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Presentation on theme: "ADENOTONSILLAR ENLARGEMENT"— Presentation transcript:


2 Common Diseases of the Tonsils and Adenoids
Acute adenoiditis/tonsillitis Recurrent/chronic adenoiditis/tonsillitis Obstructive hyperplasia Malignancy

3 The 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 capsule on 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

4 DEFINITION 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.

5 HISTOLOGY OF ADENOID Unlike other types of tonsils.
Has pseudostratified columnar ciliated epithelium. Lack crypts (opening or outlet) but has a capsule It drains to the jugulodigastric lymph nodes below the angle of the mandible.

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.

7 Protective Functions Formation of lymphocytes Formation of antibodies
Acquisition of immunity Localization of infection – “filters” to the upper respiratory passages.

8 PATHOLOGY 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. Breathing through the nose requiring an uncomfortable amount of work. Inhalation occurs instead through an open mouth. Affects voice mechanism (speech hyponasality) Recurrent upper respiratory tract infection.

It causes an atypical appearance of the face (adenoid face) Features of adenoid faces include Mouth breathing Elongated face Prominent incisors Hypoplastic maxilla Short upper lip Elevated nostril High Arched palate


11 (speech hyponasality)
Symptoms 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 Bilateral Nasal Obstruction Mouth Breathing Snoring & OSA Speech hyponasality Difficult suckling Rhinolalia clausa (speech hyponasality)

12 Signs Posterior Rhinoscopy  difficult Digital palpation not pleasant
Endoscopic examination the best

13 Investigations 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

14 Complications Restless sleep, Night mare, Nocturnal eneuresis 1- OSAS:
During Sleep: During day time 2- Descending infection 3-ِ Adenoid Facies Morning headache Impaired concentration Excessive day-time sleepiness Recurrent OM Pharyngitis, Laryngitis, bronchitis Idiot look Pinched nostril Short upper lip Prominent incisor High arched palate


16 Removal Adenoidectomy – procedure of surgical removal of the adenoid
Studies 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.

17 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 Paradise: Parallel randomized and nonrandomized clinical trials of 213 children who developed recurrence of OM after extrusion of t-tubes; In both trials, over a period of 2 years, 28-35% fewer episodes than controls. Gates: 578 children with chronic middle ear effusion. Adenoidectomy combined with myringotomy or with t tube placement proved to be more effective thatn myringotomy or tube placement alone in preventing recurrences of OM over a 2 year period * differences were small (31 vs 36 weeks as mean cumulative times with effusion in 2 treatment groups over 2 yr f/u). TT surgery alone is assoc with higher rate of repeat surgeries, increased rate of otorrhea, greater expense and human cost of illness than initial adenoidectomy and myringotomy

18 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) Contraindications: Adenoidectomy Overt or submucous CP Neurologic or neuromuscular abnormalities with impaired palatal function Anemia Disorders of hemostasis

19 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

20 PreOp Evaluation of Adenoid Disease
Differential diagnoses Allergic rhinitis Sinusitis GERD For concomitant sinus disease, treat adenoids first

21 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? Speech path consult for speech disorder. Submucous cp 1 in 1200

22 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.

23 PreOp Evaluation of Adenoid Disease

24 Treatment Adenoidectomy operation

25 Adenoidectomy with great care
Adenoidectomy for speech problems Look 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.

26 Acute tonillitis Acue inflammation of the palatine tonsils
Age: Any age but common in children Etiology : Beta hemolyic streptococci Streptococcus pneumonia Hemophylus influenza Mode of transmission droplet infection

27 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 The first 8 weeks constitutes the period of greatest embryonic development of the head and neck. There are 5 arches (pharyngeal or branchial). Btw these arches are the clefts externally and the pouches internally. Each pouch has a ventral or dorsal wing. The derivatives of arches are usually mesoderm origin. The cleft is lined by ectoderm, the pouch is lined by endoderm The adenoids are colonized with bacteria soon after birth, enlarge early and middle childhood form antigenic challenges and should regress by early adulthood. Hypertrophic tonsils are rare in adults and suggest chronic infection or lymphoma.

