Tonsillectomy and Adenoidectomy
What is Waldyer’s ring?
The tonsillar ring consisting of 2 Palatine + 1 pharyngeal + 2 tubal + 1 lingual tonsils. The lymphoid tissue is annularly arranged, hence the “ring”.
Review the blood supply, lymphatics and sensory innervation of tonsils.
Blood supply
Ascending pharyngeal artery
Ascending palatine branch of Facial
Tonsillar branch of Facial
Palatine branch of Maxillary
Dorsal lingual branch of Lingual
Innervation
sphenopalatine ganglion via the lesser palatine and glossopharyngeal nerves
Lymphatics
drain into the upper deep cervical and jugular lymph nodes.
Review the blood supply, lymphatics and sensory innervation of adenoids.
See above.
What is the effect of T&A on immune status?
This is not a well understood phenomenon.
What is Post-transplant lymphoproliferative disorder? What is the relationship between PTLD and tonsils?
Prevalence: 2-5% after transplant, can occur at any point in time.
Usually manifests with B-cell proliferation induced by EBV; this proliferation is left unopposed by the pharmacologically suppressed T-cell system.
More common in kids who are usually EBV-immune at time of transplant.
Nonbacterial tonsillar inflammation or hypertrophy associated with an EBV infection is often the first manifestation of PTLD.
Rx: Tonsillectomy combined with tapering of immunosuppression.
What is the most common bacterial pathogen in tonsillitis? What complications are associated with this pathogen and how do we test for it? Other pathogens?
GAS is the most common bacterial pathogen
suppurative complications: sinusitis, retropharyngeal abscess, peritonsillar abscess, otitis media, rarely meningitis or brain abscess
nonsuppurative complications: acute rheumatic fever, glomerulonephritis, scarlet fever, PANDAS (pediatric autoimmune neuropsychiatric disorder associated with group A strep)
use CENTOR criteria to stratify need for testing and empiric treatment
CENTOR: tonsillar exudates, tender cervical LAD, fever, absence of cough
less than 2 CENTOR criteria does not need testing or treatment
rapid antigen detection test
sensitivity 70-90%, specificity 90-100%
rapid results
throat culture
sensitivity and specificity 95%+
takes 24-48 hrs
other pathogens
viruses: EBV, CMV, HSV, HIV
bacteria: M. pneumoniae, diptheria, gonorrhea, chlamydia
How does tonsillitis due to infectious mononucleosis differ from other types of tonsillitis? How is it diagnosed and treated?
Infectious mononucleosis is caused EBV
LAD in mono more commonly involves posterior cervical chain than anterior
bloodwork in mono shows absolute lymphocytosis with atypical lymphocytes on smear
splenomegaly with risk for splenic rupture
presence of rash, which nearly always arrives after use of amoxicillin, but also with others like azithromycin, levofloxacin, Zosyn, cephalexin
diagnosis
compatible clinical syndrome with +heterophile Ab
if heterophile testing is negative, then repeat as this can be negative early in the illness
an EBV antibody panel can add further clarification
treatment
supportive
steroids for airway obstruction
antivirals have not been shown to be of benefit
avoid contact sports x 4 weeks given risk for splenic rupture
What antibiotics are commonly used for treatment of tonsillitis? What are the goals of therapy?
Goals of therapy
shorten duration and severity of illness
reduce incidence of nonsuppurative complications
reduce transmission to close contacts
ABX choices
oral PCN V
amoxicillin
first generation cephalosporins
Note: See latest Clinical Practice Guidelines on Tonsillectomy in Children.
When should tonsillectomy be considered for recurrent tonsillitis?
Indications for tonsillectomy for recurrent tonsillitis
Paradise criteria
7 episodes in the last year, or
5 episodes in each of previous two years, or
3 episodes in each of previous three years
second episode of PTA or a first episode of PTA preceded by three episodes of tonsillitis in the previous year
chronic tonsillitis unresponsive to antimicrobials
Describe the signs and symptoms of adenoidal hypertrophy.
