adenotonsillar disease shahin bastaninejad, md, orl-hns surgeon assistant professor of tehran...

Adenotonsillar Adenotonsillar diseasedisease

Shahin BastaninejadShahin Bastaninejad, MD, ORL-HNS Surgeon, MD, ORL-HNS Surgeon

Assistant professor of tehran university of Assistant professor of tehran university of medical sciencesmedical sciences

AnatomyAnatomy

Tonsil boundaryTonsil boundary Plica triangularis

Adenoid Adenoid boundaryboundary

Posterior aspect of the nasal septum

Fossa of Rosenmüller

Passavant’s ridge

Waldeyer’s RingWaldeyer’s Ring

Presentation outlinesPresentation outlines

Acute InfectionsAcute Infections

Chronic diseasesChronic diseases

Obstructive hyperplasiaObstructive hyperplasia

MassMass

SurgerySurgery

Acute Infections

Acute AdenotonsillitisAcute Adenotonsillitis

Etiology 85% of this problem is

due to the viral infection (less in children)

In bacterial infections there is about 40% antibiotic resistancy (due to beta-lactamase-producing germs)

GABHS is the most important pathogen because of potential sequelae

Bacteriology of adenotonsillitis

Group A beta-hemolytic is most recognized pathogen

This organism is associated with a risk of rheumatic fever and glomerulonephritis

Many other organisms are involved : H.influenza S. aureus Streptococcus pneumoniae

GABHS More common in 5 to 15 years old

children Not seen in less than 3 years

Diagnosis Viral pharyngitis symptoms:

Coryza Hoarseness Cough Conjunctivitis

Centor criteria for GABHS: Hx of fever more than 38 Anterior cervical LAP Pharyngeal or Tonsillar exudate Absence of cough

Approach to the Centor scoring

0-1 Abx not needed

2-4 perform Cx

Clue : when all 4 scores are present in

44% of the patients there is no GABHS

Treatment Plan

Delay in treatment up to 9 days can be

acceptebale

When empiric txy?

Lack of Pt .f/u

Lack of Lab. access

Toxic presentation

In some extends when all 4 measures present

In parentheses!!!

When culture is positive there are two possibilites: True infection Carrier state

In this scenario, serological evaluation with ASO(anti-streptolysin O) will be usefull (in true infection it will be more than 3 times than its usual range)

Medical Management

Penicillin is first line treatment oral oral

medication is preferable (penicillin V)medication is preferable (penicillin V)

Other choices: Other choices:

Amoxicillin (wide spectrum than Pencillin V)Amoxicillin (wide spectrum than Pencillin V)

MacrolidesMacrolides

ClindamycinClindamycin

Recurrent or unresponsive infections

require treatment with beta-lactamase beta-lactamase

resistant resistant antibiotics such as

Clindamycin

Augmentin

Penicillin plus rifampin (or Erythro + Metro)

If no response after 48 hrafter 48 hr, re-

evaluate patient for the followings:

Sequelea

Patient’s incompliance

Other underlying disease

Abx failure

Peritonsillar abscess

Abscess formation outside tonsillar capsule

Signs and symptoms: Fever Sore throat Dysphagia/odynophagia Drooling Trismus Unilateral swelling of soft palate/pharynx Unilateral swelling of soft palate/pharynx

with uvula deviationwith uvula deviation

Be aware of ICA Aneurysm!

Peritonsillar abscess…

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

Candidiasis

Infectious MononucleosisInfectious Mononucleosis

IMNIMN Clinical diagnosis Clinical diagnosis can be made from the

characteristic triad of fever, pharyngitis, and lymphadenopathy lasting for 1 to 4 weeks

Laboratory tests are Laboratory tests are neededneeded for for confirmationconfirmation

Serologic test results include a normal to moderately elevated white blood cell count, an increased total number of lymphocytes (more than 50%), greater than 10% atypical lymphocytes, and a positive reaction to a "mono spot" test

IMN

When "mono spot" or heterophile test results are negative, additional additional laboratory testing laboratory testing may bemay be needed needed to differentiate EBV infections from a mononucleosis-like illness

