Adenotonsilitis

Samir M. BawazirConsultant Pediatric ORL.H&NS

Adenotonsillectomy

Most commonly performed procedure in the history of surgery

$500 million annually in healthcare expenditures-USA

Anatomy

Tonsils

Palatine tonsils lie in the lateral wall of the oropharynx

Between the Ant. & Post pillars

Adenoids

Or NP-tonsil Lie at the junction of the

roof & post. Wall of the NP. Present at birth, increase

in size up to 6yrs, then atrophy at puberty .

Blood Supply

Tonsils

Tonsillar artery-from FA. Is the main supply.

Ascending palatine A.- from FA.

Ascending Ph. A- from EC.

Descending palatine A.- from maxillary A.

Dorsal linguae - from lingual A.

Adenoids

Ascending palatine- FA

Ascending phayrngeal- EC

Pharyngeal br of IMA

Ascending cervical branch of thyrocervical trunk

Venous drainage of the tonsil is thru lingual and pharyngeal veins which empty into the IJ.

In most people the ICA lies 2cm posterolateral to the deep surface of the tonsil; however in 1% of the population, it is found just deep to the superior constrictor.

Histology

Tonsils

The medial surface- Non-keratinizing Stratified squamous epith.

Medial surface has 10-15 crypts

Crypta magna (intertonsillar cleft)

Lateral (deep) surface separated from the underlying M. by fibrous capsule

Bed of the tonsil is made by Sup.constrictor M. & Styloid M.

Parenchyma contains – lymphoid follicles

Adenoids

Ciliated pseudostratified columnar epith.(mucociliary clearance)

under it lies a

- Stratified squamous epith

- then Transitional - (antigen processing)

Common Diseases of the Tonsils and Adenoids

Acute adenoiditis/tonsillitisRecurrent/chronic

adenoiditis/tonsillitisObstructive hyperplasiaMalignancy

Tonsil Grading

Grade %

1<25

225-50

351-75

4>75

Which Grade ?

How to approach this Pt.?

Acute Adenotonsillitis

• Odynophagia, fever, tender cervical lymphadenopathy.

• Fever> 38.5• Tonsillar Exudate• Tender cervical LN >2cm• Positive throat culture

Acute Adenotonsillitis

Etiology

5-30% bacterial; of these 39% are beta-lactamase-producing (BLPO)

Anaerobic BLPO

Gr.ABHS most important pathogen because of potential sequelae

Throat culturemononucleosis if sore throat and malaise persist despite abx treatment; order WBC and Paul-Bunnell. Characterized by white membrane covering one or both tonsils and hypersensitivity to ampicillin. Look for atypical mononuclear cells and positive Paul-Bunnell (mono spot test) test.

Microbiology of Adenotonsillitis

Most common organisms cultured from patients with chronic tonsillar disease

Streptococcus pyogenes (Group A beta-hemolytic streptococcus)

H.influenza

S. aureus

Streptococcus pneumoniae

Acute Adenotonsillitis

Differential diagnosis

Infectious mononucleosis- IMNMalignancy: lymphoma, leukemia, carcinomaDiptheriaScarlet feverAgranulocytosis

Medical Management

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

For 7-10 days

Injectable forms for non-compliant

Macrolides-Penicillin allergy

Erythromycin/Clarithromycin 10 days

Azithromycin (12mg/kg/day) 5 days

Good hydration

PreOp Evaluation of Adenoid DiseaseTriad of

hyponasality, snoring, and mouth breathing

Rhinorrhea, nocturnal cough, post nasal drip

“Adenoid facies”Overbite, long face,

crowded incisors

PreOp 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.

PreOp Evaluation of Adenoid Disease

PreOp Evaluation of Adenoid Disease

Evaluate palate Symptoms/FHx of

cerebral palsy (CP) or VPI

Midline diastasis of muscles, bifid uvula

CNS or neuromuscular disease

Preexisting speech disorder?

PreOp Evaluation of Tonsillar Disease

History Documentation of episodes by physician

Failure to thrive (FTT)

Cor pulmonale

Poststreptococcal GN-is a disorder of the kidneys that occurs after infection with certain strains of Streptococcus bacteria.

Rheumatic fever

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 OME

Surgical Indication

Tonsillectomy

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

- Access for the styloid process

Complications

#1 Postoperative bleeding 0.1-3.7%

Other:

Sore throat, otalgia, uvular swelling

Respiratory compromise

Dehydration

Burns and iatrogenic trauma

Rare Complications

Velopharyngeal InsufficiencyNasopharyngeal stenosisAtlantoaxial subluxation RegrowthEustachian tube injuryDepression

Obstructive Hyperplasia

Adenotonsillar hypertrophy most common cause of sleep disordered breathing (SDB) in children

Indications for polysomnography- differentiate central from obstructive and if the physical exam. Does not correlate with the symptoms

Unilateral Tonsillar Enlargement

Apparent enlargement vs true enlargement

Non-neoplastic: Acute infectiveChronic infective HypertrophyCongenital Neoplastic

Peritonsillar Abscess

Retention Cysts

Intratonsillar Cleft collect debris, cause halitosis, Rx Ts.

TEST

Click icon to add SmartArt graphic9yo male referred to the ENT clinic for evaluation and treatment of recurrent tonsillitis.

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