Tonsillitis, Tonsillectomy and Adenoidectomy Steven T. Wright, M.D. Ronald Deskin, M.D.

Tonsillitis, Tonsillectomy and
Adenoidectomy
Steven T. Wright, M.D.
Ronald Deskin, M.D.
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.
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Bibliography
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