Tonsillitis, Tonsillectomy, and Adenoidectomy

Tonsillitis, Tonsillectomy, and Adenoidectomy
by:Professor Sameer Bafaqeeh, M.D.
KSU
Otolaryngology Department


* Plica triangularis
* Gerlach’s tonsil
Adenoids
* Fossa of Rosenmüller
* Passavant’s ridge

Blood Supply
Tonsils
Adenoids
Histology
Tonsils
* Specialized squamous
* Extrafollicular
* Mantle zone
* Germinal center
Adenoids

* Ciliated pseudostratified columnar
* Stratified squamous
* Transitional

Common Diseases of the Tonsils and Adenoids
* Acute adenoiditis/tonsillitis
* Recurrent/chronic adenoiditis/tonsillitis
* Obstructive hyperplasia
* Malignancy

Acute Adenotonsillitis
Etiology
GABHS most important pathogen because of potential sequelae
* Throat culture
* Treatment
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.
Acute Adenotonsillitis
Differential diagnosis
Infectious mononucleosis
Malignancy: lymphoma, leukemia, carcinoma
Diptheria
Scarlet fever
Agranulocytosis
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%
Obstructive Hyperplasia
* Adenotonsillar hypertrophy most common cause of SDB in children
* Diagnosis
* Indications for polysomnography
* Interpretation of polysomnography
* Perioperative considerations
Unilateral Tonsillar Enlargement
Apparent enlargement vs true enlargement

Non-neoplastic:
* Acute infective
* Chronic infective
* Hypertrophy
* Congenital
Neoplastic
Peritonsillar Abscess
ICA Aneurysm
Pleomorphic Adenoma
Other Tonsillar Pathology
Candidiasis
Syphilis
Retention Cysts
Supratonsillar Cleft
Indications for Tonsillectomy; Historical Evolution
Indications for Tonsillectomy
Paradise study
Indications for Tonsillectomy
AAO-HNS:
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)
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
Differential diagnoses
* Allergic rhinitis
* Sinusitis
* GERD
* For concomitant sinus disease, treat adenoids first
Evaluate palate
* Symptoms/FH of CP or VPI
* Midline diastasis of muscles, bifid uvula
* CNS or neuromuscular disease
* Preexisting speech disorder?
PreOp Evaluation of Adenoid Disease
TONSIL SIZE
Avoid gagging the patient
Down syndrome
Coagulation disorders
Principles of Surgical Management
Numerous techniques:
* Guillotine
* Tonsillotome
* Beck’s snare
* Dissection with snare (Scissor dissection, Fisher’s knife dissection, Finger dissection
* Electrodissection
* Laser dissection (CO2, KTP)
Surgeon’s preference
Criteria for Overnight Observation
* Poor oral intake, vomiting, hemorrhage
* Age < 3
* Home > 45 minutes away
* Poor socioeconomic condition
* Comorbid medical problems
* Surgery for OSA or PTA
* Abnormal coagulation values (+/- identified disorder) in patient or family member
Complications
#1 Postoperative bleeding
Other:

* Sore throat, otalgia, uvular swelling
* Respiratory compromise
* Dehydration
* Burns and iatrogenic trauma
Rare Complications
* Velopharyngeal Insufficiency
* Nasopharyngeal stenosis
* Atlantoaxial subluxation/ Grisel’s syndrome
* Regrowth
* Eustachian tube injury
* Depression
* Laceration of ICA/ pseudoaneursym of ICA
Management of Hemorrhage
* Ice water gargle, afrin
* Overnight observation and IV fluids
* Dangerous induction
* ECA ligation
* Arteriography
Case study
Tonsillitis, Tonsillectomy, and Adenoidectomy.ppt

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Tonsillectomy & Adenoidectomy

Tonsillectomy & Adenoidectomy
Definition/Purpose of Procedure

* Removal of tonsils & adenoids by sharp or blunt dissection
* Adenoids are removed to facilitate breathing, prevent recurrent otitis media, and to restore hearing loss due to obstruction of the eustachian tube
Relevant A & P

Pathophysiology
* Upper aerodigestive tract
o Tonsillitis of the palatine tonsils
* Hypertrophy
Diagnostics
* Exams
o H & P
o Visual exam
o C & S
* Preop testing
o CBC: PTT-7 minutes

Special Considerations
* OR table position
* Order of extraction varies
* Best technique (not sterile)
* Surgeon may prefer to stand or sit
* Typical peds
* Adults: under local and sitting up

Surgical Intervention: Anesthesia
* General
o Peds mask induction
o Oral ET tube
o Lubricate and protect eyes

Surgical Intervention: Positioning
* Supine, neck hyperextended
* Supplies and equipment
o Neck roll
o Arm sleds or draw sheet
o Safety strap
o Foam headrest or donut
o Move patient to edge for ease of access
* Special considerations: high risk areas
Surgical Intervention: Skin Prep
Surgical Intervention: Draping/Incision
* Head wrap or cover sheet
* Peritonsillar incision
Surgical Intervention: Supplies
* General
small basin
* Specific
* Suture: 2-0 plain heavy, tapered 5/8 in needle
* Meds: local of choice (marcaine or lidocaine w/epinephrine)
Surgical Intervention: Instruments
* T & A set
* Sitting stool
* Headlamp
* ? Harmonic scalpel
* Suction apparatus
Procedure Steps
* See Exemplar and Procedure 17-6 STST
Counts

* Initial: sponges and sharps
* First closing
* Final closing
o Sponges
o Sharps
Specimen & Care
* Rt and left tonsils and adenoids
o Ask about separating—may “tag rt w/safety pin”
Postoperative Care
* Destination PACU—outpatient
* Position pt on side once extubated
* Elevate HOB
* Cold fluids
* Expected prognosis
o Return to normal activities within 2 wks
o Reduced incident of sore throat & ear infections
* Complications
* Hemorrhage up to 10 days post op
* Infection
* Wound Classification : II—increased for inflammation or infection
Resources
Tonsillectomy & Adenoidectomy

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Refresher Course on Cellular Homeostasis

Refresher Course on Cellular Homeostasis
from APS Education online
Organizers:Michael F. Romero, Ph.D. and Jeffrey C. Freedman, Ph.D.

The goal of this Refresher Course was to provide an overview of recent advances in areas of cellular homeostasis. The talks provided information that may not be readily available in a standard textbook.

In the beginning ... There was the cell (ppt file)
Michael F. Romero, Ph.D., Case Western Reserve University

Generation of the Membrane Potential (ppt file)
Steven H. Wright, Ph.D., University of Arizona College of Medicine

Ion Homeostasis, Channels, and Transporters: An Update on Cellular Mechanisms (ppt file)
George R. Dubyak, Ph.D., Case Western Reserve University

Cellular Volume Homeostasis (ppt file)
Kevin Strange, Ph.D., Vanderbilt University

Cellular pH Homeostasis (ppt file)
Walter F. Boron, M.D., Ph.D., Yale University

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