EBV-Specific Laboratory Tests:

IgM and IgG to the viral capsid antigen IgM to the early antigen antibody to EBNA

IMN – Test interpretation

Primary InfectionPrimary Infection: Primary EBV infection is indicated if IgM antibody to the viral capsid antigen is present and antibody to EBNA is absent

Past Infection:Past Infection: If antibodies to both the viral capsid antigen and EBNA are present, then past infection (from 4 to 6 months to years earlier) is indicated

IMN – Test interpretation

ReactivationReactivation: In the presence of antibodies to EBNA, an elevation of antibodies to early antigen suggests reactivation

Chronic EBV Infection: Reliable laboratory evidence for continued active EBV infection is very seldom found in patients who have been ill for more than 4 months

DiphtheriaDiphtheria

Chronic disease

Chronic Tonsillitis

Chronic sore throat Malodorous breath Presence of tonsilliths Persistent tender cervical

lymphadenopathy Lasting at least 3 months

Be aware of Anaerobic infectionsBe aware of Anaerobic infections

Cryptic tonsilsCryptic tonsils

Hyperkeratosis, mycosis leptothrica

Tonsilloliths

Obstructive Hyperplasia

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

Tonsillar Mass

Malignant Neoplasms

Most common is lymphoma Non-Hodgkin’s lymphoma Rapid unilateral tonsillar

enlargement associated with cervical lymphadenopathy and systemic symptoms

Lymphoma

SCC

Congenital tonsillar masses

Teratoma Hemangioma Lymphangioma Cystic hygroma

SurgerySurgery

Tonsillectomy(2010-AAOHNS)

Infection indications: Pharyngitis more than 7 / yr in 1 yr More than 5 / yr for 2yrs More than 3 / yr for 3yrs

Recurrent infections with modifying factors: Multiple Abx allergy / intolerance PF.ASP.A: periodic fever/aphthous

stomatitis and pharyngitis/adenitis History of peritonsillar abscess

Tnosillectomy Cont…

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 to be

neoplastic

Adenotonsillectomy

ATH and Sleep disordered breathing (SDB) Severity of the SDB depends on

adenotonsillar size and/or Craniofacial anatomy and/or neuromuscular tone

Ask for comorbid conditions: Growth retardation / poor school performance / enuresis / behavioral problems (ADHD,…)

Polysomnography indications (PaO2 less than 85% and/or AHI>5) check PSG in obese patient/down syndrome/craniofacial anomaly &…

Adenoidectomy Infection:Infection:

Purulent adenoiditis Adenoid hypertrophy associated with:

Chronic otitis media with effusion Chronic recurrent acute otitis media Chronic otitis media with perforation Otorrhea or chronic tube otorrhea

Obstruction Obstruction (next slide)(next slide) Other:Other:

Suspected neoplasia Adenoid hypertrophy associated with chronic

sinusitis

Adenoidectomy Cont… Obstruction:Obstruction:

Adenoid hypertrophy associated with excessive snoring and chronic mouth-breathing

Sleep apnea or sleep disturbances Adenoid hypertrophy associated with:

Cor pulmonale Failure to thrive Dysphagia Speech abnormalities Craniofacial growth abnormalities Occlusion abnormalities Speech abnormalities

Pre-Op Evaluation ofPre-Op Evaluation of

AdenoidAdenoid Disease Disease Triad of

hyponasality, snoring, and mouth breathing

Rhinorrhea, nocturnal cough, post nasal drip

“Adenoid facies” long face, crowded

incisors

Pre-Op Evaluation of Pre-Op Evaluation of AdenoidAdenoid DiseaseDisease

Evaluate palate Symptoms/FH of

CP or VPI Bifid uvula CNS or

neuromuscular disease

Preexisting speech disorder?

Pre-Op Evaluation of Pre-Op Evaluation of Adenoid DiseaseAdenoid Disease

Lateral neck films Lateral neck films are useful only when history and physical exam are not in agreement.

Accuracy of lateral neck films is dependent on proper positioning and patient cooperation.

Any questions !?Any questions !?