Tonsillitis, Tonsillectomy, and Adenoidectomy

Mary Talley Dorn, M.D. Norman R. Friedman, M.D.

History
Celsus 50 A.D. Caque of Rheims Philip Syng Wilhelm Meyer 1867 Samuel Crowe

Embryology
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

Anatomy
Tonsils
Plica triangularis Gerlachs tonsil

Adenoids
Fossa of Rosenmller Passavants ridge

Blood Supply
Tonsils
Ascending and descending palatine arteries Tonsillar artery 1% aberrant ICA just deep to superior constrictor

Adenoids
Ascending pharyngeal, sphenopalatine arteries

Histology
Tonsils
Specialized squamous Extrafollicular Mantle zone Germinal center

Adenoids
Ciliated pseudostratified columnar Stratified squamous Transitional

Common Diseases of the Tonsils and Adenoids

Acute adenoiditis/tonsillitis Recurrent/chronic adenoiditis/tonsillitis Obstructive hyperplasia Malignancy

Acute Adenotonsillitis
Etiology 5-30% bacterial; of these 39% are beta-lactamaseproducing (BLPO) Anaerobic BLPO GABHS most important pathogen because of potential sequelae Throat culture Treatment

Microbiology 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.

Acute Adenotonsillitis
Differential diagnosis
Infectious mononucleosis Malignancy: lymphoma, leukemia, carcinoma Diptheria Scarlet fever Agranulocytosis

Medical 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%

Obstructive Hyperplasia
Adenotonsillar hypertrophy most common cause of SDB in children Diagnosis Indications for polysomnography Interpretation of polysomnography Perioperative considerations

Unilateral Tonsillar Enlargement

Apparent enlargement vs true enlargement Non-neoplastic: Acute infective Chronic infective Hypertrophy Congenital Neoplastic

Peritonsillar Abscess

ICA Aneurysm

Pleomorphic Adenoma

Other Tonsillar Pathology

Hyperkeratosis, mycosis leptothrica Tonsilloliths

Candidiasis

Syphilis

Retention Cysts

Supratonsillar Cleft

Indications for Tonsillectomy; Historical Evolution

Indications 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

Indications 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

Indications 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

Indications 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 (3 or more episodes/year) Recurrent/chronic OME (+/- previous BMT)

PreOp Evaluation of Adenoid 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 Disease

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

PreOp Evaluation of Adenoid Disease

Evaluate palate
Symptoms/FH of CP or VPI Midline diastasis of muscles, bifid uvula CNS or neuromuscular disease

Preexisting speech disorder?

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 Tonsillar Disease

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

PreOp 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

PreOp 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

PreOp Evaluation for Adenotonsillar Disease

Coagulation disorders
Historical screening CBC, PT/PTT, BT, vWF activity Hematology consult von Willebrands disease ITP Sickle cell anemia

Principles of Surgical Management

Numerous techniques:
Guillotine Tonsillotome Becks snare Dissection with snare (Scissor dissection, Fishers knife dissection, Finger dissection Electrodissection Laser dissection (CO2, KTP)

Surgeons preference

Post 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

Complications
#1 Postoperative bleeding Other:
Sore throat, otalgia, uvular swelling Respiratory compromise Dehydration Burns and iatrogenic trauma

Rare Complications
Velopharyngeal Insufficiency Nasopharyngeal stenosis Atlantoaxial subluxation/ Grisels syndrome Regrowth Eustachian tube injury Depression Laceration of ICA/ pseudoaneursym of ICA

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

Case study
13 year old female referred by PCP for frequent throat infections Shes always sick. Shes been on four different antibiotics this year. You call her pediatrician he is out of town and his nurse cant find the chart

Case 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.

Case 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 Ive missed so much work from her being out sick. You hesitate. She adds, Her grades have dropped from all As to all Fs. If she misses any more school, shell be held back.

Case 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

Case 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.

Case 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.

Case 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.

Case 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