Nasal congestion
Rhinorrhea
Chronic/recurrent otitis media
Hyponasal voice
Snoring or sleep disturbances
Obligate mouth breathing
What is adenoid facies? What evidence exists that chronic mouth breathing can lead to changes in the facial structure?
Adenoid facies
Refers to the characteristic facial appearances of children with adenoid hypertrophy or severe nasal airway obstruction.
Facial appearance consists of:
underdeveloped thin nostrils
short upper lip
prominent upper teeth
crowded teeth
narrow upper alveolus
high-arched palate
hypoplastic maxilla
Hypothesis is that with the mouth open, the tongue places less pressure on the palate.
With the mouth in a chronically open position → forces on the mandible, temporal-mandibular joint → dental arches are altered → aberrant growth of the craniofacial skeleton
Evidence regarding whether chronic mouth breathing leads to changes in facial structure?
Most studies show only a temporal relationship rather than an actual cause-effect relationship
For example, Niikuni N et al. in 2004 showed that in a study of 35 preschool children, various facial dimensions and parameters were correlated with NP airway space
Study by Linder-Aronson S. et al. in 1973 showed that the craniofacial skeleton of children successfully treated with adenoidectomy of severe nasal airway obstruction had reversal of some craniofacial skeletal changes
Closest study so far to indicate more a possible cause-effect relationship
List the indications for T&A.
History
More than 7 episodes in the past year, 5 episodes per year in the past 2 years or 3 episodes per year in the past 3 years
Exceptions include: Multiple antibiotic allergy/intolerance, PFAPA (periodic fever, aphthous stomatitis, pharyngitis, and adenitis), or history of peritonsillar abscess. parapharyngeal abscess, severe infection with dehydration requiring IV fluids, or severe infections that may aggravate co-morbid conditions (eg, seizure disorder). Children who are at risk for being held back in school due to excessive absences (eg, over ten school days per academic year) may also need consideration
Sleep disordered breathing with associated tonsillar hypertrophy and/or growth retardation, poor school performance, enuresis, and behavioral problems, growth retardation, poor school, performance, enuresis, and behavioral problems
Dental malocclusion affecting orofacial growth (documented by dentist, OMFS, orthodontist)
Severe dysphagia or cardiopulmonary complications from tonsillar hypertrophy
Persistent foul taste or breath not responsive to medical therapy and with other causes eliminated/treated
Presumed neoplasm
Recurrent suppurative or chronic otitis media with effusion: Adenoidectomy alone.
Tonsillectomy added requires one of the indications listed above
Chronic sinusitis in pediatric population not response to maximal medical therapy. Again, adenoidectomy alone unless other indications
PE
Describe tonsils/adenoids
Describe uvula/palate
Lab testing
Coagulation/bleeding work-up, if indicated
PSG in children at high-risk respiratory compromise (see below)
Imaging of the sinuses to document sinusitis in pediatric population if considering adenoidectomy
Note: See latest Clinical Practice Guidelines on Tonsillectomy in Children.
Dandara de A. Bueno, Taís H. Grechi, Luciana V.V. Trawitzki, Wilma T. Anselmo-Lima, Cláudia M. Felício, Fabiana C.P. Valera, Muscular and functional changes following adenotonsillectomy in children, International Journal of Pediatric Otorhinolaryngology, Volume 79, Issue 4, April 2015, Pages 537-540, ISSN 0165-5876
Elluru RG. Adenoid Facies and Nasal Airway Obstruction: Cause and Effect?. Arch Otolaryngol Head Neck Surg. 2005;131(10):919-920. doi:10.1001/archotol.131.10.919.
Niikuni N, Nakajima L, Akasaka M. The relation- ship between tongue-base position and cranio- facial morphology in preschool children. J Clin Pe- diatr Dent. 2004;28:131-134.
Discuss the complications of T&A and how to avoid them.
How to avoid:
IO - conscious of positioning/tube placement, atlantoaxial dislocation and Downs/mucopolysaccharidoses, surgical awareness (coating of instruments), avoiding tonsillectomy during infxn if possible
PO - anesthesia management of fluids, steroids, appropriate control
Delayed - meticulous control of instrumentation
“A tonsil is NEVER just a tonsil”
Johnson, L. B., Elluru, R. G. and Myer, C. M. (2002), Complications of Adenotonsillectomy. The Laryngoscope, 112: 35–36. doi: 10.1002/lary.5541121413
Should we screen all kids for bleeding disorders prior to tonsillectomy? What is the most common bleeding disorder?
