Adenotonsillar disease

Shahin Bastaninejad, MD, ORL-HNS Surgeon

Assistant professor of tehran university of

medical sciences
 Anatomy
Tonsil boundary
Plica triangularis
Adenoid boundary
Posterior aspect of the
nasal septum
Fossa of Rosenmller
Passavants ridge
Waldeyers Ring
 Presentation outlines
Acute Infections

Chronic diseases

Obstructive hyperplasia

Mass

Surgery
Acute Infections
 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-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 medication is

preferable (penicillin V)

Other choices:

Amoxicillin (wide spectrum than Pencillin V)

Macrolides

Clindamycin
Recurrent or unresponsive infections require treatment with beta-
lactamase resistant antibiotics such as
Clindamycin

Augmentin

Penicillin plus rifampin (or Erythro + Metro)

If no response after 48 hr, re-evaluate patient for the followings:
Sequelea

Patients 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 with 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
Webers glands

Would explain superior pole involvement and the

usual absence of tonsillar erythema/exudates
Candidiasis
Infectious Mononucleosis
 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
 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
 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
 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
Diphtheria
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 infections

 Cryptic 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-Hodgkins lymphoma
Rapid unilateral tonsillar enlargement associated with cervical
lymphadenopathy and systemic symptoms
Lymphoma
SCC
 Congenital tonsillar masses

Teratoma
Hemangioma
Lymphangioma
Cystic hygroma
Surgery
 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 &
Infection:
Adenoidectomy
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
Obstruction:
Adenoidectomy Cont
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 ofAdenoid
Disease
Triad of hyponasality,
snoring, and mouth
breathing
Rhinorrhea, nocturnal
cough, post nasal drip
Adenoid facies
long face, crowded
incisors
 Pre-Op Evaluation of Adenoid
Disease
Evaluate palate
Symptoms/FH of CP or
VPI
Bifid uvula
CNS or neuromuscular
disease
Preexisting speech disorder?
 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.
Any questions !?