Tonsillitis, Tonsillectomy, and Adenoidectomy

January 30, 2018 | Author: Anonymous | Category: Science, Health Science, Immunology
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Adenotonsillar disease

Shahin Bastaninejad, MD, ORL-HNS Surgeon

Assistant professor of tehran university of medical sciences

Anatomy Tonsil boundary  Plica triangularis

Adenoid boundary  Posterior aspect of the nasal septum

 Fossa of Rosenmüller  Passavant’s ridge

Waldeyer’s Ring

Presentation outlines  Acute Infections  Chronic diseases  Obstructive hyperplasia  Mass  Surgery

Acute Infections

Acute Adenotonsillitis Etiology  85% of this problem is due to the viral infection (less in children)  In bacterial infections there is about 40% antibiotic resistancy (due to beta-lactamaseproducing germs)  GABHS is the most important pathogen because of potential sequelae

Bacteriology of adenotonsillitis  Group A beta-hemolytic is most recognized

pathogen  This organism is associated with a risk of rheumatic fever and glomerulonephritis  Many other organisms are involved :  H.influenza  S. aureus  Streptococcus pneumoniae

GABHS  More common in 5 to 15 years old children  Not seen in less than 3 years

Diagnosis  Viral pharyngitis symptoms:  Coryza  Hoarseness  Cough  Conjunctivitis

 Centor criteria for GABHS:  Hx of fever more than 38  Anterior cervical LAP  Pharyngeal or Tonsillar exudate  Absence of cough

Approach to the Centor scoring  0-1  Abx not needed

 2-4  perform Cx  Clue : when all 4 scores are present in 44% of

the patients there is no GABHS

Treatment Plan  Delay in treatment up to 9 days can be

acceptebale  When empiric txy?  Lack of Pt .f/u  Lack of Lab. access  Toxic presentation  In some extends when all 4 measures present

In parentheses!!!  When culture is positive there are two

possibilites:  True infection  Carrier state

 In this scenario, serological evaluation with

ASO(anti-streptolysin O) will be usefull (in true infection it will be more than 3 times than its usual range)

Medical Management  Penicillin is first line treatment  oral

medication is preferable (penicillin V)  Other choices:  Amoxicillin (wide spectrum than Pencillin V)  Macrolides  Clindamycin

 Recurrent or unresponsive infections require

treatment with beta-lactamase resistant antibiotics such as  Clindamycin

 Augmentin  Penicillin plus rifampin (or Erythro + Metro)

 If no response after 48 hr, re-evaluate patient

for the followings:  Sequelea  Patient’s incompliance

 Other underlying disease  Abx failure

Peritonsillar abscess  Abscess formation outside tonsillar capsule  Signs and symptoms:  Fever

 Sore throat  Dysphagia/odynophagia  Drooling  Trismus  Unilateral swelling of soft palate/pharynx with uvula

deviation

Be aware of ICA Aneurysm!

Peritonsillar abscess…  Thought to be extension of tonsillitis to involve

surrounding tissue with abscess formation  Recently described to be an infection of small

salivary glands in the supratonsillar fossa called

Weber’s glands  Would explain superior pole involvement and the

usual absence of tonsillar erythema/exudates

Candidiasis

Infectious Mononucleosis

IMN  Clinical diagnosis can be made from the

characteristic triad of fever, pharyngitis, and lymphadenopathy lasting for 1 to 4 weeks  Laboratory tests are needed for confirmation  Serologic test results include a normal to moderately elevated white blood cell count, an increased total number of lymphocytes (more than 50%), greater than 10% atypical lymphocytes, and a positive reaction to a "mono spot" test

IMN  When "mono spot" or heterophile test results are negative, additional laboratory testing may be needed to differentiate EBV infections from a mononucleosis-like illness  EBV-Specific Laboratory Tests:  IgM and IgG to the viral capsid antigen  IgM to the early antigen  antibody to EBNA