Short answer seems to be NO;
Most retrospective reviews agree that there is low sensitivity/specificity to testing and that should only test kids with family hx or strong suspicion of bleeding d/o.
Also, studies seem to suggest no increased risk of bleeding complications (though recent study out of Mayo seems to suggest may have increased risk of delayed bleeding)
Klin Padiatr. 2006 Nov-Dec;218(6):334-9.Preoperative screening for coagulation disorders in children undergoing adenoidectomy (AT) and tonsillectomy (TE): does it prevent bleeding complications?
Int J Pediatr Otorhinolaryngol. 2001 Dec 1;61(3):217-22.The need for routine pre-operative coagulation screening tests (prothrombin time PT/partial thromboplastin time PTT) for healthy children undergoing elective tonsillectomy and/or adenoidectomy.
Haemophilia. 2015 May;21(3):e151-5. doi: 10.1111/hae.12577..Haemorrhagic complications with adenotonsillectomy in children and young adults with bleeding disorders.
However:
3-year retrospective study
Population was made up of 875 patients--441 boys and 434 girls, aged 2 to 18 years
748 patients (85.5%) had normal findings on preoperative hematologic screening, and 127 (14.5%) had at least one abnormality.
Postoperatively, hemorrhagic complications occurred in 31 children (3.5%)--in 22 of the 748 patients with normal screening results (2.9%) and in 9 of the 127 with ascreening abnormality (7.1%) (p = 0.041).
The abnormalities in the latter group consisted of an elevated INR but no otherwise identifiable coagulopathy. Another 14 patients with an abnormal screening result (11.0%) were found to have at least one coagulopathy that was newly diagnosed during our preoperative evaluation; they were treated perioperatively, and none bled postoperatively. Of 21 patients who had a personal or family history of abnormal bleeding, 5 (23.8%) were found to have a coagulopathy, but none bled following surgery.
Ear Nose Throat J. 2012 Aug;91(8):346-56.Utility of preoperative hematologic screening for pediatric adenotonsillectomy.
What is the most common bleeding disorder?
Von Willebrand disease - inherited usually autosomal dominant and depending on type may have variable penetrance.
vW factor deficiency - vWF mediates the adhesion of platelets to sites of vascular injury. It also binds and stabilizes the procoagulant protein factor VIII
Sx: easy bruising, prolonged bleeding
Dx: test for vWF - levels may vary during times and may require repeat testing if suspicion high
Tx: DDAVP
http://emedicine.medscape.com/article/206996-overview
What are the indications for Quinsy tonsillectomy?
2011 Clinical practice guidelines from academy
The role of tonsillectomy in managing peritonsillar abscess remains controversial. Threshold for surgery is lowered when a child with recurrent throat infection develops, or has a past history of, peritonsillar abscess. When PTA is treated with needle aspiration or incision and drainage, the need for subsequent tonsillectomy is about 10% to 20%. This may not merit routine tonsillectomy unless a patient also has a history of frequent prior throat infections, especially when a culture is positive for GABHS. Some authors advocate “quinsy” tonsillectomy when the abscess is present, especially if general anesthesia is required for drainage (eg, uncooperative child) and there is a prior history of tonsil disease.
One proposed algorithm for pediatric patients
Retrospective chart review of 83 peds patients with PTA. 10/14 with h/o tonsillar disease treated with I&D required interval tonsillectomy for
recurrent tonsillopharyngitis.
Schraff S, McGinn JD, Derkay CS. Peritonsillar abscess in children: a 10-year review of diagnosis and management. Int J Pediatr Otorhinolaryngol. 2001;57:213-218.
Another study out of LSU
Case series of 34 children with PTA. 23 got quincy, 11 got Abx +/- I&D with interval tonsillectomy 2 weeks later. No difference in complications, hospital stay, blood loss, operative time. No postop bleeds in either group.
