Tonsillectomy & Adenoidectomy Dr.S Sohelipour Dr.SHR Abtahi بيماريهاي لوزه،...

بيماريهاي لوزه، آدنوئيد و درمانهاي آن

Tonsillectomy Tonsillectomy & &

AdenoidectomyAdenoidectomy

Dr.S SohelipourDr.S SohelipourDr.SHR AbtahiDr.SHR Abtahi

Introduction

In 1994 140,000 U.S. children under the age of 15 had adenoidectomies and 286,000 had adenotonsillectomies

This is down from a peak of over 1 million in the 1970’s

These are the most common major surgical procedures in children.

AnatomyAnatomy

TonsilsTonsils Plica triangularis Gerlach’s tonsil

AdenoidsAdenoids Fossa of Rosenmüller Passavant’s ridge

Blood SupplyBlood SupplyTonsilsTonsils Ascending and

descending palatine arteries

Tonsillar artery 1% aberrant ICA just

deep to superior constrictor

AdenoidsAdenoids Ascending pharyngeal,

sphenopalatine arteries

HistologyHistology

TonsilsTonsils Specialized squamous Extrafollicular Mantle zone Germinal center

AdenoidsAdenoids Ciliated

pseudostratified columnar

Stratified squamous Transitional

Common Diseases of the Tonsils and Common Diseases of the Tonsils and AdenoidsAdenoids Acute adenoiditis/tonsillitis Recurrent/chronic

adenoiditis/tonsillitis Obstructive hyperplasia Malignancy

Acute AdenotonsillitisAcute Adenotonsillitis

Etiology 5-30% bacterial; of these

39% are beta-lactamase-producing (BLPO)

Anaerobic BLPO

GABHS most important pathogen because of potential sequelae

Throat culture

Microbiology of AdenotonsillitisMicrobiology 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

Acute AdenotonsillitisAcute Adenotonsillitis

Differential diagnosis

Infectious mononucleosis

Malignancy: lymphoma, leukemia, carcinoma

Diptheria

Scarlet fever

Agranulocytosis

Medical ManagementMedical Management

PCN is first line, even if throat culture is negative for GABHS

For acute UAO: NP airway, steroids, IV abx, and 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 HyperplasiaObstructive Hyperplasia

Adenotonsillar hypertrophy most common cause of SDB in children

Diagnosis Indications for polysomnography Interpretation of polysomnography Perioperative considerations

Unilateral Tonsillar EnlargementUnilateral Tonsillar Enlargement

Apparent enlargement vs true enlargement

Non-neoplastic: Acute infective Chronic infective Hypertrophy Congenital

Neoplastic

Peritonsillar AbscessPeritonsillar Abscess

ICA ICA AneurysmAneurysm

Pleomorphic Pleomorphic AdenomaAdenoma

Other Tonsillar PathologyOther Tonsillar Pathology

Hyperkeratosis, mycosis leptothrica

Tonsilloliths

CandidiasisCandidiasis

SyphilisSyphilis

Retention CystsRetention Cysts

Supratonsillar CleftSupratonsillar Cleft

Indications for TonsillectomyIndications for Tonsillectomy

AAO-HNS: 4 or more episodes/year Hypertrophy causing malocclusion, UAO PTA unresponsive to nonsurgical mgmt Halitosis, not responsive to medical therapy UTE, suspicious for malignancy Individual considerations

Indications for AdenoidectomyIndications 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 (4 or more episodes/year) Recurrent/chronic OME

PreOp Evaluation ofPreOp Evaluation of Adenoid DiseaseAdenoid 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 DiseasePreOp Evaluation of Adenoid Disease

Differential diagnoses Allergic rhinitis Sinusitis GERD For concomitant sinus disease, treat adenoids

first

PreOp Evaluation of Adenoid DiseasePreOp Evaluation of Adenoid Disease

Evaluate palate Symptoms/FH of CP

or VPI Midline diastases of

muscles, bifid uvula CNS or

neuromuscular disease

Preexisting speech disorder?

PreOp Evaluation of Adenoid PreOp Evaluation of Adenoid DiseaseDiseaseLateral 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.

PreOp Evaluation of Adenoid PreOp Evaluation of Adenoid DiseaseDisease

PreOp Evaluation of Tonsillar DiseasePreOp Evaluation of Tonsillar Disease

History Documentation of episodes by physician FTT Cor pulmonale Poststreptococcal GN Rheumatic fever

PreOp Evaluation of Tonsillar DiseasePreOp Evaluation of Tonsillar Disease

TONSIL SIZE 0 in fossa +1 <25%

occupation of oropharynx

+2 25-50% +3 50-75% +4 >75%

Avoid gagging the patient

ComplicationsComplications

0.1-8.1% Postoperative bleeding

Other: Sore throat, otalgia, uvular swelling Respiratory compromise Dehydration Burns and iatrogenic trauma

Rare ComplicationsRare Complications

Velopharyngeal Insufficiency Nasopharyngeal stenosis Atlantoaxial subluxation/ Grisel’s syndrome Regrowth Eustachian tube injury Depression Laceration of ICA/ pseudoaneursym of ICA

Questions?

