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Adenotonsillar disease

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Title: Adenotonsillar disease


1
Adenotonsillar disease
  • Shahin Bastaninejad, MD, ORL-HNS Surgeon
  • Assistant professor of tehran university of
    medical sciences

2
Anatomy
  • Tonsil boundary
  • Plica triangularis
  • Adenoid boundary
  • Posterior aspect of the nasal septum
  • Fossa of Rosenmüller
  • Passavants ridge

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Waldeyers Ring
5
Presentation outlines
  • Acute Infections
  • Chronic diseases
  • Obstructive hyperplasia
  • Mass
  • Surgery


6
Acute Infections
7
Acute 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-produ
    cing germs)
  • GABHS is the most important pathogen because of
    potential sequelae

8
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

9
GABHS
  • More common in 5 to 15 years old children
  • Not seen in less than 3 years

10
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

11
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

12
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

13
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)

14
Medical Management
  • Penicillin is first line treatment ? oral
    medication is preferable (penicillin V)
  • Other choices
  • Amoxicillin (wide spectrum than Pencillin V)
  • Macrolides
  • Clindamycin

15
  • Recurrent or unresponsive infections require
    treatment with beta-lactamase resistant
    antibiotics such as
  • Clindamycin
  • Augmentin
  • Penicillin plus rifampin (or Erythro Metro)

16
  • If no response after 48 hr, re-evaluate patient
    for the followings
  • Sequelea
  • Patients incompliance
  • Other underlying disease
  • Abx failure

17
Peritonsillar abscess
  • Abscess formation outside tonsillar capsule
  • Signs and symptoms
  • Fever
  • Sore throat
  • Dysphagia/odynophagia
  • Drooling
  • Trismus
  • Unilateral swelling of soft palate/pharynx with
    uvula deviation

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Be aware of ICA Aneurysm!
22
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 Webers glands
  • Would explain superior pole involvement and the
    usual absence of tonsillar erythema/exudates

23
Candidiasis
24
Infectious Mononucleosis
25
IMN
  • Clinical diagnosis can be made from the
    characteristic triad of fever, pharyngitis, and
    lymphadenopathy lasting for 1 to 4 weeks
  • Laboratory tests are needed for confirmation
  • 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

26
IMN
  • When "mono spot" or heterophile test results are
    negative, additional laboratory testing may be
    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

27
IMN Test interpretation
  • Primary Infection Primary EBV infection is
    indicated if IgM antibody to the viral capsid
    antigen is present and antibody to EBNA is absent
  • 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

28
IMN Test interpretation
  • Reactivation 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

29
Diphtheria
30
Chronic disease
31
Chronic Tonsillitis
  • Chronic sore throat
  • Malodorous breath
  • Presence of tonsilliths
  • Persistent tender cervical lymphadenopathy
  • Lasting at least 3 months
  • Be aware of Anaerobic infections

32
Cryptic tonsils
  • Hyperkeratosis, mycosis leptothrica
  • Tonsilloliths

33
Obstructive Hyperplasia
34
Obstructive Adenoid Hyperplasia
  • Signs and Symptoms
  • Obligate mouth breathing
  • Hyponasal voice
  • Snoring and other signs of sleep disturbance

35
Obstructive Tonsillar Hyperplasia
  • Snoring and other symptoms of sleep disturbance
  • Muffled voice
  • Dysphagia

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37
Tonsillar Mass
38
Malignant Neoplasms
  • Most common is lymphoma
  • Non-Hodgkins lymphoma
  • Rapid unilateral tonsillar enlargement associated
    with cervical lymphadenopathy and systemic
    symptoms

39
Lymphoma
40
SCC
41
Congenital tonsillar masses
  • Teratoma
  • Hemangioma
  • Lymphangioma
  • Cystic hygroma

42
Surgery
43
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

44
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

45
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 AHIgt5) ? check PSG in obese patient/down
    syndrome/craniofacial anomaly

46
Adenoidectomy
  • 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 (next slide)
  • Other
  • Suspected neoplasia
  • Adenoid hypertrophy associated with chronic
    sinusitis

47
Adenoidectomy Cont
  • 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

48
Pre-Op Evaluation of Adenoid Disease
  • Triad of hyponasality, snoring, and mouth
    breathing
  • Rhinorrhea, nocturnal cough, post nasal drip
  • Adenoid facies
  • long face, crowded incisors

49
Pre-Op Evaluation of Adenoid Disease
  • Evaluate palate
  • Symptoms/FH of CP or VPI
  • Bifid uvula
  • CNS or neuromuscular disease
  • Preexisting speech disorder?

50
Pre-Op Evaluation of Adenoid Disease
  • 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.

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