Tonsillectomy, and
Adenoidectomy
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History
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Celsus 50 A.D.
Caque of Rheims
Philip Syng
Wilhelm Meyer 1867
Samuel Crowe
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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
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Anatomy
Tonsils
• Plica triangularis
• Gerlach’s tonsil
Adenoids
• Fossa of Rosenmüller
• Passavant’s ridge
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Blood Supply
Tonsils
• Ascending and descending
palatine arteries
• Tonsillar artery
• 1% aberrant ICA just deep
to superior constrictor
Adenoids
• Ascending pharyngeal,
sphenopalatine arteries
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Common Diseases of the
Tonsils and Adenoids
• Acute adenoiditis/tonsillitis
• Recurrent/chronic
adenoiditis/tonsillitis
• Obstructive hyperplasia
• Malignancy
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Acute Adenotonsillitis
Etiology
• 5-30% bacterial; of these
39% are beta-lactamaseproducing (BLPO)
• Anaerobic BLPO
GABHS most important
pathogen because of
potential sequelae
• Throat culture
• Treatment
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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.
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Acute Adenotonsillitis
Differential diagnosis
Infectious mononucleosis
Malignancy: lymphoma, leukemia, carcinoma
Diptheria
Scarlet fever
Agranulocytosis
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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%
• Co-amoxiclav or clindamycin or PCN+Rifampin
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Obstructive Hyperplasia
• Adenotonsillar hypertrophy most common cause
of SDB in children
• Diagnosis:snoring, restless sleep, FTT, daytime
symptoms… poor mentation, decreased attn span, poor
scholastic performance, dysphagia, nocturnal enuresis,
chronic mouth breathing
• Indications for polysomnography
• Interpretation of polysomnography
• Perioperative considerations
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• Interpretation of polysomnography:
Indications for surgical intervention
>1 apnea in 1 hour
Central apnea + o2sat<90%
O2sat<92%
CO2>53
CO2>45 in more than 60% of test time
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Unilateral Tonsillar
Enlargement
Apparent enlargement vs true enlargement
Non-neoplastic:
• Acute infective
• Chronic infective
• Hypertrophy
• Congenital
Neoplastic
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Peritonsillar Abscess
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ICA Aneurysm
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Pleomorphic Adenoma
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Other Tonsillar Pathology
• Hyperkeratosis,
mycosis leptothrica
• Tonsilloliths
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Candidiasis
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Retention Cysts
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Supratonsillar Cleft
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Indications for Tonsillectomy;
Historical Evolution
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Indications for Tonsillectomy
Paradise study
• Frequency criteria: 7 episodes in 1 year or 5
episodes/year for 2 years or 3 episodes/year for 3
years
• Clinical features (one or more): T 38.3, cervical
LAD (>2cm) or tender LAD; tonsillar/pharyngeal
exudate; positive culture for GABHS; antibiotic
treatment
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Indications for Tonsillectomy
AAO-HNS:
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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
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Also:
1. Recurrent tonsillitis in patient with heart valve dis
2. In patient with febrile convulsion
3. Unresponsive carrier
4. Obstructive IMN unresponsive to medical therapy
5. Carrier of diphtheria
6. Chronic tonsillitis with never-ending sore throat
7. OSAS
8. FTT
9. Disphagia
10. phonation disorders
11. Malocclusion
12. Craniofacial growth abnormalities
13. Corpulmonale
14. Suspicious malignancy
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Pathophysiology of corpulmonale in OSA:
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URT obstruction
Alveolar hypovantilation
Chronic hypoxia and hypercapnea
Respiratory acidosis
Vasoconstriction of alveolar capillaries
Right atrial dilatation
Pulmonary hypertension
Corpulmonale and CHF
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Pathophysiology of enuresis:
1. SDB
2. REM abnormalities
3. Irregularities in ADH secretion
Pathophysiology of FTT:
1. SDB
2. REM abnormalities
3. Irregularities in GH secretion, may sometimes stop totally
Both return to normal following A&T
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ADHD (Attention Deficit Hyperactivity Disorder) is the most
Common psychiatric diagnosis in children.
