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Common Diseases of the Tonsils and Common Diseases of the Tonsils and AdenoidsAdenoids
• Acute adenoiditis/tonsillitis
• Recurrent/chronic adenoiditis/tonsillitis
• Obstructive hyperplasia
• Malignancy
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The Nasopharyngeal TonsilThe Nasopharyngeal Tonsil• It is a mass of sub-epithelial
lymphoid tissue present at the junction between the roof & posterior wall of the nasopharynx
• The free surface has 6 folds• It has no capsule• It is covered by pseudo-
stratified columner epithelium• It drains to the
Retropharyngeal lymph nodes Upper Deep Cervical Lymph Nodes
The palatine tonsil has a capsuleon its lateral surface
which separate the lateral wall
from the bed The palatine tonsil
is covered by stratified columner epithelium
The palatine tonsil drains to The Jagulodigastric lymph nodes below the angle of the mandible 3
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 IMPORTANCE OF ADENOID AND TONSILLAR TISSUE.AND 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.8
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
Rhinolalia clausa(speech hyponasality)
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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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ComplicationsComplications
1- OSAS:- During Sleep:- During day time2- Descending infection3- ِ Adenoid Facies Morning headache
Impaired concentrationExcessive day-time sleepiness
Recurrent 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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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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HistologyHistologyTonsilsTonsils• 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 nodesThe 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 T32
ComplicationsLocal:- Peritonsillar abscess- Parapharyngeal abscess- Retropharyngeal abscess
Systemic- Rheumatic fever (carditis and
arthritis)- Acute glomerulonephritis
Quinzy
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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%Avoid gagging the patient
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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
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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 AdenotonsillitisMost 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 ManagmentCriteria 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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Other Tonsillar PathologyOther Tonsillar Pathology
• Hyperkeratosis, mycosis leptothrica
• Tonsilloliths
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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 TonsillectomyAAO-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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