24820633 adeno tonsillitis
TRANSCRIPT
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ADENO TONSILLITIS
Dr. A. KARUNAGARAN, M.S. D.L.O,
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Anatomy
• Waldeyer`s inner ring consists collectionof sub epithelial lymphoid tissue
• Adenoids• Palatine tonsil
• Tubal tonsil
• Lingual tonsil
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Anatomy – tonsil
• Bilateral ovoid masses of lymphoid tissue
• Almond shape
• Partly covered by capsule• Medial surface has 15 – 20 crypts, biggest
is crypta magna
• Mucosal folds – in superior pole plicasemilunaris, in inferior pole plicatriangularis
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Anatomy – adenoids
• Present at the junction of roof andposterior wall of nasopharynx
• Has furrows and ridges• Appear like bunch of banana
• Feels like bag of worms
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Anatomy
Blood supply - Tonsils
Facial a.
Lingual a. Dorsal lingual Tonsil
Ascending pharyngeal Tonsil
Maxillary Lesser descending palatine Tonsil
Tonsillar branch Tonsil (main branch)
Ascending palatine Tonsil
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Anatomy
Blood supply – Adenoids
• Ascending palatine branch of facial a.• Ascending pharyngeal a.
• Pharyngeal branch of IMAX.
• Ascending cervical branch of thyrocervicaltrunk.
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Tonsils Adenoids Paired structure Solitary structure
Present in lateral wall of oro
pharynx
Present in naso pharynx
Covered by non keratinizingstratified sqamous
epithelium
Coverd by ciliated columnar epithelium
Covered by capsule on the
lateral wall
No capsule
Has crypts No crypts, only furrows
Almond shaped Bunch of banana
Both afferent and efferents
present
no afferent only efferents
present
Differences between tonsils and adenoids
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Infecting Organisms
Aerobic Bacteria• Strep pyogenes (Gr A beta-hemolytic)
• Strep pneumoniae
• Strep viridans & other Streptococci
• Staph aureus
• H. Influenzae
• Diphtheroids
• Neisseria spp.
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Infecting Organisms
Anaerobic Bacteria
• Bacteroides
• Peptococcus
• Peptostreptococcus
• Veillonella
• Fusobacteria
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Infecting Organisms
Viruses
• Epstein-Barr
• Cytomegalovirus• Adenovirus
• Herpes simplex
• Influenza A and B
• Parainfluenzae
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Microbiology of Tonsillitis
Group A beta-hemolytic• Is most recognized - associated with a risk of
rheumatic fever and glomerulonephritis
Beta-lactamase producing organisms
• Are of particular importance.
• Produced by Staph aureus, M. catarrhalis &
H.influenzae• Protect Group A Streptococci from eradication
with penicillins
• Accounts for 39% of all cultured organisms
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Who gets Tonsillitis ?
• Most often occurs in children – allexperience at least 1 episode
• Rarely in children younger than 2 yr
• Viral tonsillitis in younger children
• Streptococcal tonsillitis in children
aged 5-15 yr • Poor socioeconomic status & over
crowding
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Pathophysiology
• Viral Infections
• Bacterial Infections
• Inflammatory exudates of the crypts• Epithelial keratinisation
• Deep-seated multiple abscess formation with
increasing germ centers• Parenchyma destruction
• Immunologic Factors
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Unanswered Questions
• Do virus infections in the pharynx and tonsilspredispose to bacterial infection?
• Is it possible to have an infective condition
involving the pharyngeal lymphoid tissuewithout affecting the tonsils?
• Is there such a condition as chronic tonsillitis?
• Why are some patients susceptible to acutepharyngitis and acute tonsillitis and othersnot?
• Does the tonsil become irreversibly diseased
after many episodes of acute tonsillitis?
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Acute Tonsillitis
Symptoms:
FeverSore throat
Dysphagia or Odynophagia
Airway Obstruction
Lethargy / malaise
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Acute Tonsillitis - Signs
• Enlarged
• Erythematous
• Exudative forming at
timespseudomembrane
• Enlarged neck nodes
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Grading the Size of Tonsils
Grading system:
A. 0 – tonsils in fossaB. +1 – tonsils less than 25%C. +2 – tonsils less than 50%D. +3 – tonsils less than 75%E. +4 – tonsils greater than 75%
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Features of adenoid facies
• Open mouth and mouth breathing• Pinched nostrils• Crowded teeth andhyper plasia of gums
• Loss of naso labial fold• Under slung mandible• High arched V shaped palate• Short upper lip• Hypo plasia of maxilla• Vacant expression• Pectus excavatum• Rouned shoulders• Voice changes- nasal and lifeless
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Lingual Tonsils
• Hyperplasia is the most common abnormality of the lingualtonsil.
