Adenotonsillar disease
Shahin Bastaninejad, MD, ORL-HNS Surgeon
Assistant professor of tehran university of
medical sciences
Anatomy
Tonsil boundary
 Plica triangularis
Adenoid boundary
 Posterior aspect of
the nasal septum
 Fossa of Rosenmüller
 Passavant’s ridge
Waldeyer’s Ring
Presentation outlines
 Acute Infections
 Chronic diseases
 Obstructive hyperplasia
 Mass
 Surgery
Acute Infections
Acute Adenotonsillitis
Etiology
 85% of this problem is
due to the viral infection
(less in children)
 In bacterial infections
there is about 40%
antibiotic resistancy (due
to
beta-lactamaseproducing germs)
 GABHS is the most
important
pathogen
because of potential
sequelae
Bacteriology of
adenotonsillitis
 Group A beta-hemolytic is most recognized
pathogen
 This organism is associated with a risk of
rheumatic fever and glomerulonephritis
 Many other organisms are involved :
 H.influenza
 S. aureus
 Streptococcus pneumoniae
GABHS
 More common in 5 to 15 years old children
 Not seen in less than 3 years
Diagnosis
 Viral pharyngitis symptoms:
 Coryza
 Hoarseness
 Cough
 Conjunctivitis
 Centor criteria for GABHS:
 Hx of fever more than 38
 Anterior cervical LAP
 Pharyngeal or Tonsillar exudate
 Absence of cough
Approach to the Centor
scoring
 0-1  Abx not needed
 2-4  perform Cx
 Clue : when all 4 scores are present in 44% of
the patients there is no GABHS
Treatment Plan
 Delay in treatment up to 9 days can be
acceptebale
 When empiric txy?
 Lack of Pt .f/u
 Lack of Lab. access
 Toxic presentation
 In some extends when all 4 measures present
In parentheses!!!
 When culture is positive there are two
possibilites:
 True infection
 Carrier state
 In this scenario, serological evaluation with
ASO(anti-streptolysin O) will be usefull (in
true infection it will be more than 3 times
than its usual range)
Medical Management
 Penicillin is first line treatment  oral
medication is preferable (penicillin V)
 Other choices:
 Amoxicillin (wide spectrum than Pencillin V)
 Macrolides
 Clindamycin
 Recurrent or unresponsive infections require
treatment with beta-lactamase resistant
antibiotics such as
 Clindamycin
 Augmentin
 Penicillin plus rifampin (or Erythro + Metro)
 If no response after 48 hr, re-evaluate patient
for the followings:
 Sequelea
 Patient’s incompliance
 Other underlying disease
 Abx failure
Peritonsillar abscess
 Abscess formation outside tonsillar capsule
 Signs and symptoms:
 Fever
 Sore throat
 Dysphagia/odynophagia
 Drooling
 Trismus
 Unilateral swelling of soft palate/pharynx with uvula
deviation
Be aware of ICA Aneurysm!
