Presentation on theme: "ADENOTONSILLAR ENLARGEMENT"— Presentation transcript:
1 ADENOTONSILLAR ENLARGEMENT BYDR. OLUFEMI OLUDE MD, DORL, ADV. CERT. ORL, PHD CONSULTANT SPECIAL GRADE 1 EAR, NOSE, THROAT AND NECK CLINIC GENERAL HOSPITAL LAGOS
2 Common Diseases of the Tonsils and Adenoids Acute adenoiditis/tonsillitisRecurrent/chronic adenoiditis/tonsillitisObstructive hyperplasiaMalignancy
3 The Nasopharyngeal Tonsil It is a mass of sub-epithelial lymphoid tissue present at the junction between the roof & posterior wall of the nasopharynxThe free surface has 6 foldsIt has no capsuleIt is covered by pseudo-stratified columner epitheliumIt drains to the Retropharyngeal lymph nodes Upper Deep Cervical Lymph NodesThe palatine tonsil has a capsuleon its lateral surfacewhich separate the lateral wallfrom the bedThe palatine tonsilis covered by stratifiedcolumner epitheliumThe palatine tonsil drains toThe Jagulodigastric lymph nodesbelow 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 nasopharynxIn 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 capsuleIt drains to the jugulodigastric lymph nodes below the angle of the mandible.
6 IMPORTANCE OF ADENOID AND TONSILLAR TISSUE. Part of lymphoid tissue of Waldeyer’s ringIts 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 immunityLocalization of infection – “filters” to the upper respiratory passages.
8 PATHOLOGYAn 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.
9 CLINICAL FEATURES OF ADENOID FACES IN CHILDREN. It causes an atypical appearance of the face (adenoid face)Features of adenoid faces includeMouth breathingElongated faceProminent incisorsHypoplastic maxillaShort upper lipElevated nostrilHigh 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 placementAdenoidectomy or T & A not indicated in children with recurrent OM who had not undergone previous tube placementGates et al (1994)Recommend adenoidectomy with M & T as the initial surgical treatment for children with MEE > 90 days and CHL > 20 dBParadise:Parallel randomized and nonrandomized clinical trials of213 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 breathingOSA with FTT, cor pulmonaleDysphagiaSpeech problemsSevere orofacial/dental abnormalitiesInfection:Recurrent/chronic adenoiditis (3 or more episodes/year)Recurrent/chronic OME (+/- previous BMT)Contraindications:AdenoidectomyOvert or submucous CPNeurologic or neuromuscular abnormalities with impaired palatal functionAnemiaDisorders of hemostasis
19 PreOp Evaluation of Adenoid Disease Triad of hyponasality, snoring, and mouth breathingRhinorrhea, nocturnal cough, post nasal drip“Adenoid facies”“Milkman” & “Micky Mouse”Overbite, long face, crowded incisors
20 PreOp Evaluation of Adenoid Disease Differential diagnosesAllergic rhinitisSinusitisGERDFor concomitant sinus disease, treat adenoids first
21 PreOp Evaluation of Adenoid Disease Evaluate palateSymptoms/FH of CP or VPIMidline diastasis of muscles, bifid uvulaCNS or neuromuscular diseasePreexisting 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.
25 Adenoidectomy with great care Adenoidectomy for speech problemsLook 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 childrenEtiology :Beta hemolyic streptococciStreptococcus pneumoniaHemophylus influenzaMode of transmissiondroplet infection
27 Embryology8 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 archesCrypts 3-6 months; capsule 5th month; germinal centers after birth16 weeks: Adenoids develop as a subepithelial infiltration of lymphocytesThe 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 endodermThe 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 RosenmüllerPassavant’s ridgeThe 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 arteriesTonsillar artery1% aberrant ICA just deep to superior constrictorAdenoidsAscending pharyngeal, sphenopalatine arteriesTonsillar branch of the facial artery is the main supply of the entire tonsil.Facial artery:Tonsillar artAscending palatine artLingual artdorsal lingual branchIMADesceding palatineGreater palatineAscending 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 zoneGerminal centerAdenoidsCiliated pseudostratified columnarStratified squamousTransitionalThe 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 tonsillitisAcute membranous tonsillitisAcute parynchymatous tonsillitisCervicalEnlarged tender jugulo-digastric lymph nodesThe crypts of the tonsilsare full of purulent exudateGiving yellow spots on thetonsilsMarked hyperemia andenlargement of the tonsilsThe yellow spots mayCoalease to form aYellow membraneAcute parynchymatous TAcute follicular T.Acute membranous T
34 PreOp Evaluation of Tonsillar Disease HistoryDocumentation of episodes by physicianFTTCor pulmonalePoststreptococcal GNRheumatic fever
35 PreOp Evaluation of Tonsillar Disease TONSIL SIZE0 in fossa+1 <25% occupation of oropharynx%%+4 >75%Avoid gagging the patient
36 PreOp Evaluation of Tonsillar Disease Down syndrome10% have AA laxityObtain lateral cervical films (flexion/extension) when positive findings on history, PEIf unstable, need neurosurgical evaluation preoperativelyLarge tongue and small mandible… difficult intubationProne to cardiac arrhythmias/hypotension during inductionInstability is caused by laxity of transverse ligament.Neck pain, muscular problems.Hyperactive DTR, clonusatlas-dens interval > 4.5mm
38 Chronic Tonsillitis Chronic inflammation of the palatine tonsils Etiology :Repeated attacks of acute tonsillitisSymptoms: one or more of the followingHistory of repeated attacks of ATIrritation in the throatFoetor orisIf hypertrophicDifficult swallowingObsrtuctive sleep apnea
39 Signs: Pharyngeal Cervical Asymmetry of the size of the tonsils Hypertrophy of the tonsilsThe crypts ooze pus on pressure by tongue depressorHyperaemia of the anterior pillarsCervicalPersistent enlargement of jagulodigastric lymph nodes
