Tonsillitis, Tonsillectomy and

Adenoidectomy

Steven T. Wright, M.D.

Faculty Advisor: Ronald Deskin, M.D.

The University of Texas Medical Branch

Department of Otolaryngology

Grand Rounds Presentation

November 5, 2003

Adenotonsillectomy

Most commonly performed procedure in the

history of surgery

$500 million annually in healthcare

expenditures

History

Almost exclusively by Otolaryngologists

Celsus in 50 A.D.

Caque of Rheims

Phillip Syng developed the tonsillotome

Anatomy

Anatomy

Histology

Clinical Evaluation

Acute Tonsillitis

Chronic Tonsillitis

Obstructive Tonsillar Hyperplasia

Clinical Evaluation

Odynophagia, fever,

tender cervical

lymphadenopathy.

Supporting

documents, 2 or more

Fever> 38.5

Tonsillar Exudate

Tender cervical

LAD >2cm

Positive throat

culture

Clinical evaluation

Viral

Lower grade fever

Lower WBC, Lymphocytic shift

Less tonsillar exudate

Bacterial

Higher WBC, Granulocytic shift

More exudative

Recurrent Acute Tonsillitis

Seven episodes in a single year

Five or more episodes in 2 years

Three or more episodes in 3 years

Chronic Tonsillitis

No true consensus on the definition.

Symptoms greater than 4 weeks

Differential Diagnosis

Infectious Mononucleosis

EBV

Scarlet Fever

Corynebacterium diptheriae

Malignancy

Complications of Tonsillitis

Cervical Adenitis

Neck Abscess

Peritonsillar abscess

Intratonsillar abscess

Lemierre’s syndrome

Post Streptococcal

Glomerulonephritis

Joint Pain and oliguric renal failure 10 days

after the pharyngitis.

Treatment aimed at eliminating the

infection and supportive therapy for renal

failure.

Excellent prognosis in children.

Adenoid Hyperplasia

Triad

Hyponasality

Snoring

Open mouth breathing

Purulent rhinorrhea, post nasal drip, chronic

cough, and headache

Obstructive Airway Symptoms

Snoring

Apneic episodes with gasping or choking

Daytime hypersomnolence

Nocturnal enuresis

Behavioral disturbances

Heart failure and Failure to thrive

Tonsil Size

Grade %

1 <25

2 25-50

3 51-75

4 >75

Obstructive Sleep Apnea

Polysomnography is the gold standard of diagnosis.

Imperative in Adults

In children, a convincing history is adequate

OSA: RDI > 5, SpO2<90%

UARS: RDI <5, SpO2 >90%

Primary Snoring: RDI <1, SpO2>90%

Medical Therapy

TCHP recommends confirming bacterial

pharyngitis before beginning antibiotics.

Rapid Strep Test

Throat Culture

Medical Therapy

First Line

Penicillin/Cephalosporin for 10 days

Injectable forms for noncompliance

BLPO, co pathogens

Macrolides

Penicillin allergy

Erythromycin/Clarithromycin 10 days

Azithromycin (12mg/kg/day) 5 days

Medical Therapy

Patients with recurrent otitis media history have higher bacterial concentrations with BLPO.

Initial treatment with anti-BLP antibiotic.

Adenotonsillar size may respond to a one month course of antibiotic therapy.

Adenoid hyperplasia may respond to a 6-8 week course of intranasal steroid.

Surgical Indications

Adenoidectomy

Absolute

Airway obstruction w/ cor pulmonale

Failure to thrive

Relative

Chronic Nasal Obstruction

Recurrent/ Chronic Adenoiditis

Recurrent/ Chronic Sinusitis

Recurrent acute otitis media/ Recurrent COME

Surgical Indications Absolute

Obstructive airway with cor pulmonale

Severe dysphagia

Failure to thrive

Relative

Recurrent acute tonsillitis

Chronic tonsillitis

Obstructive Sleep Apnea

Peritonsillar Abscess

Halitosis

Suspected Neoplasia/ Tonsillar hyperplasia

Preoperative evaluation

Most common lab test is a CBC

Coagulation studies when the history or

physical examination suggests a bleeding

disorder.

