Adenotonsillar Diseases Drbugnah

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ADENOTONSILLAR ADENOTONSILLAR DISEASESDISEASES

Dr.Sherif BugnahDr.Sherif Bugnah

ENT ResidentENT Resident

Armed Forces Hospitals Southern Region Armed Forces Hospitals Southern Region

Khamis Mushayt - Saudi ArabiaKhamis Mushayt - Saudi Arabia

ADENOTONSILLAR DISEASADENOTONSILLAR DISEAS

OutlinesOutlines INTRODUCTIONINTRODUCTION ANATOMY & PHYSIOLOGY (Adenoid & Tonsils)ANATOMY & PHYSIOLOGY (Adenoid & Tonsils) INFECTIONS : VIRAL INFECTIONSINFECTIONS : VIRAL INFECTIONS

Epstein-Barr virus (EBV)Epstein-Barr virus (EBV) Coxsackie virus Coxsackie virus

FUNGAL INFECTIONSFUNGAL INFECTIONS BACTERIAL INFECTIONSBACTERIAL INFECTIONS

Group A -hemolytic streptococcusGroup A -hemolytic streptococcus Corynebacterium diphtheriae Corynebacterium diphtheriae

Recurrent Acute TonsillitisRecurrent Acute Tonsillitis Chronic TonsillitisChronic Tonsillitis Complications of Acute AdenotonsillitisComplications of Acute Adenotonsillitis

NONSUPPURATIVE COMPLICATIONSNONSUPPURATIVE COMPLICATIONS SUPPURATIVE COMPLICATIONSSUPPURATIVE COMPLICATIONS

Chronic Adenotonsillar HypertrophyChronic Adenotonsillar Hypertrophy TONSILLAR NEOPLASMSTONSILLAR NEOPLASMS

INTRODUCTIONINTRODUCTION

The tonsils and adenoids can be a source of The tonsils and adenoids can be a source of

infection and obstruction for both adults and infection and obstruction for both adults and

children and are responsible for a significant children and are responsible for a significant

childhood illnesses. childhood illnesses.

Tonsillectomy and adenoidectomy remain two Tonsillectomy and adenoidectomy remain two

of the most commonly performed procedures of the most commonly performed procedures

by otolaryngologists.by otolaryngologists.

ANATOMY & PHYSIOLOGYANATOMY & PHYSIOLOGY

tonsils and the adenoids are both tonsils and the adenoids are both

components of Waldeyer tonsillar ring. components of Waldeyer tonsillar ring.

The lymphoid tissue of Waldeyer tonsillar ring The lymphoid tissue of Waldeyer tonsillar ring

contains B-cell lymphocytes, T-cell lymphocytes, contains B-cell lymphocytes, T-cell lymphocytes,

and a few mature plasma cellsand a few mature plasma cells. .

Functions include secretory immunity & Functions include secretory immunity &

regulating immunoglobulin production. regulating immunoglobulin production.

ANATOMY & PHYSIOLOGYANATOMY & PHYSIOLOGY

most active from the ages of 4 to 10 and tend to most active from the ages of 4 to 10 and tend to

supressed after puberty(secretory immune function supressed after puberty(secretory immune function

these tissues remains, but much less.these tissues remains, but much less.

The palatine tonsils are the largest component of the The palatine tonsils are the largest component of the

ring and have the most specialized structures..ring and have the most specialized structures..

A specialized portion of the pharyngobasilar fascia, A specialized portion of the pharyngobasilar fascia,

forming afibrous capsule, binds the deep surface of forming afibrous capsule, binds the deep surface of

the tonsil.the tonsil.

ANATOMY & PHYSIOLOGY (Tonsils)ANATOMY & PHYSIOLOGY (Tonsils)

tonsillar fossa consist of three muscles tonsillar fossa consist of three muscles form the. The form the. The palatoglossus muscle palatoglossus muscle (the (the anterior tonsillar pillar) , anterior tonsillar pillar) , palatopharyngeal palatopharyngeal muscle muscle (posterior tonsillar pillar)(posterior tonsillar pillar)

tonsillar fossa Base formed by the tonsillar fossa Base formed by the

pharyngeal constrictors pharyngeal constrictors (primarily the (primarily the superior constrictor). superior constrictor).

