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- Literature Reading

Tonsillitis,
Tonsillectomy And
Adenoidectomy

Presentan : Desti Kusmardiani


Supervisor : dr. Agung Dinasti P, M.Kes, SpTHT-KL
Department of Otolaryngology - Head & Neck Surgery
Faculty of Medicine Padjadjaran University
Hasan Sadikin General Hospital
Bandung
2015

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

Keith L. Moore. Clinically Oriented Anatomy


5th ed., 2006. p.953
3

ANATOMY

Atlas of Human Anatomy NETTER 3rd ed. 2003

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

Keith L. Moore. Clinically Oriented Anatomy


5th ed., 2006. p.958

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

Keith L. Moore. Clinically Oriented Anatomy


5th ed., 2006.

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.

COMPONENT AND PROPERTIES OF


WALDEYER RING

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

Arteries of The Tonsils


o Ascending palatine artery
facialis artery postero
inferior
o Tonsilar artery facialis
artery antero inferior
o Dorsal lingual artery
maksilaris interna antero
media
o Ascending pharyngeal
artery external carotid
artery postero superior
o Palatine mayor & minor
artery descendens
palatine artery
anterosuperior
11

Tonsilar branch of Lingual veins- the main drainase system of


the tonsillar veins.
Tonsilar accesoria veins plexus pharyngealis
Peritonsilar veins superior of tonsillar bed. Main bleeding source
after tonsillectomy.
Internal JugularVeins

12

Lymphatic Drainage Of The Tonsil


stream of Limfe of tonsil
parenkim
eferen limfe in trabecula
gland of servikalis profunda
chest area limfaticus nodulus
thorasikus duktus
(No Afferent lymphatic)
13

Nerves of the tonsil :

N IX
(Glossopharyngeal)
the main nerve.
Descenden branch of
N. palatine.

14

Anatomic and Physiologic Differences


Between The Adenoids and Tonsils
Adenoids

Tonsils

Anatomic
Location

Posterior wall
nasopharynx
- May extend into
posterior choane

Lateral wall orofaring


Occasionaly extend
into nasopharynx or
hypopharynx

Gross

Triangular shape; invaginated


by deep fold,few crypts

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)

play an important rule as initiators of


mucosal inflamation, crypts obstruction,
ulceration leading to bacterial superinfection
rhinovirus, coronavirus, adenovirus, herpes
simplex virus, parainfluenza, epstein-barr
virus, cytomegalovirus
symptom: sore throat, odynophagia, otalgia,
headache, fever
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
17
one. Lippincot Williams & Wilkins. Philadelphia, 2014 p. 1430-44

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

Group A Beta Hemolytic Streptococcus (GABHS)


Group B, C, F Streptococcus
Hemophilus influenza (tipe B dan non tipe)
Streptococcus pneumoniae, Streptococcus epidermidis
Moraxella catarrhalis, Staphyllococcus aureus
Hemophyllus parainfluenzaNeisseria sp.
Micobacteria sp., Lactobacillus sp.
E. colli, Helicobacter pylori
Chlamydia pneumoniae

Anaerobic

Bacteroides sp., Peptococcus sp.


Microaerophillic streptococci
Veillonella parvula
Bifidobacterium adolescences
Eubacterium sp., Lactobacillus sp.
Fusobacterium sp., Bacteroides sp.
Porphyromonas asaccharolytica
Prevotella sp.

Virus

Epstein-Barr, Adenovirus
Influenza A, B
Herpes simplex, Respiratoy syncytial
Parainfluenza

Others

Mycobacterium (atypical nontuberculosis)


Candida albicans

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,

staphylococcus, haemophyllus influenza,


and Epstein-Barr virus.

Pathology : Hyperplasia and inflammasi


sellular tissue, leukosit, debris and
bacteria patogen at the crypta.