DEFINITIONDEFINITION Adenoid =pharyngeal tonsil = Nasopharyngeal Mass of sub – epithelial lympoid tissue situated

posterior to the nasal cavity in the roof of the nasopharynx

In children it forms a soft mound in the roof and posterior wall of the nasopharynx, above and behind the uvula.

Age – enlargement from less than a year old to 12 years.

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HISTOLOGY OF ADENOIDHISTOLOGY OF ADENOIDUnlike other types of tonsils.Has pseudostratified columnar

ciliated epithelium.Lack crypts (opening or outlet) but

has a capsuleIt drains to the jugulodigastric

lymph nodes below the angle of the mandible.

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IMPORTANCE OF ADENOID AND IMPORTANCE OF ADENOID AND TONSILLAR TISSUE.TONSILLAR TISSUE.

Part of lymphoid tissue of Waldeyer’s ring

Its size increases progressively until puberty, then diminishes until about the age of 20 years and from this time onwards, maintains its adult size.

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Protective FunctionsFormation of lymphocytesFormation of antibodiesAcquisition of immunityLocalization of infection – “filters” to

the upper respiratory passages.

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PATHOLOGYPATHOLOGY An enlarged adenoid or adenoid

hypertrophy, can become nearly the size of a ping pong ball. Completely block airflow through the nasal

passages or block the back of the nose.1. Breathing through the nose requiring an

uncomfortable amount of work.

2. Inhalation occurs instead through an open mouth.

3. Affects voice mechanism (speech hyponasality)

4. Recurrent upper respiratory tract infection.

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CLINICAL FEATURES OF ADENOID FACES IN CHILDREN. It causes an atypical appearance of the face

(adenoid face)Features of adenoid faces includeMouth breathingElongated faceProminent incisorsHypoplastic maxillaShort upper lipElevated nostrilHigh Arched palate

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Symptoms

- Bilateral Nasal Obstruction

- Mouth Breathing- Snoring & OSA- Speech hyponasality- Difficult suckling

Bilateral Nasal discharge- Mucoid or mucopurulent

discharge WHY? Due to blockage of the choanae

- Excoriation of the nasal vestibule & upper lip

- Post nasal discharge causing frequent nocturnal cough

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Rhinolalia clausa(speech hyponasality)

Signs

Posterior Rhinoscopy difficult Digital palpation not pleasant Endoscopic examination the best

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InvestigationsInvestigations

Lateral soft tisue X ray of the nasopharynx

It is not the size of the

nasopharyngeal tonsil which is

important but the size of the

mass in relation to the

nasopharyngeal space

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ComplicationsComplications1- OSAS:- During Sleep:- During day time

2- Descending infection

3- ِ Adenoid Facies

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Morning headacheImpaired concentrationExcessive day-time sleepinessRecurrent OMPharyngitis, Laryngitis,

bronchitis

Restless sleep, Night mare, Nocturnal

eneuresis

Idiot lookPinched nostrilShort upper lipProminent incisorHigh arched

palate

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RemovalRemoval

Adenoidectomy – procedure of surgical removal of the adenoidStudies have shown that adenoid regrowth

occurs in as many as 20% of the cases after removal. Why?

Adenoid tissue is not encompassed by a capsule like the tonsils. Complete removal of all adenoid tissue is nearly impossible and thus recurrent hypertrophy or infection is possible.

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Indications for AdenoidectomyIndications for Adenoidectomy

Paradise study (1984) 28-35% fewer acute episodes of OM with adenoidectomy

in kids with previous tube placement Adenoidectomy or T & A not indicated in children with

recurrent OM who had not undergone previous tube placement

Gates et al (1994) Recommend adenoidectomy with M & T as the initial

surgical treatment for children with MEE > 90 days and CHL > 20 dB

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Indications for AdenoidectomyIndications for AdenoidectomyObstruction: 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)

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PreOp Evaluation ofPreOp Evaluation of Adenoid DiseaseAdenoid Disease

Triad of hyponasality, snoring, and mouth breathing

Rhinorrhea, nocturnal cough, post nasal drip

“Adenoid facies” “Milkman” & “Micky

Mouse” Overbite, long face,

crowded incisors

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PreOp Evaluation of Adenoid DiseasePreOp Evaluation of Adenoid Disease

Differential diagnosesDifferential diagnoses• Allergic rhinitis• Sinusitis• GERD• For concomitant sinus disease, treat adenoids

first

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PreOp Evaluation of Adenoid DiseasePreOp Evaluation of Adenoid Disease

Evaluate palateEvaluate palate• Symptoms/FH of CP or

VPI• Midline diastasis of

muscles, bifid uvula• CNS or neuromuscular

disease

• Preexisting speech disorder?

