Tonsillitis, Tonsillectomy, and Adenoidectomy

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

• Gerlach’s tonsil

Adenoids

• Fossa of Rosenmüller

• Passavant’s 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-lactamase-producing (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.

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

Non-neoplastic:

• Acute infective

• Chronic infective

• Hypertrophy

• Congenital

Neoplastic

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

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)

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

Differential diagnoses

• Allergic rhinitis

• Sinusitis

• GERD

• For concomitant sinus disease, treat adenoids first

Evaluate palate

• Symptoms/FH of CP or VPI

• Midline diastasis of muscles, bifid uvula

• CNS or neuromuscular disease

• Preexisting speech disorder?

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.

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%

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 Willebrand’s disease

• ITP

• Sickle cell anemia

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

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/ Grisel’s 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

Mary Talley Dorn, M.D.

Norman R. Friedman, M.D