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

RECURRENT Acute Tonsilitis


Recurrent acute infection has been
variably
defined as :
1. Four to seven episodes of acute
tonsillitis in one year
2. Five episodes for two consecutive
years
3. Three episodes per year for 3
consecutive years
22

CHRONIC PERSISTENT Tonsilitis


Clinical Signs :
Chronic sore throat, malodorous breath, excessive tonsillar
debris (tonsilloliths), peritonsillar erythema, and persistent,
tender cervical adenopathy, foreign body sensation.
Physical Examination :
Hypertrophi
Cicatric of the tonsil
Stenosis of the crypta
Purulent exudat
Therapy :
Hydration, Antibiotik and Tonsillectomy
23

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

Bull, RT. Colot Atlas of ENT Diagnosis.


4th ed., Thieme, 2003. p. 196-210
24

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

Recurrent Acute Adenoiditis


Presence of four or greater discrete episodes
of acute adenoiditis during of a 6-month
period

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

CHRONIC (PERSISTENT) Adenoiditis


Often associated with chronic sinusitis and otitis media.
Clinical Signs :
Persistent nasal discharge,
malodorous breath,
postnasal drip, and
chronic congestion

- The role of EER as contributory to chronic adenoid


inflammation, especially in younger children.
- Although initially adenoidectomy may be chosen for
treatment of adenoiditis and/or sinusitis, prognosis for
improvement after the surgery could differ
significantly (unpublished data).
27

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

Assessed Nasality Speech


* emphasize nasal emission
milkman or mickey mouse
* pinch the nose during a
nasality transmitted phrase
* anterior and posterior
rhinoscopy
* direct flexible fiberoptic
nasopharyngoscopy (>> 3.5
y.o)
abnormalities in the
maxillary- mandibular
relationship
* palate evaluation

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

Brodsky, L. Poje, C. Tonsilitis, Tonsillectomy and


Adenoidectomy. In Head and Neck SurgeryOtolaryngology, 5th ed. Bailey, vol. I, 2006. p.
1188

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

PARADISE CRITERIA FOR


TONSILLECTOMY

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

Post Operative Care


1.
2.
3.
4.

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

Brodsky, L. Poje, C. Tonsilitis, Tonsillectomy and


Adenoidectomy. In Head and Neck SurgeryOtolaryngology, 5th ed. Bailey, vol. I, 2006. p.
1188

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

Helal, Z. 6-Endoscopic Powered


Adenoidectomy.
http://www.googleserarh/image/endoscopic
adenoidectomy

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

Complications of adenotonsillar disease


and adenoidectomy and tonsillectomy
Complication

Presentation

Peritonsillar abscess

Management

Sore throat/dysphagia Antibiotics (i.v.)

Pharyngotonsillar bulge

Needle aspiration/I & D in OR

Trismus
Drooling

Immediate tonsillectomy

Acute airway obstruction

Stridor

secondary to T & A

Muffled/hyponasal voice

hyperplasia

Drooling

Nasopharyngeal airway
Steroids (i.v.)

Antibiotics (i.v.)

Enlarged tonsils (and adenoids)


Hemorrhage postor
tonsillectomy

Bleeding from mouth or nose


Frequent swallowing

Local control (cautery

vasoconstriction)

Control in OR
Evaluate for coagulopathy in
selected cases

45

Complication

Presentation

Post T & A airway obstruction

Occurs in first 424 h Nasopharyngeal airway

Palatal swelling

Suction gently

Hypopharyngeal secretions
Dehydration post T & A

Poor oral intake

Dry mucous membranes


Lethargy

Management

Steroids (i.v.)
Control emesis if present

i.v. Hydration

Parental education
Pain control prn

Persistent VPI after


Adenoidectomy

Hypernasal speech (lasting

Speech therapy

beyond 2 mo postop) Palate surgery

Nasal regurgitation of fluids


Pulmonary edema after
ventilation

Difficulty with oxygenation

relief of airway obstruction noted


by anesthesiologist
Frothy pink secretions from
endotracheal tube
History of obstructiona46

Lasix

Morphine

Positive and expiratory

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

2010 CLINICAL PRACTICE GUIDELINES

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