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PreOp Evaluation of Adenoid DiseasePreOp 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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PreOp Evaluation of Adenoid DiseasePreOp Evaluation of Adenoid Disease

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Treatment Treatment

Adenoidectomy operation

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Adenoidectomy with great careAdenoidectomy with great care

Adenoidectomy for speech problemsLook for short palate, submucous cleft of the short or hard palate to avoid velopharyngeal insufficiency after the procedure as the voice may become hypernasal.

Should be avoided in patients with cleft palate.

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Acute tonillitisAcue inflammation of the palatine tonsils

Age: Any age but common in

children

Etiology :- Beta hemolyic streptococci

- Streptococcus pneumonia

- Hemophylus influenza

Mode of transmissiondroplet infection

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EmbryologyEmbryology

• 8 weeks: Tonsillar fossa and palatine tonsils develop from the dorsal wing of the 1st pharyngeal pouch and the ventral wing of the 2nd pouch; tonsillar pillars originate from 2nd/3rd arches

• Crypts 3-6 months; capsule 5th month; germinal centers after birth

• 16 weeks: Adenoids develop as a subepithelial infiltration of lymphocytes

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AnatomyAnatomy

TonsilsTonsils• Plica triangularis• Gerlach’s tonsil

AdenoidsAdenoids• Fossa of

Rosenmüller• Passavant’s ridge

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Blood SupplyBlood Supply

TonsilsTonsils• Ascending and

descending palatine arteries

• Tonsillar artery• 1% aberrant ICA just

deep to superior constrictor

AdenoidsAdenoids• Ascending pharyngeal,

sphenopalatine arteries

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HistologyHistology

TonsilsTonsils• Specialized squamous• Extrafollicular• Mantle zone• Germinal center

AdenoidsAdenoids• Ciliated pseudostratified

columnar• Stratified squamous• Transitional

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SymptomsRapid onset of - Fever, Headache, Anorrhexia, Malaise- Severe sore throat ± referred otagia- Halitosis

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SignsGeneral :High Fever with flushed face

PharyngealAcute follicular tonsillitisAcute membranous tonsillitisAcute parynchymatous tonsillitis

CervicalEnlarged tender jugulo-digastric

lymph nodes

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The crypts of the tonsils are full of purulent exudateGiving yellow spots on the tonsils

The yellow spots may Coalease to form a Yellow membrane

Marked hyperemia and enlargement of the tonsils

Acute follicular T. Acute membranous T Acute parynchymatous T

ComplicationsLocal:- Peritonsillar abscess

- Parapharyngeal abscess

- Retropharyngeal abscess

Systemic- Rheumatic fever

(carditis and arthritis)

- Acute glomerulonephritis

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Quinzy

PreOp Evaluation of Tonsillar DiseasePreOp Evaluation of Tonsillar Disease

History Documentation of episodes by physician FTT Cor pulmonale Poststreptococcal GN Rheumatic fever

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PreOp PreOp EvaluationEvaluation of Tonsillar Disease of Tonsillar Disease

TONSIL SIZE 0 in fossa +1 <25% occupation

of oropharynx +2 25-50% +3 50-75% +4 >75%

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Avoid gagging the patient

PreOp Evaluation of Tonsillar DiseasePreOp Evaluation of Tonsillar Disease

Down syndrome 10% have AA laxity Obtain lateral cervical films (flexion/extension)

when positive findings on history, PE If unstable, need neurosurgical evaluation

preoperatively Large tongue and small mandible… difficult

intubation Prone to cardiac arrhythmias/hypotension during

induction

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Treatment

Antibiotics: 10 days

Rest

Ample fluid intake

Cold compresses

Analgesic Antipyretics

Gargles

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Chronic TonsillitisChronic TonsillitisChronic inflammation of the palatine tonsilsChronic inflammation of the palatine tonsils

Etiology :

Repeated attacks of acute tonsillitis

Symptoms: one or more of the following- History of repeated attacks of AT- Irritation in the throat- Foetor oris

If hypertrophic- Difficult swallowing- Obsrtuctive sleep apnea

Signs:Pharyngeal - Asymmetry of the size of the

tonsils- Hypertrophy of the tonsils- The crypts ooze pus on

pressure by tongue depressor- Hyperaemia of the anterior

pillars

Cervical Persistent enlargement of

jagulodigastric lymph nodes

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Acute AdenotonsillitisAcute AdenotonsillitisEtiology 5-30% bacterial; of

these 39% are beta-lactamase-producing (BLPO)

Anaerobic BLPO

GABHS most important pathogen because of potential sequelae

Throat culture Treatment

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Microbiology of AdenotonsillitisMicrobiology 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.