• Lingual tonsils sit on the base of the tongue and extend tothe vallecula and do not have a capsule.
• Can be visualized by indirect mirror or flexible laryngoscopy
• Clinically, infection is marked by erythema and enlargementof tonsillar tissue.
• Suspension microlaryngoscopy with removal by CO2 laser,sharp dissection or hot knife cautery are some of thetreatments available.
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Lingual Tonsil
• History and Physical: – Sore throat
– Globus sensation
– Speech change – Dysphagia
– Obstructive sleep apnea in adults
– Pediatric airway obstruction
– Often discovered incidentally during intubation inpreparation for surgery that is unrelated to the ear,nose, and throat.
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Lingual Tonsils
• Differential diagnosis – lingual thyroid tissue – thyroglossal duct cyst – dermoid cyst
– lymphangioma – angioma – adenoma – fibroma
– papilloma – lymphoma – squamous cell carcinoma – minor salivary gland tumors on the base of the tongue
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Lingual Tonsils
• Hypertrophy of lingual tonsils in 62% of personswith laryngoscopic signs of reflux and in 75% of persons with pharyngolaryngeal symptoms of LPR.
• Although the lymphoid tissue in Waldeyer's ringtends to decrease with advancing age, the lingualtonsil may increase in size.
• The most important cause of lingual tonsilhypertrophy is the occurrence of compensatoryhyperplasia following adenotonsillectomy.
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Differential Diagnosis of pseudomembranous tonsillitis
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Infectious Mononucleosis
• Cheesy exudatescovering tonsil
• Lymphadenopathy of
neck, axilla & groin
• Hepato/Spleenomegaly
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Oral Thrush
• Painful throat
• White candidiasis
patches whenremoved leaveserythematous ulcer
• Immunosuppressive
state
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Keratosis tonsils
• Incidental finding
• May cause slightdiscomfort
• Yellow hornyoutgrowths in thecrypts
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Agranulocytosis
• Halistosis, fever,headache &
dysphagia• Single , multiple orcoalesce necroticslough covered
ulcers• Leucopenia
• H/O causative drugs
intake
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Diphtheria
• Malaise, fever & headache
• Greyish greenmembrane acrosstonsils to larynx
• Tender bilateral
cervicallymphadenopathy
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Vincent‟s angina • Fetor oris, pyrexia
• Tonsillar deep ulcers withgrey slough in its base
• Necrotising gingivitis
• Enlarged tender cervicaladenitis
• Smear:
Spirochaetes & Fusiform
bacilli
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Acute lymphatic leukemia
• Fever, anaemia & bleeding disorders
•Slough coveredmembrane formingulcerations
• Cervical
lymphadenopathy• Exaggeratedleucocytosis
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Recurrent Acute Tonsillitis
• Same signs andsymptoms as
acute• Occurring in 4-7separate episodesper year
• 5 episodes peryear for 2 years
• 3 episodes per
year for 3 years
• Ant pillar peritonsillar erythema
• Smooth glisteningtonsil with dilatedblood vessels on thesurface
• Debris in cryptswhich are few dueto loss of tonsilarchitecture
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Chronic Tonsillitis
• Chronic sore throat
• Malodorous breath
• Presence of tonsilliths
• Peritonsillar erythema
• Persistent cervical lymphadenopathy
• Lasting at least 3 months
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Local Complications
• Respiratory obstruction
• Quinsy
• Acute retropharyngeal abscess
• Parapharyngeal abscess
• Neck space infections
• Acute otitis media
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Retropharyngeal abscess
• Dysphagia, fever
• Pharynx eithernormal or smoothbulge of posteriorpharyngeal wall
• Airway obstruction
• Neck rigid
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Peritonsillar Abscess• Abscess formation
outside tonsillar capsule• Signs and symptoms:
– Fever
– Sore throat
– Dysphagia/odynophagia – Drooling
– Trismus
– Unilateral swelling of soft
palate/pharynx with uvuladeviation
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Peritonsillar Abscess
• Incidence: estimated 30 casesper 100,000 in US.
