Beruflich Dokumente
Kultur Dokumente
Tonsillitis,
Tonsillectomy And
Adenoidectomy
Introduction
Health problems from disease in the tonsils and adenoids
Jeyakumar A et al, . Adenotonsilar Disease in Children. In Head and Neck Surgery Otolaryngology. 5 th ed. Editor: Bailey B.J. &
Johnson T.J. Volume one. Lippincot Williams & Wilkins. Philadelphia, 2014 p. 1430-44
David H Darrow, Disorder of the Tonsils and Adenoid. In Pediatric Otolaryngology. Editor: Scott R.S & David HD . American
Academy of Pediatric, USA , 2012 p.171-213
ANATOMY
PHARYNX
ANATOMY
WALDEYER RINGS
1. Adenoid
(pharyngeal)
2. Tonsil lingualis
3. Tonsil palatina
4. Lateral faringeal
band
5. Pharyngeal
Granulation
6. Tubal Tonsil
(Gerlach)
7. Ventricel lat
lymphoid tissue
5
ADENOID/PHARYNGEAL
TONSILS
Triangular mass of
lymphoid on the
posterior aspect of
the boxlike
nasopharynx
Formed during the 3rd
to 7th months of
embryogenesis
7
LINGUAL TONSILS
Uncapsulated
Most recent
development adult.
Superficial
crypte
8
PALATINE TONSILS
Palatine Tonsils :
Lateral wall of the oropharynx
Anterior : Pillar anterior
Posterior : Pillar posterior
Lateral : M. constrictor pharyngeus superior
Composition : Lymphoid tissue.
Jeyakumar A et al, . Adenotonsilar Disease in Children. In Head and Neck Surgery Otolaryngology. 5 th ed. Editor:
10
Bailey B.J. & Johnson T.J. Volume one. Lippincot Williams & Wilkins. Philadelphia, 2014 p. 1430-44
12
N IX
(Glossopharyngeal)
the main nerve.
Descenden branch of
N. palatine.
14
Tonsils
Anatomic
Location
Posterior wall
nasopharynx
- May extend into
posterior choane
Gross
Generally ovoid
shape,sometimes bilobed.
Invaginated by 20-30
branching crypts
Microscopic
3 types of epithelium :
Cilliated pseudostratified
columnar
Squamous
Transitional Ag processing
No afferent limphatics
Specialized Ag processing
No afferent limphatics
Physiologic
Mucocilliary clearance
Ag processing
Immune surveillance
Ag processing, immune
surveillance
15
Brodsky, L. Poje, C. Tonsilitis, Tonsillectomyand Adenoidectomy. In Head and Neck Surgery-Otolaryngology,
5 th ed.
Bailey, vol. I, 2006. p. 1184
IMMUNOPHYSIOLOGY
The tonsils and adenoids involved
in both local immunity and in immune
surveillance for the development of
the bodys immunologic defense
system.
FOREIGN
MATERIAL
(INGESTED/
INHALED)
Activati
on B,Tlymphos
ite, APC
Locally
presented
antigenic
stimuli
Generate
memory
lymphosite to
be
disseminated to
other mucosal
site
Jeyakumar A et al, . Adenotonsilar Disease in Children. In Head and Neck Surgery Otolaryngology. 5 th ed. Editor:
16 Bailey B.J. & Johnson T.J. Volume
one. Lippincot Williams & Wilkins. Philadelphia, 2014 p. 1430-44
Clinical Presentation
(Viruses)
Clinical Presentation
(Bacteriology/Microbiology)
Most infections can be linked to the presence of betalactamase producing organisms that distort the normal
aerodigestive bacterial milieu and can cause
commensal organisms to become pathogenic.
Infections are often polymicrobial in nature and often
include anaerobic pathogens.
Obstruction of tonsillar crypts can serve as a nidus for
bacterial stasis and can further perpetuate a condition
of chronic infection, suppuration, and fistulae
Jeyakumar A et al, . Adenotonsilar Disease in Children. In Head and Neck Surgery Otolaryngology. 5 th ed. Editor: Bailey B.J. & Johnson T.J. Volume
18
one. Lippincot Williams & Wilkins. Philadelphia, 2014 p. 1430-44
MICROBIOLOGY
Bacteria
Aerobic
Anaerobic
Virus
Epstein-Barr, Adenovirus
Influenza A, B
Herpes simplex, Respiratoy syncytial
Parainfluenza
Others
Brodsky, L. Poje, C. Tonsilitis, Tonsillectomy and Adenoidectomy. In Head and Neck Surgery-Otolaryngology, 5 th ed. Bailey,19
vol. I, 2006. p. 1186
DIFFERENTIAL OF ADENOTONSILL
20
21
TONSILS
Acute Tonsilitis
Etiology : GABHS, pneumococcus,
Clinical Signs : Sore throat, dysphagia, weakness, fever, tender cervical nodes
in the presence of tonsil that are erymatous and have exudates, mallodorous
breath, otalgia.
