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
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
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
Congenital tonsillar masses
Teratoma
Hemangioma
Lymphangioma
Cystic hygroma
Malignant Neoplasms
Most common is lymphoma
Non-Hodgkin’s lymphoma
Rapid unilateral tonsillar enlargement associated with cervical lymphadenopathy and systemic symptoms
Medical Management
Penicillin is first line treatment
Recurrent or unresponsive infections require treatment with beta-lactamase resistant antibiotics such as
Clindamycin
Augmentin
Penicillin plus rifampin
Adenotonsillar hyperplasia may respond to one month of therapy with beta-lactamase resistant antibiotics
Tonsillectomy
Current clinical indicators of AAO-HNS:
3 or more infections per year despite adequate medical therapy
Hypertrophy causing dental malocclusion or adversely affecting orofacial growth documented by orthodontist
Hypertrophy causing upper airway obstruction, severe dysphagia, sleep disorder, cardiopulmonary complications
Peritonsillar abscess unresponsive to medical management and drainage documented by surgeon, unless surgery performed during acute stage
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 beta-lactamase resistant antibiotics
Unilateral tonsil hypertrophy presumed neoplastic
Adenoidectomy
Current clinical indicators from AAO-HNS:
4 or more episodes of recurrent purulent rhinorrhea in prior 12 months in a child <12. One episode documented by intranasal examination or diagnostic imaging.
Persisting symptoms of adenoiditis after 2 courses of antibiotic therapy. One course of antibiotics should be with a beta-lactamase stable antibiotic for at least 2 weeks.
Sleep disturbance with nasal airway obstruction persisting for at least 3 months
Hyponasal or hypernasal speech
Otitis media with effusion >3 months or second set of tubes
Dental malocclusion or orofacial growth disturbance documented by orthodontist
Cardiopulmonary complications including cor pulmonale, pulmonary hypertension, right ventricular hypertrophy associated with upper airway obstruction
Otitis media with effusion over age 4
Surgical methods
Adenoidectomy
Adenotome
Curettes
Hemostasis with packing and/or electrocautery
Tonsillectomy
Tonsillotome
Cold dissection with snare
Monopolar/bipolar electrocautery
CO2 or KTP laser
Hemostasis with packing, electrocautery, sutures
Complications
Incidence of mortality reported between 1 in 16,000 and 1 in 35,000 cases
Anesthetic complications and hemorrhage cause majority of deaths
Depending on threshold for recording hemorrhage ranges from 0.1% to 8.1%
Hemorrhage is divided into primary bleeding, in the first 24 hours
Secondary bleeding 7-10 days post op
Dehydration
Airway obstruction from edema
Pulmonary edema
Fever
Velopharyngeal insufficiency
Dental injury
Burns
Nasopharyngeal stenosis
Atlantoaxial subluxation with Down’s syndrome or Grisel’s syndrome(vertebral body decalcification and anterior transverse ligament laxity from infection/inflammation
Indications for Observation
Controversies
Tonsillectomy for recurrent tonsillitis
Adenoidectomy for otitis media
Obstructive sleep apnea
Coagulation studies
Tonsillectomy for Recurrent tonsillitis
Paradise et al 1984
Reported on 187 severely affected children
7 episodes/one year, 5 per year for 2 years, or 3 per year for 3 years
Children who had tonsillectomy had fewer throat infections in the first 2 years postoperatively
Tonsillectomy/Adenoidectomy for Otitis Media
Gates et al reported on 578 children with chronic some benefit of adenoidectomy with or without myringotomy tube placement versus myringotomy or tubes alone
Paradise et al 461 children who had recurrent otitis media and no prior tubes for benefit from adenoidectomy or T&A
No benefit in rate of infections from adenoidectomy 1.8 vs. 2.1 , mild lowering of time with effusion 22.4% vs. 18.6%
T&A 1.4 vs. 2.1 mean annual rate of episodes, 18.6% vs. 29.9% time spent with effusion
Concluded that neither surgical procedure should be first line treatment for recurrent otitis media
Obstructive Sleep Apnea
Rising indication for adenotonsillectomy
When is polysomnography indicated?
Of benefit in establishing those children with OSA however parameters for abnormal results are not standardized in children RDI > 1 or 5
Number of centers equipped to handle children is limited, may delay treatment, expensive
Is of most use in questionable cases or in those with persistent obstructive symptoms after T&A
PTA in young Children
Estimated 13,500 cases of PTA per year
Most common in teenagers and young adults
PE may be difficult in uncooperative child
CT scan can help with diagnosis
In a cooperative patient needle aspiration or incision and drainage is effective 80-100%
This may be difficult in younger children
Dodds and Manglia recommended surgery in all patients 79% I&D, 21% tonsillectomy
Blotter et all: series 102 patients 8mos-19 years, 51% responded to medical therapy, 49% underwent tonsillectomy
Preoperative Coagulation Studies
PT/PTT, CBC, bleeding time
Tami et al found 24% patients with abnormal PT/PTT experienced postoperative bleeding, only 10% normal PT/PTT
Bolger et al found that despite a history without evidence of bleeding tendency 11.5% had abnormal PT/PTT or BT
Manning et al 994 patients , perioperative bleeding, sensitivity 5.5% specificity 94% PPV 3.4% : concluded unjustifiable test
Zwack and Derkay 4373 patients , examined those with post operative bleeding (0.98%) , 1 had elevated PTT by 0.1
AAO-HNS recommends coagulation and bleeding workup only if indicated by history or genetic information is unavailable
Case Study
A 3 yo boy presents to your office whose parents complain that he snores loudly and stops breathing sometimes while sleeping. The child’s pediatrician told the parents that his tonsils were “big” and that the child is under weight for his age
Also has dysphagia and daytime somnolence
Apneic spells last >10 seconds
PMH: otherwise healthy
Meds:none
No allergies
PE:
Dark circles under eyes
Breathing with mouth open
Small amount of clear rhinorrhea
Tonsils are almost touching in the midline
Adenotonsillar hypertrophy
Sleep disturbance