• Diagnosis is usually by physical exambut other modalities have been used such as US
and CT.• Widely accepted that Staphylococcus aureus is
the most common organism causing the infection
and origin is usually from the superior pole of thetonsil (from minor salivary gland - AKA: Webergland).
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Peritonsillar Abscess
• Quinsy tonsillectomy vs. Interval tonsillectomy – Quinsy tonsillectomy can be a treatment option inpediatric patients to young to withstand bedsideaspiration or I&D for recurrent PTA.
– Quinsy tonsillectomy can be surgically easier thaninterval tonsillectomy as fibrosis has not had time to setinto the tonsillar capsule.
– Review by Johnson, discussed interval tonsillectomy forrecurrent PTA with prevalence of 10%.
– Interval tonsillectomy can be considered after successfulabscess drainage, usually from recurrent PTA after 6weeks.
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Parapharyngeal
abscess• Fever, dysphagia
& airway
obstruction• Swelling below
soft palate overthe pharynx
• Tender firmswelling in theupper part of neck
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Acute otits media
• Preceding URI & blocked ear
• Severe otalgia• Bulging congested
ear drum
• Eustachian catarrh
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Systemic Complications
• Acute rheumatic fever
• Acute glomerulonephritis
• Bacterial endocarditis
• Dermatitis
• Septicemia
• Septic abscesses
• Septic arthritis
• Menigitis
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Investigations
• CBC & serum electrolytes• Crypt swab culture & sensitivity – 60% specificity
• Crypt aspiration culture & sensitivity –ed specificity
• A rapid antigen detection test (RADT) has 95%
specificity• Serum examined for anti-streptococcal antibodies –
ASO titre - Useful for documenting prior infections in – acute rheumatic fever, glomerulonephritis or other
complications• Monospot serum test
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Medical Management of Acute Tonsillitis
Largely supportive
Adequate hydration and caloric intake
Control pain Antibiotics –
• Penicillin – 1st line treatment
• Macrolides, Cephalosporins, Clindamycin
• Vancomycin and Rifampin are also used
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Current Indications forTonsillectomy
• Recurrent tonsillitis
• Chronic persistent tonsillitis
• Hypertrophic obstructive Tonsillitis not responding to
medicine causing dysphagia or OSA• Diphtheria carrier state
• Rec Peritonsillar abscess +/_ Rec tonsillitis
• Unilateral tonsillar hypertrophy
• Benign tumours of tonsil like papilloma, adenoma• Chronic tonsillolith
• As an approach to IX nerve, elongated styloid process
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Adenoidectomy-Indications
• Recurrent or chronic sinusitis or adenoiditis – Poorly understood - possibly caused by obstructive
adenoid tissue causing stasis of secretions predisposingthe nasal cavity to infection.
• Otitis media – Proximity of adenoid tissue to eustachian tube
– Adenoidectomy can be recommended on 1st set of tubes
if nasal obstruction and recurrent rhinorrhea is presentor on 2nd set of tubes if needed.
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Contra indications for adenotonsillectomy
• Epidemic of polio
• Age below 3 years
• Acute infections
• Blood dyscrasiasis: hemophilia, purpura• Uncontrolled systemic diseases like diabetes and heart
diseases
• Velopharyngeal insufficiency
– Overt cleft palate, submucous (covert) cleft – Neurologic or neuromuscular abnormality leading to impaired
palate function
• Anemia
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Cold steel Instruments
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Complications of Tonsillectomy
• Haemorrhage
• Haematoma & oedema uvula
• Infection• Pulmonary complications
• Remnant tonsils
• Referred otalgia• Post operative scarring causing voice change ornasal regurgitation
C li i
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Complications• Noniatrogenic complications after adenoidectomy
– Regrowth of adenoid tissue , particularly in very youngchildren, which may require revision (secondary)adenoidectomy.
– Hypernasality , because of temporary pain splinting.Persistent hypernasality is rare and probably caused by
unrecognized pre-existing velopharyngeal weakness. – Atlantoaxial subluxation (Grisel‟s syndrome), which
presents with persistent torticollis 1-2 weeks aftersurgery.