28 Anatomy Tonsils Adenoids Plica triangularis Gerlach’s tonsil
Fossa of Rosenmüller Passavant’s ridge The tonsil is nestled in a fossa formed by the muscular anterior and posterior tonsillar pillars (palatoglossus and palatopharyngeus) and lying superficial to the superior constrictor muscle; preservation of these muscular condensations and the overlying mucosa is critical to maintaining physiologic function of the palate postoperatively. The tonsil is contiguous inferiorly with the lingual tonsil. The point of attachment (plica triangularis) must be transected during tonsillectomy. In pts with marked hypertrophy, this extension is freq quite large and can result in troublesome bleeding at the pt of transection at the base of the tongue. The adenoid is positioned in the midline of the posterior wall of the NP immediately inferior to the rostrum of the sphenoid and extending laterally to but not onto the lateral wall of the NP. It makes up the most rostral portion of the pharyngeal lymphoid tissue termed Waldeyer’s ring. The space created lateral to the adenoid and posteromedial to the ET orifice is termed the FOSSA of Rosenmuller. Gerlach’s tonsil is lymphoid tissue within lip of the fossa of Rosenmuller; goes into ET. Inferiorly, the adenoid extends nearly to the superior margin of the superior constrictor…Passavant’s ridge.

29 Blood Supply Tonsils Adenoids
Ascending and descending palatine arteries Tonsillar artery 1% aberrant ICA just deep to superior constrictor Adenoids Ascending pharyngeal, sphenopalatine arteries Tonsillar branch of the facial artery is the main supply of the entire tonsil. Facial artery: Tonsillar art Ascending palatine art Lingual art dorsal lingual branch IMA Desceding palatine Greater palatine Ascending pharyngeal (ECA) 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. Adenoids: Ascending palatine, ascending phayrngeal, pharyngeal br of IMA, ascending cervical branch of thyrocervical trunk

30 Histology Tonsils Adenoids Specialized squamous Extrafollicular
Mantle zone Germinal center Adenoids Ciliated pseudostratified columnar Stratified squamous Transitional The luminal surface of the tonsil is covered by stratified squamous epithelium (E) which deeply invaginates the tonsil; the base of the tonsil is separated from underlying muscle by a dense collagenous hemi-capsule (Cap). The parenchyma contains numerous lymphoid follicles (F) dispersed just beneath the epithelium of the crypts. The surface of the adenoids differs from the tonsils in that the adenoids have deep folds and few crypts , while the tonsils have from crypts and the surface of the adenoids is composed of ciliated pseudostratified columnar epithelium which functions in mucociliary clearance. With chronic infection, this layer is thinned, resulting in stasis of secretions and increased exposure of the tissue to antigenic stimuli. Deep to the surface epithelium lies a stratified squamous layer followed by a transitional layer. The SS layer thickens with chronic infection. The transitional layer is responsible for antigen processing.

31 Symptoms Rapid onset of - Fever, Headache, Anorrhexia, Malaise
- Severe sore throat ± referred otagia - Halitosis

32 Signs General : High Fever with flushed face Pharyngeal Cervical
Acute follicular tonsillitis Acute membranous tonsillitis Acute parynchymatous tonsillitis Cervical Enlarged tender jugulo-digastric lymph nodes The crypts of the tonsils are full of purulent exudate Giving yellow spots on the tonsils Marked hyperemia and enlargement of the tonsils The yellow spots may Coalease to form a Yellow membrane Acute parynchymatous T Acute follicular T. Acute membranous T

33 Complications Local: Systemic Peritonsillar abscess
Parapharyngeal abscess Retropharyngeal abscess Systemic Rheumatic fever (carditis and arthritis) Acute glomerulonephritis Quinzy

34 PreOp Evaluation of Tonsillar Disease
History Documentation of episodes by physician FTT Cor pulmonale Poststreptococcal GN Rheumatic fever