Simon LM, et al. Pediatric peritonsillar abscess: Quinsy ie versus interval tonsillectomy. International Journal of Pediatric Otorhinolaryngology 2013 77:1355-1358.
Hemorrhage
Reported postop hemorrhage rate of 13% in Quinsy tonsillectomy (done bilaterally), interestingly more common on contralateral side. 41% of the bleeds were in patients that were also on aspirin preop.
Giger R, et al. Hemorrhage risk after quinsy tonsillectomy. Otolaryngol Head Neck Surg. 2005 Nov;133(5):729-34.
Bottom line
There are no guidelines out there for Quinsy.
It is controversial and most people are steering away from this. eMedicine refers to Quinsy as obsolete.
Some data out there advocating for Quinsy. The thought is that if they have a h/o tonsillar disease they have a higher probability of needing a tonsillectomy in the future.
If the child is uncooperative and will require anesthesia anyway for I&D then it may be reasonable to do a Quinsy. Also if the abscess is in an odd location such as posterior. The risk of hemorrhage may be higher.
Describe the day and nocturnal symptoms of obstructive sleep apnea.
What is the physiologic reason children with OSA sometimes have enuresis?
Definition of clinically significant nocturnal enuresis (NE)
>= 1 episode/month
8-47% of pts w sleep disorder breathing will have NE
Physiology
increased negative intrathoracic pressure 2/2 to increased respiratory effort
get more dramatic swings in intrathoracic pressure during respiration leading to increased cardiac distention
this leads to release of atrial natriuretic peptide triggering sodium/water excretion (enuresis)
Surgical Tx leads to 31-76% resolution of NE within months
Unknown to why some respond to T&A and others do not despite resolution of OSA.
Study from Children’s Hospital of Detroit Case series for children with sleep disordered breathing and NE from age 5-18yo
N=46
Recorded log for 1 mo after T&A
clinical resolution defined as 90% or greater decrease in number of weekly NE episodes
43.5% became dry after T&A
For those who became dry had pre op PSG which showed more apneic and arousal episodes
Those who continued to have NE has pre op PSG that had more awakenings
All other factors had no significant difference
Why do some children with OSA have poor growth?
Exact mechanism unclear but possible theories…
OSA disrupts normal GH-IGF1 axis resulting in lower IGF compared w normal values
Long term intermittent hypoxia and CO2 retention leads to respiratory acidosis w compensatory metabolic alkalosis which may lead to reductions in head circumference and height
OSA increases accessory respiratory muscle utilization and the hypoxia stimulates sympathetic nerve activity and correlating catecholamine release which increases metabolism and energy consumption
Which children should undergo a sleep study?
1. Indications for PSG: Before performing tonsillectomy, the clinician should refer children with SDB for PSG if they exhibit any of the following:
obesity
Down syndrome
craniofacial abnormalities
neuromuscular disorders
sickle cell disease
mucopolysaccharidoses
Recommendation based on observational studies with a preponderance of benefit over harm.
2. Advocating for PSG: The clinician should advocate for PSG prior to tonsillectomy for SDB in children
without any of the comorbidities listed in statement 1
for whom the need for surgery is uncertain or
when there is discordance between tonsillar size on physical examination and the reported severity of SDB.
Recommendation based on observational and case control studies with a preponderance of benefit over harm.
Also, note the following 2 statements:
In children for whom PSG is indicated to assess SDB prior to tonsillectomy, clinicians should obtain laboratory-based PSG, when available.
Clinicians should communicate PSG results to the anesthesiologist prior to the induction of anesthesia for tonsillectomy in a child with SDB.
After tonsillectomy which children should stay overnight in the hospital?
Inpatient admission for children with OSA documented in results of PSG: Clinicians should admit children with OSA documented in results of PSG for inpatient, overnight monitoring after tonsillectomy if
they are younger than age 3 or
have severe OSA (apnea-hypopnea index of 10 or more obstructive events/hour, oxygen saturation nadir less than 80%, or both).
Recommendation based on observational studies with a preponderance of benefit over harm.