• Iatrogenic complications after adenoidectomy include – Dental injury , from intubation or the mouth gag
– Nasopharyngeal stenosis , caused by excessive tissueremoval.
– Eustachian tube injury
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The Modern
Tonsillectomy
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• History
• Indications• Innovative Techniques and Comorbidites
– Intracapsular tonsillectomy
– Harmonic scalpel – Laser
– Coblation
• Adjuvant Therapy – Local Anesthesia: Bupivacaine
– Postoperative Antibiotics
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History
• Aulus Cornelius Celsus – 1st Century AD
– “the tonsils are loosened by scraping around themand then torn out” with a finger
– Used vinegar and medication for postoperative
hemostasis• Aetius of Amida
– 6th Century AD
– Hook and knife method
• Philip Syng Physick (“Father of Americansurgery”) – First to develop the tonsillotome
• Mackenzie – Late 1800s
– Made tonsillotome use common
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Innovative Techniques
• IntracapsularTonsillectomy
• Harmonic Scalpel• Laser
• Coblation
• Guiding Principle:reduce morbidity – Hemorrhage
– Pain
– Diet
– Activity
– Cost
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Intracapsular Tonsillectomy
– Tonsillar hypertrophy causing sleep disordered
breathing• Intracapsular tonsillectomy
– Microdebrider at 1500 rpm in oscillating mode
– Hemostasis with suction cautery
• Total tonsillectomy – Subcapsular
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• Conclusions – Intracapsular tonsillectomy is safe andefficacious in children under 3 years fortonsillar hypertrophy and sleep disordered
breathing without need for admission• Limitations
– Retrospective study
– Uneven distribution
– Long term results of tonsillar regrowthunknown
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Harmonic Scalpel Tonsillectomy
• Ultrasonic dissector and coagulator
• Vibratory energy
– Cutting: sharp blade with frequency of 55.5kHz over distance of 80 μm
– Coagulating: vibration breaks H-bonds,thermal energy
• 50° – 100° C• Electrocautery 150° – 400° C
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• Operative time statistically significant – Harmonic scalpel 8 min 42 sec – Electrocautery 4 min 33 sec
• No significant difference in intraoperative bloodloss and postoperative ability to eat and drink
• Level of activity for the first postop daysignificantly lower in harmonic scalpel group
• Postoperative pain scores tended to be lower inharmonic scalpel group
• Postoperative bleeding – Harmonic scalpel: 6 – Electrocautery: 3 – Not statistically significant
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Laser Tonsillectomy
Compared the use of KTP laser tonsillectomyversus cold dissection and snare
– KTP 532 laser at 10W, continuous beam
– Outcomes measured• Operative time
• Operative bleeding
• Postoperative pain• Postoperative advancement to diet
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• Results – Operative time:
• Laser 12 min• Dissection 10 min• Not statistically significant
– Intraoperative blood loss• Laser 20 mL• Dissection 95 mL• Statistically significant
– Laser group with higher postop pain scores – Laser group with greater difficulty resuming
postoperative diet – Readmission for delayed hemorrhage was 8% in the
laser group and 4% in the dissection group• Not statistically significant
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• Conclusion
– KTP laser provides little benefit overdissection tonsillectomy except to minimize
intraoperative bleeding• Limitations
– Technical expertise
– Electrocautery not included
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Coblation Tonsillectomy
• Bipolar radiofrequency energy transferred tosodium molecules to create an ion or plasmafield
• This thin layer of plasma is utilized to ablatetissues at molecular level
• No need for electrocautery for hemostasis
• Temperature from 40° to 85° C• Electrocautery at 20W: above 400° C
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• Coblation
– From surface out laterally – Coblate 9 setting to ablate tissues
– Coblate 5 setting to coagulate
– Capsule not penetrated
• Electrocautery – Bovie set to 20 W
• Outcomes measured – Questionnaire
• Pain
• Analgesics• Nausea/vomiting
• Diet
• Activity
– Complications
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Coblation Tonsillectomy
• Future considerations
– To evaluate coblation forintracapsular tonsillectomy,
a fair study would useanother intracapsulartechnique such as power-assisted tonsillectomy witha microdebrider
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• Technique – Monopolar electrocautery used most often• Greatest for otolaryngologists in practice < 20 years
• Hemostasis
– Sharp dissection most common for group inpractice > 20 years• Decreased pain
• Method of hemostasis not mentioned• Local Anesthetic evenly distributed
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Conclusions
• Tonsillectomy is a surgical procedure thatcarries significant postoperative morbidity
• To minimize postoperative morbidityvarious techniques and adjuvant therapieshave been studied
• There are many options available and itbehooves an otolaryngologist to stay as upto date as possible
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THANK YOU
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DISEASES OF TONSILS
& ADENOID
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ACUTE TONSILLITIS
• Etiology : Viral followed bysecondarily invaded by
•Hemolytic streptococcus•Staph aureas
•H.influenza
•Dipl. Pneumoniae
• Age : Commonest <9yrs
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• Spread : Droplet infection
• Types:
– Ac cattarhal – Ac parenchymatous
– Ac follicular – Ac membranous
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A t b t illiti
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Acute membraneous tonsillitis
A t h t t illiti
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Acute parenchymatous tonsillitis
ACUTE TONSILLITIS:CLINICAL
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ACUTE TONSILLITIS:CLINICALFEATURES
SYMPTOMS
• Sore throat
• Fever• Malaise
• Odynophagia
• Thick speech• Earache
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SIGNS
• Pyrexia,halitosis.