35 PreOp Evaluation of Tonsillar Disease
TONSIL SIZE 0 in fossa +1 <25% occupation of oropharynx % % +4 >75% Avoid gagging the patient

36 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 Instability is caused by laxity of transverse ligament. Neck pain, muscular problems. Hyperactive DTR, clonus atlas-dens interval > 4.5mm

37 Treatment Antibiotics: 10 days Rest Ample fluid intake Cold compresses
Analgesic Antipyretics Gargles

38 Chronic Tonsillitis Chronic 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

39 Signs: Pharyngeal Cervical 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

40 Acute Adenotonsillitis
Etiology 5-30% bacterial; of these 39% are beta-lactamase-producing (BLPO) Anaerobic BLPO GABHS most important pathogen because of potential sequelae Throat culture Treatment 1. MC bacteria: Beta streptoccoci, staphylococci, streptoccocus pneumoniae, hemophilus 2. Prevalence of beta-lactamase producing organisms is rising: from 2 % in 1980 to 44% in (FIND STUDY) 3. Prevalence of anaerobic org is also rising Asymptomatic streptococcal pharyngitis responsible for at least 1/3 of ARF in 3rd world. Gold std is throat culture. Blood agar plate with septra more sensitive than plain agar plate. Culture both tonsils; if only one, may miss 25%. Rapid streptococcal antigen test, 12 min.; highly specific but variable sensitivity; must confirm negative result with a throat cx. Newer solid-phase enzyme immunoassay Older latex agglutination test Treat with 10 day course of PCN if high clinical suspicion (augmentin, clinda, pcn + rifampin for recurrence) Post treatment culture: high risk RF, remain symptomatic, recurring symptoms; if asymptomatic but positive cx, treat if h/o RF or if FH of RF Suspect infectious mononucleosis 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 blood test.

41 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. Study by Brodsky et al (1988) taking cultures from core specimens (not surface). Core species do not always correlate with surface bacteria. 90% correlation with H.influenza, 73% strept pyogenes

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

43 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%

44 PreOp Evaluation for Adenotonsillar Disease
Coagulation disorders Historical screening CBC, PT/PTT, BT, vWF activity Hematology consult von Willebrand’s disease ITP Sickle cell anemia Von Willebrand’s disease is the most common inherited coagulopathy (AD with variable expression) (1% population) and is caused by a deficiency in Factor VIII:VW complex necessary in platelet activation. 3 types… type 1 is the most common (80-90%) with subnormal levels of qualitatively normal vWF and most will respond to desmopressin. Type 2 is a defect in the factor, type 3 is complete absence of the factor. DX elevated PTT, BT, decreased vWF antigen, factor VIII procoagulant activity, ristocetin cofactor activity; measure response of levels to desmopressin (0.3microg/kg IV) RX give IV over 30 min preop (peak levels min), 12 hr postop, then q am until eschar completely sloughed and fossae completely healed; also give aminocaproic acid or tranexamic acid preop and postop to decrease fibrinolysis (oral cavity high conc of fibrinolytic enzymes); not useful type 2/3 adverse effects… Na <132 or tachyphylaxis, d/c desmopressin, give cryoprepipitate or vWF-containing antihemophilic factor ITP:

45 Principles 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

46 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 MC reasons for inpt stays… emesis, dehydration, hemorrhage, obstruction, pulm edema < 3years: 7% airway complications (2.3 times other kids), 4% dehydration, 1.5 % hemorrhage; less likely to cooperate with oral intake and more likely to have surgery for airway obstruction Conditions associated with a complicated postop course (resp compromise): CP, seizures, age <3, congenital heart disease, prematurity, chromosomal abnormalities, loud snoring with apnea, difficulty breathing during sleep Excessive adenotonsillar tissue obstructs airway and increases resistance to inspiration/expiration… maintains PEEP with increased intrathoracic venous and hydrostatic pressure. Sudden relief of excess PEEP by intubation or T & A results in transudation of fluid into interstitial and alveolar spaces….pulm edema. Treatment… intubation and reestablishment of PEEP.

