
  for 3-6 weeks will eliminate need for surgery in
  17

77
PreOp Evaluation for Adenotonsillar Disease

• Coagulation disorders
• Historical screening
• CBC, PT/PTT, BT, vWF activity
• Hematology consult
• von Willebrands disease
• ITP
• Sickle cell anemia

78
Principles of Surgical Management

• Numerous techniques
• Guillotine
• Tonsillotome
• Becks snare
• Dissection with snare (Scissor dissection,
  Fishers knife dissection, Finger dissection
• Electrodissection
• Laser dissection (CO2, KTP)
• Surgeons preference

79
Post Operative Managment

• Criteria for Overnight Observation
• Poor oral intake, vomiting, hemorrhage
• Age lt 3
• Home gt 45 minutes away
• Poor socioeconomic condition
• Comorbid medical problems
• Surgery for OSA or PTA
• Abnormal coagulation values (/- identified
  disorder) in patient or family member

80
Complications

• 1 Postoperative bleeding
• Other
• Sore throat, otalgia, uvular swelling
• Respiratory compromise
• Dehydration
• Burns and iatrogenic trauma

81
Rare Complications

• Velopharyngeal Insufficiency
• Nasopharyngeal stenosis
• Atlantoaxial subluxation/ Grisels syndrome
• Regrowth
• Eustachian tube injury
• Depression
• Laceration of ICA/ pseudoaneursym of ICA

82
Management of Hemorrhage

• Ice water gargle, afrin
• Overnight observation and IV fluids
• Dangerous induction
• ECA ligation
• Arteriography

83
Obstructive Hyperplasia

• Adenotonsillar hypertrophy most common cause of
  SDB in children
• Diagnosis
• Indications for polysomnography
• Interpretation of polysomnography
• Perioperative considerations

84
Unilateral Tonsillar Enlargement

• Apparent enlargement vs true enlargement
• Non-neoplastic
• Acute infective
• Chronic infective
• Hypertrophy
• Congenital
• Neoplastic

85
Peritonsillar Abscess
86
Pleomorphic Adenoma
87
Other Tonsillar Pathology

• Hyperkeratosis, mycosis leptothrica
• Tonsilloliths

88
Candidiasis
89
Syphilis
90
Retention Cysts
91
Supratonsillar Cleft
92
Indications for Tonsillectomy Historical
Evolution
93
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 38.3, cervical
  LAD (gt2cm) or tender LAD tonsillar/pharyngeal
  exudate positive culture for GABHS antibiotic
  treatment

94
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, suspicious for malignancy
• Individual considerations

95
Case study

• 13 year old female referred by PCP for frequent
  throat infections
• Shes always sick. Shes been on four different
  antibiotics this year.
• You call her pediatrician he is out of town and
  his nurse cant find the chart

96
Case study

• No known medical problems, no prior surgical
  procedures
• Takes motrin for menustrual cramps
• No personal history of bleeding other than
  occasional nose bleeds and extremely heavy
  periods.
• Family history unknown. Patient is adopted.

97
Case study

• Physical exam is unremarkable.
• 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
  Ive missed so much work from her being out
  sick.
• You hesitate. She adds, Her grades have dropped
  from all As to all Fs. If she misses any more
  school, shell be held back.

98
Case study

• You confirm with her pediatrician that she has
  had 4 episodes of tonsillitis this year and agree
  to T A.
• Because of her history of epistaxis and
  menorrhagia, you order a PT, PTT, CBC, BT.
• She has a mild microcytic anemia and prolonged
  bleeding time.
• You order vWF activity level and consult
  hematology

99
Case study

• She has a subnormal level of vWF, which responds
  to a DDAVP challenge (rise in vWF and Factor VII
  greater than 100).
• You advise her to stop taking motrin.
• Before surgery, she receives desmopressin 0.3
  microg/kg IV over 30 min and amicar 200mg/kg.

100
Case study

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

101
Case study

• Patient presents to the ER on POD 7 complaining
  of intermittent bleeding from her mouth.
• You order cryoprecipitate, draw a Factor VII
  level and CBC, and call her hematologist.
• Hemoglobin has dropped from 11.9 to 9.6.

102
Case study

• PE reveals no active bleeding an old clot is
  present
• You establish IV access, admit the patient for
  overnight observation, have her gargle with ice
  water, and administer crypoprecipitate
• No further bleeding occurs, patient is discharged
  the next day