• Furred tongue.• Enlarged congested tonsil.
• Others signs according to type.
• Tender & enlarged J-D nodes.
ACUTE TONSILLITIS :
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ACUTE TONSILLITIS :TREATMENT
• Bed rest : Isolation
• Mouth gurgles : How it helps ?
• Analgesics :
• Antibiotics :
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Medical Therapy
• First Line – Penicillin/Cephalosporin for 10 days
– Injectable forms for noncompliance
• Macrolides – Penicillin allergy
– Erythromycin/Clarithromycin 10 days
– Azithromycin (12mg/kg/day) 5 days
DYNAMICS OF TONSILLITIS
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DYNAMICS OF TONSILLITIS
Group AStreptococci
Viruses
Other aerobicand anaerobic
bacteria
Recurrence PersistenceCure
Nonsepticcomplications
SepticComplications
Penicillin Rx
ACUTE TONSILLITIS
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ACUTE TONSILLITISCOMPLICATIONS :
• Peritonsillar abscess
• Parapharyngeal abscess
• Retropharyngeal abscess
• Oedema of larynx
• Cervical supp. Lymphadenitis
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• Acute middle ear cleft infection
• Chronic tonsillitis
• Septicaemia
• Acute rheumatism
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• Rheumatic heart disease
• Chorea
• S.B.E.
• Acute nephritis
ACUTE TONSILLITIS : d/ds
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ACUTE TONSILLITIS : d/ds
• Infectious Mononucleosis• Faucial diphtheria
• Agranulocytosis
• Scarlet fever• Oral thrush
• ALL
• Vincent‟s angina • Tertiary syphilis
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Differential Diagnosis of pseudomembranous tonsillitis
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Infectious Mononucleosis
• Cheesy exudatescovering tonsil
• Lymphadenopathy of
neck, axilla & groin
• Hepato/Spleenomegaly
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Oral Thrush
• Painful throat
• White candidiasis
patches whenremoved leaveserythematous ulcer
• Immunosuppressive
state
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Keratosis tonsils
• Incidental finding
• May cause slightdiscomfort
• Yellow hornyoutgrowths in the
crypts
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Agranulocytosis
• Halistosis, fever,headache & dysphagia
• Single , multiple orcoalesce necroticslough covered
ulcers• Leucopenia
• H/O causative drugsintake
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Diphtheria
• Malaise, fever & headache
• Greyish greenmembrane acrosstonsils to larynx
• Tender bilateral
cervicallymphadenopathy
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Vincent‟s angina • Fetor oris, pyrexia
• Tonsillar deep ulcers withgrey slough in its base
• Necrotising gingivitis• Enlarged tender cervical
adenitis
• Smear:
Spirochaetes & Fusiformbacilli
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Acute lymphatic leukemia
• Fever, anaemia & bleeding disorders
• Slough covered
membrane formingulcerations
• Cervicallymphadenopathy
• Exaggeratedleucocytosis
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FAUCIAL DIPHTHERIA
fi i i
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Definition
• Diphtheria is an acute, toxin-mediateddisease caused by toxigenicCorynebacterium diphtheriae ( 白喉棒状杆菌
).