Peritonsillar abscess…
 Thought to be extension of tonsillitis to involve
surrounding tissue with abscess formation
 Recently described to be an infection of small
salivary glands in the supratonsillar fossa called
Weber’s glands
 Would explain superior pole involvement and the
usual absence of tonsillar erythema/exudates
Candidiasis
Infectious Mononucleosis
IMN
 Clinical diagnosis can be made from the
characteristic triad of fever, pharyngitis, and
lymphadenopathy lasting for 1 to 4 weeks
 Laboratory
tests
are
needed
for
confirmation
 Serologic test results include a normal to
moderately elevated white blood cell count,
an increased total number of lymphocytes
(more than 50%), greater than 10% atypical
lymphocytes, and a positive reaction to a
"mono spot" test
IMN
 When "mono spot" or heterophile test results
are negative, additional laboratory testing
may be needed to differentiate EBV
infections from a mononucleosis-like illness
 EBV-Specific Laboratory Tests:
 IgM and IgG to the viral capsid antigen
 IgM to the early antigen
 antibody to EBNA
IMN – Test interpretation
 Primary Infection: Primary EBV infection is
indicated if IgM antibody to the viral capsid
antigen is present and antibody to EBNA is
absent
 Past Infection: If antibodies to both the viral
capsid antigen and EBNA are present, then
past infection (from 4 to 6 months to years
earlier) is indicated
IMN – Test interpretation
 Reactivation: In the presence of antibodies
to EBNA, an elevation of antibodies to early
antigen suggests reactivation
 Chronic EBV Infection: Reliable laboratory
evidence for continued active EBV infection is
very seldom found in patients who have been
ill for more than 4 months
Diphtheria
Chronic disease
Chronic Tonsillitis
 Chronic sore throat
 Malodorous breath
 Presence of tonsilliths
 Persistent tender cervical lymphadenopathy
 Lasting at least 3 months
 Be aware of Anaerobic infections
Cryptic tonsils
 Hyperkeratosis,
mycosis leptothrica
 Tonsilloliths
Obstructive Hyperplasia
Obstructive Adenoid
Hyperplasia
 Signs and Symptoms
 Obligate mouth breathing
 Hyponasal voice
 Snoring and other signs of sleep disturbance
Obstructive Tonsillar
Hyperplasia
 Snoring and other symptoms of sleep
disturbance
 Muffled voice
 Dysphagia
Tonsillar Mass
Malignant Neoplasms
 Most common is lymphoma
 Non-Hodgkin’s lymphoma
 Rapid unilateral tonsillar enlargement
associated with cervical lymphadenopathy
and systemic symptoms
Lymphoma
SCC
Congenital tonsillar masses
 Teratoma
 Hemangioma
 Lymphangioma
 Cystic hygroma
Surgery
Tonsillectomy
(2010-AAOHNS)
 Infection indications:
 Pharyngitis more than 7 / yr in 1 yr
 More than 5 / yr for 2yrs
 More than 3 / yr for 3yrs
 Recurrent infections with modifying factors:
 Multiple Abx allergy / intolerance
 PF.ASP.A: periodic fever/aphthous stomatitis and
pharyngitis/adenitis
 History of peritonsillar abscess
Tnosillectomy Cont…
 Persistent foul taste or breath due to chronic tonsillitis
not responsive to medical therapy
 Chronic or recurrent tonsillitis associated with
streptococcal carrier state and not responding to betalactamase resistant antibiotics
 Unilateral tonsil hypertrophy presumed to be
neoplastic
Adenotonsillectomy
 ATH and Sleep disordered breathing (SDB)
 Severity of the SDB depends on adenotonsillar
size and/or Craniofacial anatomy and/or
neuromuscular tone
 Ask for comorbid conditions: Growth retardation /
poor school performance / enuresis / behavioral
problems (ADHD,…)
 Polysomnography indications (PaO2 less than
85% and/or AHI>5)  check PSG in obese
patient/down syndrome/craniofacial anomaly &…
 Infection:
Adenoidectomy
 Purulent adenoiditis
 Adenoid hypertrophy associated with:
 Chronic otitis media with effusion
 Chronic recurrent acute otitis media
 Chronic otitis media with perforation
 Otorrhea or chronic tube otorrhea
 Obstruction (next slide)
 Other:
 Suspected neoplasia
 Adenoid hypertrophy associated with chronic
sinusitis
Adenoidectomy Cont…
 Obstruction:
 Adenoid hypertrophy associated with excessive
snoring and chronic mouth-breathing
 Sleep apnea or sleep disturbances
 Adenoid hypertrophy associated with:
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Cor pulmonale
Failure to thrive
Dysphagia
Speech abnormalities
Craniofacial growth abnormalities
Occlusion abnormalities
Speech abnormalities
Pre-Op Evaluation of Adenoid
Disease
 Triad of hyponasality,
snoring, and mouth
breathing
 Rhinorrhea, nocturnal
cough, post nasal drip
 “Adenoid facies”
 long face, crowded
incisors
Pre-Op Evaluation of Adenoid
Disease
Evaluate palate
 Symptoms/FH of CP
or VPI
 Bifid uvula
 CNS or
neuromuscular
disease
 Preexisting speech
disorder?
Pre-Op 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.
Any questions !?