Tonsillitis, Tonsillectomy and

Adenoidectomy
Steven T. Wright, M.D.
Faculty Advisor: Ronald Deskin, M.D.
The University of Texas Medical Branch
Department of Otolaryngology
Grand Rounds Presentation
November 5, 2003
Adenotonsillectomy
Most commonly performed procedure in the
history of surgery
$500 million annually in healthcare
expenditures
History
Almost exclusively by Otolaryngologists
Celsus in 50 A.D.
Caque of Rheims
Phillip Syng developed the tonsillotome
Anatomy
Anatomy
Histology
Clinical Evaluation
Acute Tonsillitis
Chronic Tonsillitis
Obstructive Tonsillar Hyperplasia

Clinical Evaluation
Odynophagia, fever,
tender cervical
lymphadenopathy.
Supporting
documents, 2 or more
Fever> 38.5
Tonsillar Exudate
Tender cervical
LAD >2cm
Positive throat
culture

Clinical evaluation
Viral
Lower grade fever
Lower WBC, Lymphocytic shift
Less tonsillar exudate
Bacterial
Higher WBC, Granulocytic shift
More exudative
Recurrent Acute Tonsillitis
Seven episodes in a single year
Five or more episodes in 2 years
Three or more episodes in 3 years
Chronic Tonsillitis
No true consensus on the definition.
Symptoms greater than 4 weeks
Differential Diagnosis
Infectious Mononucleosis
EBV
Scarlet Fever
Corynebacterium diptheriae
Malignancy
Complications of Tonsillitis
Cervical Adenitis
Neck Abscess
Peritonsillar abscess
Intratonsillar abscess
Lemierres syndrome
Post Streptococcal
Glomerulonephritis
Joint Pain and oliguric renal failure 10 days
after the pharyngitis.
Treatment aimed at eliminating the
infection and supportive therapy for renal
failure.
Excellent prognosis in children.
Adenoid Hyperplasia
Triad
Hyponasality
Snoring
Open mouth breathing
Purulent rhinorrhea, post nasal drip, chronic
cough, and headache
Obstructive Airway Symptoms
Snoring
Apneic episodes with gasping or choking
Daytime hypersomnolence
Nocturnal enuresis
Behavioral disturbances
Heart failure and Failure to thrive
Tonsil Size
Grade %
1 <25
2 25-50
3 51-75
4 >75
Obstructive Sleep Apnea
Polysomnography is the gold standard of
diagnosis.
Imperative in Adults
In children, a convincing history is
adequate
OSA: RDI > 5, SpO2<90%
UARS: RDI <5, SpO2 >90%
Primary Snoring: RDI <1, SpO2>90%
Medical Therapy
TCHP recommends confirming bacterial
pharyngitis before beginning antibiotics.
Rapid Strep Test
Throat Culture
Medical Therapy
First Line
Penicillin/Cephalosporin for 10 days
Injectable forms for noncompliance
BLPO, co pathogens
Macrolides
Penicillin allergy
Erythromycin/Clarithromycin 10 days
Azithromycin (12mg/kg/day) 5 days
Medical Therapy
Patients with recurrent otitis media history
have higher bacterial concentrations with
BLPO.
Initial treatment with anti-BLP antibiotic.
Adenotonsillar size may respond to a one
month course of antibiotic therapy.
Adenoid hyperplasia may respond to a 6-8
week course of intranasal steroid.
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
COME

Surgical Indications
Absolute
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

Preoperative evaluation
Most common lab test is a CBC
Coagulation studies when the history or
physical examination suggests a bleeding
disorder.
Lateral Neck/Adenoid films
Von Willebrands Disease
Autosomal dominant bleeding disorder
Increased bleeding time and prolonged
aPTT.
Perioperative management
IV Desmopressin (0.3ugm/kg)
Serum Sodium
Idiopathic Thrombocytopenic
Purpura
Most common thrombocytopenia of
childhood.
90% resolution by 9-12 months
Splenectomy
IVIG preoperatively
Innovative Surgical Techniques
Cold Dissection
Electrosurgery
Intracapsular partial tonsillectomy
Harmonic Scalpel
Radiofrequency tonsillar ablation and
coblation.
Electrosurgery
Most popular technique for tonsillectomy
Equivalent or superior to the other methods
of tonsillectomy.

Intracapsular Partial
Tonsillectomy
45 degree Microdebrider (1500rpm).
Advantages
As effective as standard tonsillectomy in
relieving obstruction.
Less pain, quicker return to normal diet
Disadvantages:
Tonsillar regrowth
Greater intraoperative blood loss
Harmonic Scalpel
Advantages:
Better visibility
Smaller risk of stray energy shocks
Improved post operative pain
Disadvantages:
Must use alternate device for adenoidectomy
Similar intraoperative blood loss.
Radiofrequency tonsillar
coblation
Coblation is superior to ablation.
Early elimination of pain and reduced pain
medicine usage.
Early resumption of normal diet.
Currently inadequate for adenoidectomy
Adjuvant Therapies
Perioperative local anesthetic
0.25% bupivicaine w/ 1:100,000
Epinephrine
Advantages:
ease of dissection, postoperative pain
Disadvantages:
Airway obstruction, cardiac dysrrhythmias,
seizures




Adjuvant Therapies
Perioperative antibiotics
Fewer episodes of fever, offensive odor,
improved oral intake, less pain, fewer
days to return to normal activity
Cardiac abnormality
Adjuvant Therapies
Perioperative Steroids
Dexamethasone (0.15-1.0mg/kg)
Two times less likely to have an episode
of postoperative emesis, and more likely
to advance to eating a soft diet.
Reducing postoperative pulmonary
distress, subglottic edema, pain reduction.
Adjuvant Therapies
Pain control
Tylenol and Tylenol w/ codeine are the
most commonly used.
Similar pain control, less oral intake with
codeine versus Tylenol alone.
NSAIDS still controversial.
Complications
Mortality rate is 1 in 16000-35000.
Anesthetic complications
Eustachian tube injury
VPI
Nasopharyngeal stenosis
Pulmonary Edema
Atlantoaxial subluxation
23 hour observation
Age younger than 3.
Obstructive sleep apnea/craniofacial
syndromes involving the airway.
Systemic disorders
Poor socioeconomic situation
Peritonsillar abscess
Emesis or Hemorrhage
Post Operative Hemorrhage
The best treatment is prevention.
Early vs. Delayed hemorrhage.
Overnight observation and venous access
Surgical intervention.
Carotid angiography if any suspicion of
carotid artery injury.
Case Study
8yo male referred to the Pediatric clinic for
evaluation and treatment of recurrent
tonsillitis.
History
Only 2 episodes of documented pharyngitis
in the past 12 months, strep negative, only
missed 5 days of school total last year.
Loud snoring, frequent pauses up to 5
seconds terminated with gasps of breath.
Physical Examination
Normal facies, open mouth breathing,
tonsils 3+, no cleft deformities.
Remainder of exam is normal.
Case Study
Undergoes uneventful tonsillectomy and
adenoidectomy with 23 hour observation.
On follow up visit 2 weeks postoperatively,
his mom complains that he doesnt like
some of his favorite foods. He says they
taste yucky.
Decreased perception of taste with no smell
abnormalities.
Diagnosis
Dysgeusia
Unknown mechanism- thought to be due to
prolonged pressure on the tongue by the
mouth retractor.
Treatment is reassurance.
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