• It’s a very contagious and potentially life-threatening bacterial disease.
Corynebacterium
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ydiphtheriae
• • Causative organism of diphtheria
• • Gram- positive bacillus
• • Produces exotoxin at site of infection
• Travels to heart and nervous
system
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• • Spread by close contact viadroplets or
• contaminated articles
• • Humans are the sole carriers of the organism
• • More common in children < 10
years• • Rare occurrence today because of
routine vaccination
C di hth i
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C. diphtheria
• • Clinical manifestations
• – Systemic symptoms fromexotoxin
• • Fatigued
• • Lethargic
• • Tachycardic • • toxic
C diphtheria
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C. diphtheria
• • Clinical characteristics • – Pharynx
• • grayish membrane (composed of fibrin,
• leukocytes, and cellular debris)
• • extends from pharynx to larynx • – Extensive cervicallymphadenopathy („bull neck‟)
Ph l di hth i
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Pharyngeal diphtheria
Ph l di hth i
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Pharyngeal diphtheria
L l di hth i
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Laryngeal diphtheria
C diphtheria
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C. diphtheria
• Diagnosis• – Isolation of the organism
• • Culture from local lesion • • Grows on selective mediacontaining potassium tellurite
• • Notify microbiology lab if diphtheriasuspected
C diphtheria
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C. diphtheria
• • Treatment • – Started before culture
confirmation
• – Airway
• – Resuscitation
• – Skin test for allergy to horseserum
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• – Administer diphtheria antitoxin
• – Have epinephrine available
• – Antibiotics (erythromycin,penicillin G, rifampin, orclindamycin) used to eradicate
carrier state
C. Diphtheria
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p
• • Prevention
• – Vaccine
• • Trivalent vaccine – diphtheria toxoid,tetanus toxoid and pertussis (DTP)
• • 6 weeks of age, 2 more 4-8 weeks
intervals, and 4th
6-12 months later.
Complications
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Complications:
• Myocarditis.
• Cardiac arrhythmias.
• Acute circulatory failure.• Paralysis of soft palate,diaphragm & ocular
muscles.
• Laryngeal-airway obstruction.
Ac tonsillitis Faucialdiphtheria
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diphtheria
Onset Acute Insidious
Membrane Yellowish,easily
separable
Ashy gray ,bleeds onseparation
Fever High Low
Pulse Proportionate Disproportionate
Toxaemia +/- + +
Throat swab Heam.strepto CBD / KLB
Urine:
Albuminuria
+/- + +
Recurrent Acute Tonsillitis
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Recurrent Acute Tonsillitis
• Seven episodes in a single year
• Five or more episodes in 2 years
• Three or more episodes in 3 years
Chronic Tonsillitis
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Chronic Tonsillitis
• No true consensus on the definition.
• Symptoms greater than 4 weeks
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CHRONIC TOSILLITIS
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SYMPTOMS
• RECURRENT PAINHALITOSIS
• COUGH
• SNORING
• SLEEP APNOEA
• ASYMPTOMATIC
• SEPTIC FOCUS
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CHRONIC TONSILLITIS-SIGNS
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CHRONIC TONSILLITIS SIGNS
• LARGE TONSILS
• SMALL FIBROTIC IN ADULTS
• ANTERIOR PILLAR CONGESTED
• SQUEEZE – IRWINMOORE‟S SIGN
• LYMPHADENOPATH Y
JUGULODIGASTRIC LYMPH
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NODES
ADENOIDS
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ADENOIDS
• Normally regress by 10 yrs
• Etiology:
– Age ; 3-4 years
–Physiological hypertrophy
–Infection
–Rarely tuberculosis
• Predisposing factors
Adenoiditis : Clinical features
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• Associated with nasal obstruction :
– Adenoid facies (develop gradually)
•Nose – Pinched ,narrow
•Mouth - Remains open,dribbling of saliva,mouth breathing
•Teeth – Protruded,irregular,crowded
•Lower jaw – Undershot
Adenoid Hypertrophy
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Adenoid Hypertrophy
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• Palate – High arched.
• Feeding difficulties.
• Face - Loss of nasolabial furrow,dulllook.