Lateral Neck/Adenoid films

Von Willebrand’s Disease

Autosomal dominant bleeding disorder

Increased bleeding time and prolonged

aPTT.

Perioperative management

IV Desmopressin (0.3ugm/kg)

Serum Sodium

Idiopathic Thrombocytopenic

Purpura

Most common thrombocytopenia of

childhood.

90% resolution by 9-12 months

Splenectomy

IVIG preoperatively

Innovative Surgical Techniques

Cold Dissection

Electrosurgery

Intracapsular partial tonsillectomy

Harmonic Scalpel

Radiofrequency tonsillar ablation and

coblation.

Electrosurgery

Most popular technique for tonsillectomy

Equivalent or superior to the other methods

of tonsillectomy.

Intracapsular Partial

Tonsillectomy 45 degree Microdebrider (1500rpm).

Advantages

As effective as standard tonsillectomy in

relieving obstruction.

Less pain, quicker return to normal diet

Disadvantages:

Tonsillar regrowth

Greater intraoperative blood loss

Harmonic Scalpel

Advantages:

Better visibility

Smaller risk of stray energy shocks

Improved post operative pain

Disadvantages:

Must use alternate device for adenoidectomy

Similar intraoperative blood loss.

Radiofrequency tonsillar

coblation

Coblation is superior to ablation.

Early elimination of pain and reduced pain

medicine usage.

Early resumption of normal diet.

Currently inadequate for adenoidectomy

Adjuvant Therapies

Perioperative local anesthetic

0.25% bupivicaine w/ 1:100,000 Epinephrine

Advantages:

ease of dissection, postoperative pain

Disadvantages:

Airway obstruction, cardiac dysrrhythmias, seizures

Adjuvant Therapies

Perioperative antibiotics

Fewer episodes of fever, offensive odor,

improved oral intake, less pain, fewer

days to return to normal activity

Cardiac abnormality

Adjuvant Therapies

Perioperative Steroids

Dexamethasone (0.15-1.0mg/kg)

Two times less likely to have an episode

of postoperative emesis, and more likely

to advance to eating a soft diet.

Reducing postoperative pulmonary

distress, subglottic edema, pain reduction.

Adjuvant Therapies

Pain control

Tylenol and Tylenol w/ codeine are the

most commonly used.

Similar pain control, less oral intake with

codeine versus Tylenol alone.

NSAIDS still controversial.

Complications

Mortality rate is 1 in 16000-35000.

Anesthetic complications

Eustachian tube injury

VPI

Nasopharyngeal stenosis

Pulmonary Edema

Atlantoaxial subluxation

23 hour observation

Age younger than 3.

Obstructive sleep apnea/craniofacial

syndromes involving the airway.

Systemic disorders

Poor socioeconomic situation

Peritonsillar abscess

Emesis or Hemorrhage

Post Operative Hemorrhage

The best treatment is prevention.

Early vs. Delayed hemorrhage.

Overnight observation and venous access

Surgical intervention.

Carotid angiography if any suspicion of

carotid artery injury.

Case Study

8yo male referred to the Pediatric clinic for

evaluation and treatment of recurrent

tonsillitis.

History

Only 2 episodes of documented pharyngitis

in the past 12 months, strep negative, only

missed 5 days of school total last year.

Loud snoring, frequent pauses up to 5

seconds terminated with gasps of breath.

Physical Examination

Normal facies, open mouth breathing,

tonsils 3+, no cleft deformities.

Remainder of exam is normal.

Case Study

Undergoes uneventful tonsillectomy and adenoidectomy with 23 hour observation.

On follow up visit 2 weeks postoperatively, his mom complains that he doesn’t like some of his favorite foods. He says they taste “yucky”.

