1. Consultant Pediatric ORL.H&NS
Adenotonsilitis
Samir M. Bawazir
Consultant Pediatric ORL.H&NS

2. Adenotonsillectomy
Most commonly performed procedure in the history of surgery
$500 million annually in healthcare expenditures-USA

3. Anatomy 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 .

4. Blood Supply Tonsillar artery-from FA. Is the main 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

5. 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.

6. Histology
Tonsils
The medial surface- Non-keratinizing Stratified squamous epith.
Medial surface has 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)
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.

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

8. Tonsil Grading
Grade %
1 <25
4 >75

9. Which Grade ?

10. How to approach this Pt.?

11. Acute Adenotonsillitis
Odynophagia, fever, tender cervical lymphadenopathy.
Fever> 38.5
Tonsillar Exudate
Tender cervical LN >2cm
Positive throat culture

12. 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 culture
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.
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 (mono spot test) test.

13. 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
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

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

15. 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

16. PreOp Evaluation of Adenoid Disease
Triad of hyponasality, snoring, and mouth breathing
Rhinorrhea, nocturnal cough, post nasal drip
“Adenoid facies”
Overbite, long face, crowded incisors

17. 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.

18. PreOp Evaluation of Adenoid Disease

19. 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?
Speech path consult for speech disorder.
Submucous cp 1 in 1200

20. 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

21. 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

22. Surgical Indication Tonsillectomy Absolute Relative
- 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

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

24. Rare Complications Velopharyngeal Insufficiency
Nasopharyngeal stenosis
Atlantoaxial subluxation
Regrowth
Eustachian tube injury
Depression

25. 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

26. Unilateral Tonsillar Enlargement
Apparent enlargement vs true enlargement
Non-neoplastic:
Acute infective
Chronic infective
Hypertrophy
Congenital Neoplastic

27. Peritonsillar Abscess

28. Retention Cysts

29. Intratonsillar Cleft collect debris, cause halitosis, Rx Ts.

30. TEST
9yo male referred to the ENT clinic for evaluation and treatment of recurrent tonsillitis.