40 Acute Adenotonsillitis Etiology5-30% bacterial; of these 39% are beta-lactamase-producing (BLPO)Anaerobic BLPOGABHS most important pathogen because of potential sequelaeThroat cultureTreatment1. MC bacteria:Beta streptoccoci, staphylococci, streptoccocus pneumoniae, hemophilus2. Prevalence of beta-lactamase producing organisms is rising:from 2 % in 1980 to 44% in (FIND STUDY)3. Prevalence of anaerobic org is also risingAsymptomatic 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 immunoassayOlder latex agglutination testTreat 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 RFSuspect 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.influenzaS. aureusStreptococcus pneumoniaeTonsil 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
43 Medical ManagementPCN is first line, even if throat culture is negative for GABHSFor acute UAO: NP airway, steroids, IV abx, and immediate tonsillectomy for poor responseRecurrent tonsillitis: PCN injection if concerned about noncompliance or antibiotics aimed against BLPO and anaerobesFor 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 disordersHistorical screeningCBC, PT/PTT, BT, vWF activityHematology consultvon Willebrand’s diseaseITPSickle cell anemiaVon 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 2/3adverse effects… Na <132 or tachyphylaxis, d/c desmopressin, give cryoprepipitate or vWF-containing antihemophilic factorITP:
46 Post Operative Managment Criteria for Overnight ObservationPoor oral intake, vomiting, hemorrhageAge < 3Home > 45 minutes awayPoor socioeconomic conditionComorbid medical problemsSurgery for OSA or PTAAbnormal coagulation values (+/- identified disorder) in patient or family memberMC 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 obstructionConditions 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 sleepExcessive 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 swellingRespiratory compromiseDehydrationBurns and iatrogenic traumaMortality 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 > 20Anesthetic: kinking, extubation, fire, laryngospasmResp compromise: sudden loss of PEEP… pulmonary edema; avoid sedating analgesicsAssess for loose teeth… post op CXR to r/o aspiration if loss of toothDraping 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 edemaFever: normal in 1st 36 hr… watch for dehydrationDehydration: 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 stenosisAtlantoaxial subluxation/ Grisel’s syndromeRegrowthEustachian tube injuryDepressionLaceration of ICA/ pseudoaneursym of ICAVPI: usu transient; sig in 1 in ; only 1/3 identified preop as increased risk; > 2mo speech therapy; > 6-12mo pharyngeal flapNP stenosis: circumferential contracture of pharynx Waldeyer’s ring, T AND A; syphilis; increased risk with excessive mucosal excision; difficult to rxAA 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 pharyngitisadenoids 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, afrinOvernight observation and IV fluidsDangerous inductionECA ligationArteriographyAnesthetic 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 childrenDiagnosisIndications for polysomnographyInterpretation of polysomnographyPerioperative considerationsDiagnosis 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 hourcentral apnea assoc with desat <90%Pco2>53 or Pco2>45 for more than 60% test timefall of o2 sat < 92%No consensus on indications for surgery for those without severe obstruction/apnea.
51 Unilateral Tonsillar Enlargement Apparent enlargement vs true enlargementNon-neoplastic:Acute infectiveChronic infectiveHypertrophyCongenitalNeoplasticApparent: tonsil sits in more medial position, displacement medially by PTA or parapharyngeal space mass.Chronic infections: tubercular tonsillitis, actinomycosis, and congenital syphilisCongenital include teratoma, hemangioma, lymphangioma, and cystic hygroma.Neoplastic:Benign papillomasLymphoma (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 leptothricaTonsillolithsYellow 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
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 studyFrequency criteria: 7 episodes in 1 year or 5 episodes/year for 2 years or 3 episodes/year for 3 yearsClinical features (one or more): T 38.3, cervical LAD (>2cm) or tender LAD; tonsillar/pharyngeal exudate; positive culture for GABHS; antibiotic treatmentFrom the Children’s Hospital of Pittsburgh conducted parallel randomized and nonrandomized clinical trials to determine1. 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, and3. the effect of adenoidectomy of the course of nasal obstruction due to large adenoidsFindings:1. Histories of recurrent throat infections that are undocumented do not validly predict recurrence; need documentation by physician before performing tonsillectomy2. Using the selection criteria, the incidence of throat infection during the first 2 years of f/u was significantly lower in the surgical groups3. 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/yearHypertrophy causing malocclusion, UAOPTA unresponsive to nonsurgical mgmtHalitosis, not responsive to medical therapyUTE, suspicious for malignancyIndividual considerationsContraindications:TonsillectomyAcute infectionAnemiaDisorders of hemostasis
62 Case study13 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 crampsNo 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 studyYou 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 studyShe 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 studyShe 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 studyPatient 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 crypoprecipitateNo further bleeding occurs, patient is discharged the next day