47 Complications #1 Postoperative bleeding Other:
Sore throat, otalgia, uvular swelling Respiratory compromise Dehydration Burns and iatrogenic trauma Mortality 1 in 16,000 to 35,000 (anesthetic and hemorrhage); Hemorrhage %; 76% occur within first 6 hrs; 0.04% require transfusion; 0.002% mortality (mc for primary); Etiology: retained adenoid tissue, damage to post pharyngeal wall muscle; Increased incidence winter, age > 20 Anesthetic: kinking, extubation, fire, laryngospasm Resp compromise: sudden loss of PEEP… pulmonary edema; avoid sedating analgesics Assess for loose teeth… post op CXR to r/o aspiration if loss of tooth Draping to avoid burns… avoid towel clips (penetration); avoid tape (accidental extubation when take drapes off) Sore throat: increased with increased age, electrocautery, KTP/ less with CO2 lasere and periop/postop antibiotics (4.4 to 3.3 days) Otalgia: referred from IX, r/o otitis, ET tube injury or edema Fever: normal in 1st 36 hr… watch for dehydration Dehydration: n/v 2nd to anesth, swallowed blood; decreased po intake with pain, esp younger kids less cooperative and smaller volume reserve; single intraoperative steroid earlier return to nl diet

48 Rare Complications Velopharyngeal Insufficiency
Nasopharyngeal stenosis Atlantoaxial subluxation/ Grisel’s syndrome Regrowth Eustachian tube injury Depression Laceration of ICA/ pseudoaneursym of ICA VPI: usu transient; sig in 1 in ; only 1/3 identified preop as increased risk; > 2mo speech therapy; > 6-12mo pharyngeal flap NP stenosis: circumferential contracture of pharynx Waldeyer’s ring, T AND A; syphilis; increased risk with excessive mucosal excision; difficult to rx AA subluxation.. Grisel’s syndrome vertebral body decalcification and laxity of anterior transverse ligament secondary to infection in the nasopharynx… may cause spontaneous subluxation 1 week postoperatively…pain and torticollis (traumatic adenoidectomy or injection of local anesthestic into prevertebral space) 15-28% tonsil tags; 6% recurrent pharyngitis adenoids may grow from adjacent lymphoid tissue… incomplete removal? Laceration of ICA usu occurs medially and near the skull base. Pseudoanerusym of ICA requires embolization and proximal ligation.

49 Management of Hemorrhage
Ice water gargle, afrin Overnight observation and IV fluids Dangerous induction ECA ligation Arteriography Anesthetic induction is hazardous…. Hypovolemic, underestimated blood loss (T &C). Risk of aspiration, stomach full of swallowed blood… tracheotomy if active hemorrhage prevents intubation. ECA ligation via lateral neck incision, retraction of SCM posteriorly if unable to stop bleeding. Angiography if ECA ligation fails… ICA and ECA communicate via opthalmic/angular nasal arteries and via middle meningeal artery

50 Obstructive Hyperplasia
Adenotonsillar hypertrophy most common cause of SDB in children Diagnosis Indications for polysomnography Interpretation of polysomnography Perioperative considerations Diagnosis of OSA is based on H & P (snoring, restless sleep, FTT, daytime symptoms… poor mentation, decreased attn span, poor scholastic performance, dysphagia, nocturnal enuresis, chronic mouth breathing; predisposing conditions craniofacial abnormalities, NM disorders, FTT, cor pulmonale, Downs syndrome) MC symptom in kids is snoring (adults is daytime somnolence). Obtain sleep study when PE does not correlate with history ($1600), or when suspect central component. Apnea (10s breathing pause)from complete obstruction is uncommon in children. Children tend to have a continuous partial obstructive hypoventilation that is characterized by decreased oxygen saturation, hypercapnia, labored paradoxical resp efforts, and snoring. Controversy over how to interpret sleep study in kids… few normative data. Marcus et al.(1992) studied normal resp patterns in children during sleep. Abnormal values: >1 obstructive apnea of any duration per hour central apnea assoc with desat <90% Pco2>53 or Pco2>45 for more than 60% test time fall of o2 sat < 92% No consensus on indications for surgery for those without severe obstruction/apnea.

