Tonsillitis, Tonsillectomy and Adenoidectomy Steven T. Wright, M.D. Faculty Advisor: Ronald Deskin, M.D. The University of Texas Medical Branch Department of Otolaryngology Grand Rounds Presentation November 5, 2003 Adenotonsillectomy Most commonly performed procedure in the history of surgery  $500 million annually in healthcare expenditures  History Almost exclusively by Otolaryngologists  Celsus in 50 A.D.  Caque of Rheims  Phillip Syng developed the tonsillotome  Anatomy Anatomy Histology Clinical Evaluation Acute Tonsillitis  Chronic Tonsillitis  Obstructive Tonsillar Hyperplasia  Clinical Evaluation   Odynophagia, fever, tender cervical lymphadenopathy. Supporting documents, 2 or more  Fever> 38.5  Tonsillar Exudate  Tender cervical LAD >2cm  Positive throat culture Clinical evaluation Viral  Lower grade fever  Lower WBC, Lymphocytic shift  Less tonsillar exudate  Bacterial  Higher WBC, Granulocytic shift  More exudative  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  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.  Adenoid Hyperplasia Triad  Hyponasality  Snoring  Open mouth breathing  Purulent rhinorrhea, post nasal drip, chronic cough, and headache  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 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%  Medical Therapy TCHP recommends confirming bacterial pharyngitis before beginning antibiotics.  Rapid Strep Test  Throat Culture  Medical Therapy    First Line  Penicillin/Cephalosporin for 10 days  Injectable forms for noncompliance BLPO, co pathogens Macrolides  Penicillin allergy  Erythromycin/Clarithromycin 10 days  Azithromycin (12mg/kg/day) 5 days Medical Therapy 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.  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  Von Willebrand’s Disease Autosomal dominant bleeding disorder  Increased bleeding time and prolonged aPTT.  Perioperative management  IV Desmopressin (0.3ugm/kg)  Serum Sodium  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.  Intracapsular Partial Tonsillectomy    45 degree Microdebrider (1500rpm). Advantages  As effective as standard tonsillectomy in relieving obstruction.  Less pain, 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. 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  Adjuvant Therapies Perioperative local anesthetic 0.25% bupivicaine w/ 1:100,000 Epinephrine Advantages: ease of dissection, postoperative pain Disadvantages: Airway obstruction, cardiac dysrrhythmias, seizures Adjuvant Therapies  Perioperative antibiotics  Fewer episodes of fever, offensive odor, improved oral intake, less pain, fewer days to return to normal activity  Cardiac abnormality Adjuvant Therapies  Perioperative Steroids  Dexamethasone (0.15-1.0mg/kg)  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. Adjuvant Therapies  Pain control  Tylenol and Tylenol w/ codeine are the most commonly used.  Similar pain control, less oral intake with codeine versus Tylenol alone.  NSAIDS still controversial. Complications Mortality rate is 1 in 16000-35000.  Anesthetic complications  Eustachian tube injury  VPI  Nasopharyngeal stenosis  Pulmonary Edema  Atlantoaxial subluxation  23 hour observation Age younger than 3.  Obstructive sleep apnea/craniofacial syndromes involving the airway.  Systemic disorders  Poor socioeconomic situation  Peritonsillar abscess  Emesis or Hemorrhage  Post Operative Hemorrhage The best treatment is prevention.  Early vs. Delayed hemorrhage.  Overnight observation and venous access  Surgical intervention.  Carotid angiography if any suspicion of carotid artery injury.  Case Study  8yo male referred to the Pediatric clinic for evaluation and treatment of recurrent tonsillitis. History 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.  Physical Examination Normal facies, open mouth breathing, tonsils 3+, no cleft deformities.  Remainder of exam is normal.  Case Study 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.  Diagnosis Dysgeusia  Unknown mechanism- thought to be due to prolonged pressure on the tongue by the mouth retractor.  Treatment is reassurance.                         Bibliography Allen GC, et al. “Adenotonsillectomy in Children with von Willebrand Disease.” Archives of Otolaryngology 1999, May; 125(5) pp547-551. 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