Decreased perception of taste with no smell abnormalities.

Diagnosis

Dysgeusia

Unknown mechanism- thought to be due to

prolonged pressure on the tongue by the

mouth retractor.

Treatment is reassurance.

Bibliography

Allen GC, et al. “Adenotonsillectomy in Children with von Willebrand Disease.” Archives of Otolaryngology 1999, May; 125(5) pp547-551.

Bailey BJ: Head and Neck Surgery- Otolaryngology, 3rd ed. Philadelphia, Lippincott-Raven, 2001, pp 979- 1006.

Brook I, et al. “Microbiology of Healthy and Diseased Adenoids.” Laryngoscope 2000, June; 110(6): pp994-999.

Darrow D, Siemens C. “Indications for Tonsillectomy and Adenoidectomy.” Laryngoscope 2002, August; 112(8 part 2): pp6-10.

Derkay C, Maddern B. “Innovative Techniques for Adenotonsillar Surgery in Children: Introduction and Commentary.” Laryngoscope 2002, August; 112(8 part 2): p2.

Friedman M, et al. “Radiofrequency Tonsil Reduction: Safety, Morbidity, and Efficacy.” Laryngoscope 2003, May; 113(5): pp882-887.

Goldstein N. “Child Behavior and Quality of Life Before and After Tonsillectomy and Adenoidectomy.” Archives of Otolaryngology 2002, July; 128(7): pp770-775.

Harley E. “Asymmetric Tonsil Size in Children.” Archives of Otolaryngology 2002, July; 128(7): pp767-769.

Johnson L, et al. “Complications of Adenotonsillectomy.” Laryngoscope 2002, August; 112: pp35-36.

Kay D, et al. “Perioperative Adenotonsillectomy Management in Children: Current practices.” Laryngoscope 2003, April: 113(4): pp 592-597.

Koempel J. “On the Origin of Tonsillectomy and the Dissection Method.” Laryngoscope 2002, September; 112(9): pp1583-1586.

Koltai P, et al. “Intracapsular Partial Tonsillectomy for Tonsillar Hypertrophy in Children.” Laryngoscope 2002, August; 112 (8 part 2): pp 17-19.

Leinbach R, et al. “Hot versus Cold Tonsillectomy: A systematic review of the literature.” Otolaryngology-Head and Neck Surgery 2003, October; 129 (4): pp360-364.

Maddern B. “Electrosurgery for tonsillectomy.” Laryngoscope 2002, August; 112(8 part 2): pp11-13.

Mui S, et al. “Efficacy of Tonsillectomy for Recurrent Throat Infection in Adults.” Laryngoscope 1998, September; 108(9): pp1325-1328.

Plant R. “Radiofrequency Treatment of Tonsillar Hypertrophy.” Laryngoscope 2002, August; 112(8 part 2): pp20-22.

Steward D, et al. “Do Steroids Reduce Morbidity of Tonsillectomy? A Meta-analysis of Randomized Trials.” Laryngoscope 2001, October; 111(10): pp1712-1718.

Stewart R, et al. “Dexamethasone reduces pain after tonsillectomy in adults.” Clinical Otolaryngology and Allied Sciences 2002, October; 27(5): pp321-326.

Thomsen J, Gower V. “Adjuvant Therapies in Children Undergoing Adenotonsillectomy.” Laryngoscope 2002, August; 112(8 part 2): pp32-34.

Warltier et al. “Effects of Non-Steroidal, Anti-inflammatory Drugs on Bleeding Risk after Tonsillectomy, Meta-analysis of Randomized Controlled Trails.” Anesthesiology 2003, June; 98(6): pp1497-1502.

Wiatrak B, Willging J. “Harmonic Scalpel for Tonsillectomy.” Laryngoscope 2002, August; 112(8 part 2): pp14-16.

Younis R, Lazar R. “History and Current Practice of Tonsillectomy.” Laryngoscope 2002, August; 112 (8 part 2): pp3-5.