In direct correlation with Sleep Disordered Breathing(SDB)
Pathophysiology uncertain, Maybe due to abnormal sleep pattern
Neurocognitive development delays:
Healthy sleeping pattern: important component of brain growth
Frontal cortex growth continues up to puberty
Most critical age: 3-7
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Indications for Adenoidectomy
Paradise study
• 28-35% fewer acute episodes of OM with adenoidectomy
in kids with previous tube placement
• Adenoidectomy or T & A not indicated in children with
recurrent OM who had not undergone previous tube
placement
Gates et al
• Recommend adenoidectomy with M & T as the initial
surgical treatment for children with MEE > 90 days and
CHL > 20 dB
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Indications for Adenoidectomy
Obstruction:
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Chronic nasal obstruction or obligate mouth breathing
SDB 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)
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Also:
• Chronic sinusitis: first step
biofilm in 95% adenoid specimen vs.
2% in SDB
• Chronic recurrent AOM
• COM
• Chronic otorrhea
• VT and persistent discharge
• Suspecious malignancy
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PreOp Evaluation of Adenoid
Disease
• Triad of hyponasality,
snoring, and mouth
breathing
• Rhinorrhea, nocturnal
cough, post nasal drip
• “Adenoid facies”
• “Milkman” & “Micky
Mouse”
• Overbite, long face,
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PreOp Evaluation of Adenoid
Disease
Differential diagnoses
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Allergic rhinitis
Sinusitis
GERD
For concomitant sinus disease, treat
adenoids first
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PreOp Evaluation of Adenoid
Disease
Evaluate palate
• Symptoms/FH of CP
or VPI
• Midline diastasis of
muscles, bifid uvula
• CNS or neuromuscular
disease
• Preexisting speech
disorder?
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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.
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PreOp Evaluation of Adenoid
Disease
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PreOp Evaluation of Tonsillar
Disease
History
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Documentation of episodes by physician
FTT
Cor pulmonale
Poststreptococcal GN
Rheumatic fever
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PreOp Evaluation of Tonsillar
Disease
TONSIL SIZE
• 0 in fossa
• +1 <25% occupation
of oropharynx
• +2 25-50%
• +3 50-75%
• +4 >75%
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Avoid gagging the patient
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PreOp Evaluation of Tonsillar
Disease
Down syndrome
• 10% have AtlantoAxial 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
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PreOp Evaluation for
Adenotonsillar Disease
Coagulation disorders
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Historical screening
CBC, PT/PTT, BT, vWF activity
Hematology consult
von Willebrand’s disease
ITP
Sickle cell anemia
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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)
• Coblation
• RadioFrequency
… Surgeon’s preference
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Post Operative Managment
Criteria for Overnight Observation
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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
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Complications
#1 Postoperative bleeding
Other:
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Sore throat, otalgia, uvular swelling
Respiratory compromise
Dehydration
Burns and iatrogenic trauma
Dental problems and trauma
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Rare Complications
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Velopharyngeal Insufficiency
Nasopharyngeal stenosis
Atlantoaxial subluxation/ Grisel’s syndrome
Regrowth
Eustachian tube injury
Depression
Laceration of ICA/ pseudoaneursym of ICA
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Management of Hemorrhage
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Ice water gargle, afrin
Overnight observation and IV fluids
Dangerous induction
ECA ligation
Arteriography
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Case study
• 13 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
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Case study
• No known medical problems, no prior
surgical procedures
• Takes motrin for menustrual cramps
• No personal history of bleeding other than
occasional nose bleeds and extremely heavy
periods.
• Family history unknown. Patient is
adopted.
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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
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back.”
Case study
• You 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
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hematology
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Case study
• She 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.
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Case study
• She 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.
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Case study
• Patient 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.
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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
crypoprecipitate
• No further bleeding occurs, patient is
discharged the next day
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