Tonsillectomy, and Adenoidectomy

Tonsillectomy, and Adenoidectomy
By:Babak Saedi
Assistant professor of Tehran university


Introduction
History
Anatomy
Tonsils
* Plica triangularis
* Gerlach’s tonsil
Adenoids
* Fossa of Rosenmüller
* Passavant’s ridge
Blood Supply
Tonsils
* Ascending and descending palatine arteries
* Tonsillar artery
* 1% aberrant ICA just deep to superior constrictor

Adenoids
* Ascending pharyngeal, sphenopalatine arteries
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
* 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
Obstructive Hyperplasia
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
* Hyperkeratosis, mycosis leptothrica
* Tonsilloliths
Candidiasis
Syphilis
Retention Cysts
Supratonsillar Cleft
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
PreOp Evaluation of Adenoid Disease
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?
TONSIL SIZE
Avoid gagging the patient
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

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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
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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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