Physical examination : Hypertrophi and inflamasi, white eksudat, obstruction
of airway and muffle sign.
Diagnosis : Throat culture or rapid strep antigen test for GABHS.
Therapy : bedrest, hydration, diet, Analgetik and Antibiotik.
21
OBSTRUCTIVE TONSILLAR
HYPERPLASIA
Clinical Signs : Snoring with obstructive disturbances (asleep and
awake), dysphagia, voice changes (muffling or hyponasality),
change behaviour and emotion
Physical examination : Hyperplasia tonsil with healthy crypta
Therapy :
Paliatif, Preventif and Tonsillectomy
ADENOIDS
Acute Adenoiditis
Difficult to differentiate from a generalized virally
induce URI or a true bacterial rhinosinusitis.
Clinical Signs :
Purulent rhinorrhea
Nasal obstruction
Fever
Otitis media
Loud snoring
25
Treatment :
Antimicrobial prophylaxis
asymptomatic between
infection, especially if
comorbidity occurs (reactive
airway disease, recurrent otitis)
daily low dose (one half to
one third the full dose)
episodic prophylaxis (short
course of AB with the onset
of URI)
Differential Diagnosis
:
Recurrent acute sinusitis
Extraesophageal reflux
(EER)-induced
adenoiditis
26
OBSTRUCTIVE Adenoid
HYPERPLASIA
-Etiology :
Enlarge adenoids
Nasopharyngeal obstruction
-The triad of
symptoms :
chronic nasal obstruction
(associated with snoring and
obligate mouth breathing),
rhinorrhea, and
a hyponasal voice.
28
Clinical Evaluation
Physical examination should be performed with
the child's mouth open and the tongue on the
floor of the mouth. within the oral cavity.
Having the child say "aah" will allow assessment
of palatal integrity and motion.
Tonsillar hypertrophy is usually defined as falling
within the 3+ to 4+ range.
The otolaryngologist must be cognizant of signs of
chronic disease, such as peritonsillar erythema,
tender cervical lymphadenopathy, tonsilloliths,
smooth glistening tonsils, or excessively ayptic
tonsils.
Jeyakumar A et al, . Adenotonsilar Disease in Children. In Head and Neck Surgery Otolaryngology. 5 th ed. Editor:
29 Bailey B.J. & Johnson T.J. Volume
one. Lippincot Williams & Wilkins. Philadelphia, 2014 p. 1430-44
Brodsky grading
of tonsil size
- Grade 0
surglcally absent (A)
- Grade 1
within the tonsillar pillars (B) (0%
to 25% airway obstruction)
-Grade 2
just to/beyond the tonsillar pillars
(C) (25% to 50% airway
obstruction)
-Grade 3
beyond the tonsillar pillars, but not
to midline (D) (50% to 75% airway
obstruction)
-Grade 4
touchlng In the midline (E) (75% to
100% airway obstruction)
Jeyakumar A et al, . Adenotonsilar Disease in Children. In Head and Neck Surgery Otolaryngology. 5 th ed. Editor: Bailey B.J. & Johnson T.J. Volume
30
one. Lippincot Williams & Wilkins. Philadelphia, 2014 p. 1430-44
Clinical Evaluation
ADENOID
History
* rhinorrhea
* chronic cough
* postnasal drip
* obligate mouth breathing
* snoring
* hyponasal speech
Physical Examination
open mouth appearance
flattened mid face
classic adenoid facies
dark circles under the eye
31
TONSILS
The First-line antibiotic in acute tonsillitis due to GABHS
peniciillin
Antibiotic effective against -lactamase-producing m.o or
encapsulated anaerobes (3-6 weeks) in chronic tonsillitis or
obstructive hyperplasia
Amox-clavulanat or
clyndamicin
Acute upper airway obstruction : Nasopharyngeal airway
Immediate tonsillectomy :
-PTA coexist with infections of mononucleosis
-child with poor clinical response to medical therapy
32
Indication of Tonsillectomy
Obstruction
Tonsillar hyperplasia with chronic
obstruction
Sleep-related disordered breathing
Obstructive sleep apnea syndrome
Upper airway resistance syndrome
Obstructive hypoventilation
syndrome
Failure to thrive
Cor pulmonale
Swallowing abnormalities
Speech abnormalities
Orofacial/dental abnormalities
Lymphoproliferative disorder
Infection
Recurrent/chronic tonsillitis
Tonsillitis with :
Abscessed cervical nodes
Acute airway obstruction
Cardiac valve disease
Persistent tonsillitis with :
Persistent sore throat
Tender cervical nodes
Halitosis
Tonsilolithiasis
Streptococcal carrier state
unresponsive
to medical therapy in a child of
household
at risk
Peritonsillar abscess unresponsive to
medical therapy or in a patient with
33 or recurrent
recurrent tonsillitis
Jeyakumar A et al, . Adenotonsilar Disease in Children. In Head and Neck Surgery Otolaryngology. 5 th ed. Editor: Bailey B.J. & Johnson T.J. Volume
34