• Chest – Pigeon shaped.
• Pot belly.
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• NASAL DISCHARGE.
• SINUSITIS.
• EPISTAXIS.
• VOICE CHANGE.
Adenoid Hyperplasia
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Adenoid Hyperplasia
• Triad
– Hyponasality
– Snoring – Open mouth breathing
• Purulent rhinorrhea, post nasal drip,chronic cough, and headache
Adenoiditis : Clinical features(contd)
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Adenoiditis : Clinical features(contd)
• Associated with E-T obstruction:
•ET cattarh,SOM,AOM,CSOM
• Associated with infection :•Rhinitis,Sinusitis,URTI,
Tonsillopharyngitis.•Lymphadenitis
•General :
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•General :
•Nocturnal enuresis
•Deafness leads to mentalretardation
Adenoiditis :Diagnosis &Diff diagnosis
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diagnosis
• Diagnosis : –Clinical features: clinch diagnosis
– Posterior rhinoscopy:
– Digital palpation :--bag of worms – X-ray nasopharynx soft tissue lateral
view
– Nasal endoscopy ,Nasopharyngoscopy
PreOp Evaluation of Ad id Di
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Adenoid Disease
Lateral neck films areuseful only whenhistory and physical
exam are not inagreement.
Accuracy of lateralneck films isdependent onproper positioning
and patient
cooperation
Adenoiditis : Treatment
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Adenoiditis : Treatment
• Conservative : in acute & mild cases
– Antibiotics,Decongestants,Breathing exercises
• Surgical : – Adeoidectomy-for persistent & rec. infection
– Precautions:
– Grommet insertion : in case of SOM
TONSILLECTOMY
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Chronic Tonsillitis
Sleep apnoea
Quinsy
Tonsillolith
Foreign body
Benign tumor
Diphtheria carrier
Approach for Styloid
Approach for IX
LOCAL
JD lymphadenopathy Middle ear disease
FOCAL
RHD SBE
Glomerulonephritis
RF RA
GENERAL
INDICATIONS
CONTRAINDICATIONS
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CONTRAINDICATIONS
• AGE < 5 yrs
• Hb < 10
• BLEEDING DISORDERS / BT CT• EPIDEMIC OF POLIO
• HT
• DM
Preoperative evaluation
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Preoperative evaluation
• Most common lab test is a CBC
• Coagulation studies when the history or
physical examination suggests a bleedingdisorder.
• Lateral Neck/Adenoid films
METHODS
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O S
• DISSECTION• GUILLOTINE
• ELECTROCAUTERY
• CRYOSURGERY • LASER
• HARMONIC SCALPEL
•COBLATION
• MICRODEBRIDER
ROSE‟S POSITION
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ROSE S POSITION
INSTRUMENTS
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INSTRUMENTS
TONSILLAR DISSECTOR
EVE’S TONSILLAR SNARE
DISSECTION METHOD
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DISSECTION METHOD
Adjuvant Therapies
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Adjuvant Therapies
• Perioperative Steroids
– Dexamethasone (0.15-1.0mg/kg)
– Two times less likely to have an episode of postoperative emesis, and more likely toadvance to eating a soft diet.
– Reducing postoperative pulmonary distress,
subglottic edema, pain reduction.
POST OP CARE
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• POSITION
• PULSE BP
• W/F BLEEDING
• DIET COLD FEEDS
• ANTIBIOTICS
• ANALGESICS
• GARGLES
COMPLICATIONS
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COMPLICATIONS
• HAEMORRHAGE
• PRIMARY
• REACTIONARY 48 hrs
• SECONDARY 5-8 days
• Trauma
• TM joint
• ASPIRATION
• VOICE CHANGE
Unilateral TonsillarE l t
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Enlargement
Apparent enlargement vs true enlargement
Non-neoplastic:
• Acute infective
• Chronic infective
• Hypertrophy
• Congenital
Neoplastic
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Peritonsillar Abscess
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RetentionCysts
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Pleomorphic Adenoma
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• Ca tonsil
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ICA Aneurysm
Peritonsillar abscess
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• Abscess formation outside tonsillar capsule
• Signs and symptoms: – Fever
– Sore throat
– Dysphagia/odynophagia
– Drooling
– Trismus
– Unilateral swelling of soft palate/pharynx with uvuladeviation
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