Tonsillectomy
Considerations
Indications
Chronic Tonsillitis
Paradise Criteria:7 infections in 1 year, 5 infections in 2 year, 3 infections in 3 years (Paradise et al. 1984)
Each episode of infection requires documentation of: fever >38.3C, GB strep culture, cervical LAD, or tonsillar exudate
OR tonsillitis under special circumstances:
severe infections, hospital admissions or medication/antibiotic intolerance
clinical syndromes: PFAPA (periodic fever, aphthous stomatitis, pharyngitis, adenitis), PTA
quinsy tonsillectomy: at the time of concurrent PTA
PANDAS (pediatric autoimmune neuropsychiatric disorder with associated strep infections)
febrile seizures, halitosis, malocclusion
Pediatric OSA
Childhood OSA can lead to: poor behavior, secondary enuresis, failure to thrive. These improve after tonsillectomy.
Recommend PSG if <2yo, obese, downs, craniofacial abnormalities, etc
Recommendations for inpatient stay after tonsillectomy:
<3yo
Severe OSA (AHI>10 or O2 nadir 80%)
Preparation
Anesthesia Considerations
No perioperative antibiotics - no reduction in pain or bleeding
Intraoperative Steroids - single dose of dexamethasone to reduce postop N/V
Procedure
Sample operative report
- Findings:
Sub-mucous cleft *** not present
Uvula *** normal
Adenoids ***% occluding
Tonsils ***+, ***phytic
Performed complete Bovie tonsillectomy and suction Bovie adenoidectomy
Procedure in Detail:
PARC of procedure was reviewed with the patient and family in ASU. The patient was transported to the room and laid down in a supine position. Time out was performed. GETA induced.
Patient was draped. Patient's head extended with shoulder roll and head donut. McIvor placed to allow visualization of the pharynx. Red Robin catheter passed through the right nares to retract the soft palate. Soft palate palpated.
The left tonsil was retracted medially with Allis-Coakley tonsil forceps. Bovie cut used to incise the mucosa. The tonsillar capsule was bluntly dissection. Bovie coagulation was used to dissect the capsule adherent to the tonsillar fossa wall. Upon tonsil enucleation, Herd retractor used to inspect the tonsillar fossa. Hemostasis ensured with Bovie. The right tonsil was removed in an identical manner. Tongue and palate rested.
A curved mirror was then used to visualize the adenoids. A suction Bovie used to remove adenoid tissue by combination of buried and shallow strokes. The choanae, torus tubarius, and eustachian tube orifices were not violated.
Tonsillar fossa were again examined; bilateral superior and inferior poles were lightly cauterized with suction Bovie. Hemostasis observed.
The nasal cavity and oropharynx were suctioned. An OG tube was placed to suction stomach contents. The Red Robinson catheter and McIvor were removed.
GETA discontinued. Count correct. To PACU in stable condition.
Post-op
Ibuprofen 10 mg/kg q 6 hours, alternating with Acetaminophen
Acetaminophen 15 mg/kg q 6 hours, alternating with Ibuprofen
If patient is admitted, communicate with pediatrics team
Be sure to inform Peds team: no toradol
Not routinely prescribed:
Oxicodone 0.1 mg/kg q4h PRN - 20 doses - age 4 and older, sometimes 2+ (case specific) (vs Academy rec age 5+)