51 Unilateral Tonsillar Enlargement
Apparent enlargement vs true enlargement Non-neoplastic: Acute infective Chronic infective Hypertrophy Congenital Neoplastic Apparent: tonsil sits in more medial position, displacement medially by PTA or parapharyngeal space mass. Chronic infections: tubercular tonsillitis, actinomycosis, and congenital syphilis Congenital include teratoma, hemangioma, lymphangioma, and cystic hygroma. Neoplastic: Benign papillomas Lymphoma (usually non-Hodgkins B-cell) and squamous cell

52 Peritonsillar Abscess
Displacement of tonsil and uvula medially, trismus, dysphagia, pain referred to the ear, malaise, fever, cervical adenopathy. Initial mgmt is needle aspiration, IM penicillin, oral penicillin. Quinsy tonsillectomy for uncooperative, toxic patient, bleeding. Peritonsillar Abscess

53 Consider masses in the parapharyngeal space for apparent UTE including tumors of the deep lobe of the parotid gland (ie pleomorphic adenoma), chemodectomas, neurofibromata, and enlargement of the parapharyngeal lymph nodes. Pleomorphic Adenoma

54 Other Tonsillar Pathology
Hyperkeratosis, mycosis leptothrica Tonsilloliths Yellow spicules due to hyperkearatineized areas of epithelium are sometimes extensive over the tonsil. It is important to probe the tonsil to be certain these areas are not exudate. No treatment is required unless assoc with tonsillitis. Tonsilloliths are yellow gritty particles in crypts, more commonly seen in adults with a h/o recurrent tonsillitis. Elongated styloid process causes pain exacerbated during maximal deglutition and deep breathing…. 2nd branchial arch derivitative, approx 2.5 cm long, located btw internal and ECA just lateral to tonsillar fossa.

55 A fungal infection of the pharynx and one of the most common upper respiratory tract manifestation of AIDS. Also seen in neonates and may complicate treatment with broad spectrum antibiotics. Characterized by extensive white areas (either continuous or punctate) covering the entire oropharynx and not limited to the tonsil. Swab shows candida albicans. Candidiasis

56 Snail-track ulcers of secondary syphilis.

57 These are common on the tonsil and appear as sessile yellow swellings
These are common on the tonsil and appear as sessile yellow swellings. If small, they can be ignored. Also seen after tonsillectomy in region of the fauces. Retention Cysts

58 This recess near the superior pole of the tonsil tends if large to collect debris. A mass of yellow fetid tissue can be extruded from the tonsil with pressure, and discomfort, halitosis are symptoms. Tonsillectomy may be necessary. Supratonsillar Cleft

59 Indications for Tonsillectomy; Historical Evolution

60 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 From the Children’s Hospital of Pittsburgh conducted parallel randomized and nonrandomized clinical trials to determine 1. efficacy of tonsillectomy in reducing the frequency and severity of episodes of pharyngitis, 2. the efficacy of adenoidectomy in reducing the freq/severity of OM, and 3. the effect of adenoidectomy of the course of nasal obstruction due to large adenoids Findings: 1. Histories of recurrent throat infections that are undocumented do not validly predict recurrence; need documentation by physician before performing tonsillectomy 2. Using the selection criteria, the incidence of throat infection during the first 2 years of f/u was significantly lower in the surgical groups 3. Many pts in the nonsurgical group had fewer than 3 episodes of infx, and most cases were mild… therefore, treatment should be individualized, taking into consideration pt/parental preference, anxieties, tolerance of illness, tolerance of antimicrobial drugs, child’s school performance in relation to illness-related absence, accessability of health-care services, out-of-pocket costs, nature of available anesthetic and surgical services/facilities

61 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 Contraindications: Tonsillectomy Acute infection Anemia Disorders of hemostasis

62 Case 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

63 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.

64 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 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.”

65 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

66 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.

67 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.

68 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.

69 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


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