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Acute AdenotonsillitisAcute Adenotonsillitis

Differential diagnosisInfectious mononucleosisMalignancy: lymphoma, leukemia, carcinomaDiptheriaScarlet feverAgranulocytosis

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Medical ManagementMedical 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%

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PreOp Evaluation for Adenotonsillar DiseasePreOp Evaluation for Adenotonsillar Disease

Coagulation disordersCoagulation disorders• Historical screening• CBC, PT/PTT, BT, vWF activity• Hematology consult• von Willebrand’s disease• ITP• Sickle cell anemia

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Principles of Surgical ManagementPrinciples 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

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Post Operative ManagmentPost Operative Managment

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

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ComplicationsComplications#1 Postoperative bleeding

Other: Sore throat, otalgia, uvular swelling Respiratory compromise Dehydration Burns and iatrogenic trauma

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Rare ComplicationsRare 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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Management of HemorrhageManagement of Hemorrhage

Ice water gargle, afrin Overnight observation and IV fluids Dangerous induction ECA ligation Arteriography

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Obstructive HyperplasiaObstructive Hyperplasia

Adenotonsillar hypertrophy most common cause of SDB in children

Diagnosis Indications for polysomnography Interpretation of polysomnography Perioperative considerations

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Unilateral Tonsillar EnlargementUnilateral Tonsillar EnlargementApparent enlargement vs true enlargement

Non-neoplastic: Acute infective Chronic infective Hypertrophy Congenital

Neoplastic

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Peritonsillar Abscess

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Pleomorphic AdenomaPleomorphic Adenoma86

Other Tonsillar PathologyOther Tonsillar Pathology

Hyperkeratosis, mycosis leptothrica

Tonsilloliths

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Candidiasis88

SyphilisSyphilis89

Retention Retention CystsCysts 90

Supratonsillar Supratonsillar CleftCleft 91

Indications for Tonsillectomy; Historical Indications for Tonsillectomy; Historical EvolutionEvolution

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Indications for TonsillectomyIndications for Tonsillectomy

Paradise study Frequency criteria: 7 episodes in 1 year

or 5 episodes/year for 2 years or 3 episodes/year for 3 years

Clinical features (one or more): T 38.3, cervical LAD (>2cm) or tender LAD; tonsillar/pharyngeal exudate; positive culture for GABHS; antibiotic treatment

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Indications for TonsillectomyIndications for Tonsillectomy

AAO-HNS: 3 or more episodes/year Hypertrophy causing malocclusion, UAO PTA unresponsive to nonsurgical mgmt Halitosis, not responsive to medical therapy UTE, suspicious for malignancy Individual considerations

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Case studyCase study 13 year old female referred by PCP

for frequent throat infections “She’s always sick. She’s been on

four different antibiotics this year.” You call her pediatrician… he is out

of town and his nurse can’t find the chart

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Case studyCase study No known medical problems, no prior

surgical procedures Takes motrin for menustrual cramps No personal history of bleeding other than

occasional nose bleeds and extremely heavy periods.

Family history unknown. Patient is adopted.

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Case studyCase study Physical exam is unremarkable. Mom breaks down in tears when you tell her you

do not have enough documentation of illness to warrant T & A. “I had to go on welfare because I’ve missed so much work from her being out sick.”

You hesitate. She adds, “Her grades have dropped from all A’s to all F’s. If she misses any more school, she’ll be held back.”

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Case studyCase study You confirm with her pediatrician that she has

had 4 episodes of tonsillitis this year and agree to T & A.

Because of her history of epistaxis and menorrhagia, you order a PT, PTT, CBC, BT.

She has a mild microcytic anemia and prolonged bleeding time.

You order vWF activity level and consult hematology

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Case studyCase study

She has a subnormal level of vWF, which responds to a DDAVP challenge (rise in vWF and Factor VII greater than 100%).

You advise her to stop taking motrin. Before surgery, she receives

desmopressin 0.3 microg/kg IV over 30 min and amicar 200mg/kg.

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Case studyCase study She receives the same dose of DDVAP 12

hours postoperatively and every morning. Amicar is given 100mg/kg PO q 6 hr. Before each dose of DDAVP, serum

sodium is drawn. Sodium levels drop to 130.

Desmopressin is discontinued and substituted with cryoprecipitate.

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Case studyCase study

Patient presents to the ER on POD # 7 complaining of intermittent bleeding from her mouth.

You order cryoprecipitate, draw a Factor VII level and CBC, and call her hematologist.

Hemoglobin has dropped from 11.9 to 9.6.

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Case studyCase study PE reveals no active bleeding; an old clot

is present You establish IV access, admit the patient

for overnight observation, have her gargle with ice water, and administer crypoprecipitate

No further bleeding occurs, patient is discharged the next day

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