one. Lippincot Williams & Wilkins. Philadelphia, 2014 p. 1430-44
Tonsillectomy
Technique of Tonsillectomy :
1. Dissection and Snare Method
2. Tonsil Guillotine (Sluder) Technique
3. Tonsillectomy with Local Anesthesia
4. Cryogenic Tonsillectomy
5. Electrosterilization of The Tonsil
6. Laser Tonsillectomy
35
36
Technique of Tonsillectomy
Metode Dissection-Snare
37
Maintain airway
Controlled of bleeding
Maintenance in general
Diet stages:
- 1-2 day: liquid food and cold
- 3-5 day: strain porridge or strain
foods
- 6-8 day: regular porridge
- 9-10 day: Team rice
- 11 day : Rice/regular food
38
ADENOID
Antimicrobial effective against -lactamase-producing
m.o : recurrent / chronic adenoiditis
Intra nasal steroid (6-to-8 weeks) : adenoid hyperplasia
Surgical techniques : mirror visualization of the
nasopharynx and removal of the tissue with sharp
curette, adenotome, powered microdebrider, or with
cauter
Hemostasis : Intraoperative packing, application of
bismuth subgalleate, electrocoagulation of adenois bed
39
Management
Obstruction
Adenoid hyperplasia with chronic nasal
obstruction or
obligate mouth breathing
Sleep-related disordered breathing
Obstructive sleep apnea syndrome
Upper airway resistance syndrome
Obstructive hypoventilation
syndrome
Failure to thrive
Cor pulmonale
Swallowing abnormalities
Speech abnormalities
Orofacial/dental abnormalities
Lymphoproliferative disorder
Infection
Recurrent/chronic adenoiditis
Recurrent/chronic otitis media with
effusion
Chronic otitis media
Chronic sinusitis
Neoplasia
Suspected neoplasia, benign or
malignant
INDICATIONS
OF
ADENOIDECTO
MY
40
Complications
Nasopharyngeal
stenosis
Bleeding
Torticollis
C-spine luxation
(rare)
41
Technique of Adenoidectomy
1. Curetase adenoidectomy
- Prepare of curetase
- Curetase
- Examination
a. Adenoidectomy with head
extension position
b. Beckmanns ring curette
42
Technique of
Adenoidectomy
2. Adenoidectomy with endoscopy
43
CONTRAINDICATION
Contraindications to T&A include
coagulation abnormalities that should be
addressed prior to surgery, and often require
a multidisciplinary approach including
hematology involvement and coordination.
Children with acute illnesses that might
impair the ability to maintain adequate
postoperative hydration or safely undergo
general anesthesia should defer elective
surgery.
Jeyakumar A et al, . Adenotonsilar Disease in Children. In Head and Neck Surgery Otolaryngology. 5 th ed. Editor: Bailey B.J. & Johnson T.J. Volume
44
one. Lippincot Williams & Wilkins. Philadelphia, 2014 p. 1430-44
Presentation
Peritonsillar abscess
Management
Pharyngotonsillar bulge
Trismus
Drooling
Immediate tonsillectomy
Stridor
secondary to T & A
Muffled/hyponasal voice
hyperplasia
Drooling
Nasopharyngeal airway
Steroids (i.v.)
Antibiotics (i.v.)
vasoconstriction)
Control in OR
Evaluate for coagulopathy in
selected cases
45
Complication
Presentation
Palatal swelling
Suction gently
Hypopharyngeal secretions
Dehydration post T & A
Management
Steroids (i.v.)
Control emesis if present
i.v. Hydration
Parental education
Pain control prn
Speech therapy
Lasix
Morphine
47
Jeyakumar A et al, . Adenotonsilar Disease in Children. In Head and Neck Surgery Otolaryngology. 5 th ed. Editor: Bailey B.J. & Johnson T.J. Volume
48
one. Lippincot Williams & Wilkins. Philadelphia, 2014 p. 1430-44
Jeyakumar A et al, . Adenotonsilar Disease in Children. In Head and Neck Surgery Otolaryngology. 5 th ed. Editor: Bailey B.J. & Johnson T.J. Volume
49
one. Lippincot Williams & Wilkins. Philadelphia, 2014 p. 1430-44
HIGHLIGHT
Adenotonsillar disease usually presents in
children with either recurrent throat
infections or SDB. Presently. the most
common indication for T&A is SDB.
Approximately 30% of bacterial cases of
acute tonsillopharyngitis are caused by
GABA, with a varying contribution from
other pathogens, including group C betahemolytic streptococci, N. g01101Thoeae,
C. diphtheria, C. pneumoniae, and M.
pneumuniae.
50
HIGHLIGHT
The American Academy of OtolaryngologyHead and Neck Surgery published a
Clinical Practice Guidelines on the
indications for tonsillectomy based on an
extensive literature review and an expert
panel that included both otolaryngologists
and nonotolaryngologists. They made
recommendations to address the two most
common indications for tonsillectomy:
recurrent tonsillitis and SDB.
51
Thank You
52