IMN – Test interpretation  Primary Infection: Primary EBV infection is

indicated if IgM antibody to the viral capsid antigen is present and antibody to EBNA is absent  Past Infection: If antibodies to both the viral capsid antigen and EBNA are present, then past infection (from 4 to 6 months to years earlier) is indicated

IMN – Test interpretation  Reactivation: In the presence of antibodies

to EBNA, an elevation of antibodies to early antigen suggests reactivation  Chronic EBV Infection: Reliable laboratory evidence for continued active EBV infection is very seldom found in patients who have been ill for more than 4 months

Diphtheria

Chronic disease

Chronic Tonsillitis  Chronic sore throat  Malodorous breath  Presence of tonsilliths  Persistent tender cervical lymphadenopathy  Lasting at least 3 months

 Be aware of Anaerobic infections

Cryptic tonsils

 Hyperkeratosis,

mycosis leptothrica  Tonsilloliths

Obstructive Hyperplasia

Obstructive Adenoid Hyperplasia  Signs and Symptoms  Obligate mouth breathing  Hyponasal voice

 Snoring and other signs of sleep disturbance

Obstructive Tonsillar Hyperplasia  Snoring and other symptoms of sleep

disturbance  Muffled voice  Dysphagia

Tonsillar Mass

Malignant Neoplasms  Most common is lymphoma  Non-Hodgkin’s lymphoma

 Rapid unilateral tonsillar enlargement associated with cervical lymphadenopathy and systemic symptoms

Lymphoma

SCC

Congenital tonsillar masses

 Teratoma  Hemangioma  Lymphangioma  Cystic hygroma

Surgery

Tonsillectomy (2010-AAOHNS)  Infection indications:  Pharyngitis more than 7 / yr in 1 yr  More than 5 / yr for 2yrs  More than 3 / yr for 3yrs

 Recurrent infections with modifying factors:  Multiple Abx allergy / intolerance

 PF.ASP.A: periodic fever/aphthous stomatitis and

pharyngitis/adenitis  History of peritonsillar abscess

Tnosillectomy Cont…  Persistent foul taste or breath due to chronic tonsillitis

not responsive to medical therapy  Chronic or recurrent tonsillitis associated with

streptococcal carrier state and not responding to betalactamase resistant antibiotics  Unilateral tonsil hypertrophy presumed to be

neoplastic

Adenotonsillectomy  ATH and Sleep disordered breathing (SDB)  Severity of the SDB depends on adenotonsillar

size and/or Craniofacial anatomy and/or neuromuscular tone  Ask for comorbid conditions: Growth retardation / poor school performance / enuresis / behavioral problems (ADHD,…)  Polysomnography indications (PaO2 less than 85% and/or AHI>5)  check PSG in obese patient/down syndrome/craniofacial anomaly &…

 Infection:

Adenoidectomy

 Purulent adenoiditis  Adenoid hypertrophy associated with:  Chronic otitis media with effusion  Chronic recurrent acute otitis media  Chronic otitis media with perforation  Otorrhea or chronic tube otorrhea

 Obstruction (next slide)

 Other:  Suspected neoplasia  Adenoid hypertrophy associated with chronic

sinusitis

Adenoidectomy Cont…  Obstruction:  Adenoid hypertrophy associated with excessive

snoring and chronic mouth-breathing  Sleep apnea or sleep disturbances  Adenoid hypertrophy associated with:       

Cor pulmonale Failure to thrive Dysphagia Speech abnormalities Craniofacial growth abnormalities Occlusion abnormalities Speech abnormalities

Pre-Op Evaluation of Adenoid Disease  Triad of hyponasality, snoring, and mouth breathing

 Rhinorrhea, nocturnal cough, post nasal drip  “Adenoid facies”

 long face, crowded incisors

Pre-Op Evaluation of Adenoid Disease Evaluate palate  Symptoms/FH of CP or VPI  Bifid uvula  CNS or neuromuscular disease

 Preexisting speech

disorder?

Pre-Op 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.

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