adenotonsillar disease shahin bastaninejad, md, orl-hns surgeon assistant professor of tehran...
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Adenotonsillar Adenotonsillar diseasedisease
Shahin BastaninejadShahin Bastaninejad, MD, ORL-HNS Surgeon, MD, ORL-HNS Surgeon
Assistant professor of tehran university of Assistant professor of tehran university of medical sciencesmedical sciences
AnatomyAnatomy
Tonsil boundaryTonsil boundary Plica triangularis
Adenoid Adenoid boundaryboundary
Posterior aspect of the nasal septum
Fossa of Rosenmüller
Passavant’s ridge
Waldeyer’s RingWaldeyer’s Ring
Presentation outlinesPresentation outlines
Acute InfectionsAcute Infections
Chronic diseasesChronic diseases
Obstructive hyperplasiaObstructive hyperplasia
MassMass
SurgerySurgery
Acute Infections
Acute AdenotonsillitisAcute 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-lactamase-producing 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 oral
medication is preferable (penicillin V)medication is preferable (penicillin V)
Other choices: Other choices:
Amoxicillin (wide spectrum than Pencillin V)Amoxicillin (wide spectrum than Pencillin V)
MacrolidesMacrolides
ClindamycinClindamycin
Recurrent or unresponsive infections
require treatment with beta-lactamase beta-lactamase
resistant resistant antibiotics such as
Clindamycin
Augmentin
Penicillin plus rifampin (or Erythro + Metro)
If no response after 48 hrafter 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 Unilateral swelling of soft palate/pharynx
with uvula deviationwith 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 MononucleosisInfectious Mononucleosis
IMNIMN Clinical diagnosis Clinical diagnosis can be made from the
characteristic triad of fever, pharyngitis, and lymphadenopathy lasting for 1 to 4 weeks
Laboratory tests are Laboratory tests are neededneeded for for confirmationconfirmation
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 additional laboratory testing laboratory testing may bemay be needed 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 InfectionPrimary Infection: Primary EBV infection is indicated if IgM antibody to the viral capsid antigen is present and antibody to EBNA is absent
Past Infection: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
ReactivationReactivation: 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
DiphtheriaDiphtheria
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 infectionsBe aware of Anaerobic infections
Cryptic tonsilsCryptic 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
SurgerySurgery
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 beta-lactamase 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 &…
Adenoidectomy Infection:Infection:
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 Obstruction (next slide)(next slide) Other:Other:
Suspected neoplasia Adenoid hypertrophy associated with chronic
sinusitis
Adenoidectomy Cont… Obstruction: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 ofPre-Op Evaluation of
AdenoidAdenoid Disease Disease Triad of
hyponasality, snoring, and mouth breathing
Rhinorrhea, nocturnal cough, post nasal drip
“Adenoid facies” long face, crowded
incisors
Pre-Op Evaluation of Pre-Op Evaluation of AdenoidAdenoid DiseaseDisease
Evaluate palate Symptoms/FH of
CP or VPI Bifid uvula CNS or
neuromuscular disease
Preexisting speech disorder?
Pre-Op Evaluation of Pre-Op Evaluation of Adenoid DiseaseAdenoid Disease
Lateral neck films 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.
Any questions !?Any questions !?