Blood supply - TonsilsBlood supply - Tonsils

Tonsillar branch Tonsil(main branch)

Ascending palatine Tonsil

Dorsal lingual Tonsil

Tonsil

Lesser descending palatine Tonsil

ANATOMY & PHYSIOLOGY (TonsilsANATOMY & PHYSIOLOGY (Tonsils))

Facial ArteryFacial Artery

Lingual A.Lingual A.

Ascending PharyngealAscending Pharyngeal

MaxillaryMaxillary

Venous DrainageVenous Drainage peritonsillar plexus peritonsillar plexus

lingual and pharyngeal veins IJV lingual and pharyngeal veins IJV

Lymphatic DrainageLymphatic Drainage tonsillar lymph tonsillar lymph

node node (behind angle of the mandible), (behind angle of the mandible), jugulodigastric jugulodigastric

/upper cervical lymph nodes. /upper cervical lymph nodes.

Nerve Supply (tonsils)Nerve Supply (tonsils): tonsillar branch of the : tonsillar branch of the

glossopharyngeal nerve, also descending glossopharyngeal nerve, also descending

branches of the lesser palatine nerve. branches of the lesser palatine nerve.

ANATOMY & PHYSIOLOGY (Tonsils)ANATOMY & PHYSIOLOGY (Tonsils)

ANATOMY & PHYSIOLOGY (Adenoids)ANATOMY & PHYSIOLOGY (Adenoids)

he adenoids are he adenoids are locatedlocated over the surface of the superior and over the surface of the superior and

posterior wall of the nasophposterior wall of the nasoph

Blood supply – AdenoidsBlood supply – Adenoids

Ascending palatine branch of facial a.Ascending palatine branch of facial a.

Ascending pharyngeal a.Ascending pharyngeal a.

Pharyngeal branch of IMAX.Pharyngeal branch of IMAX.

Ascending cervical branch of thyrocervical trunkAscending cervical branch of thyrocervical trunk

Venous drainage Venous drainage pharyngeal plexuspharyngeal plexus

Lymphatic drainLymphatic drain retropharyngeal or retropharyngeal or

pharyngomaxillary lymph nodes.pharyngomaxillary lymph nodes.

INFECTIONS : VIRAL INFECTIONSINFECTIONS : VIRAL INFECTIONS

Usually associated with viral pharyngitis, Usually associated with viral pharyngitis, common common

complaintcomplaint: sore throat and difficulty swallowing. : sore throat and difficulty swallowing.

often fever and oropharyngeal erythema, usually often fever and oropharyngeal erythema, usually

without a tonsillar exudate. without a tonsillar exudate.

Possible VirusesPossible Viruses: adenovirus, rhinovirus, (RSV), : adenovirus, rhinovirus, (RSV),

influenza and parainfluenza .influenza and parainfluenza .

Most of these infections are Most of these infections are self-limitedself-limited and require and require

only symptomatic treatment.only symptomatic treatment.


Epstein-Barr virus (EBV)Epstein-Barr virus (EBV)

Causes pharyngitis (infectious mononucleosis syndrome) Causes pharyngitis (infectious mononucleosis syndrome) Children and young adultsChildren and young adults, P, Presents as resents as fever, malaise, fever, malaise,

lymphadenopathy, hepatosplenomegalylymphadenopathy, hepatosplenomegaly Petechiae may present at the junction of the soft & hard Petechiae may present at the junction of the soft & hard

palates. Tonsils severely enlarged (may affect the palates. Tonsils severely enlarged (may affect the airway),covered with grayish-white exudate. airway),covered with grayish-white exudate.

Treatment: Treatment: supportive, with IV fluids and rest. supportive, with IV fluids and rest. If progressive airway obstruction, short course of If progressive airway obstruction, short course of

systemic steroids can be helpful. Rarely, a systemic steroids can be helpful. Rarely, a nasopharyngeal airway, nasotracheal intubation or nasopharyngeal airway, nasotracheal intubation or tracheotomy may needed.tracheotomy may needed.


Coxsackie virus Coxsackie virus

ulcerative vesicles over the tonsils, posterior ulcerative vesicles over the tonsils, posterior

pharynx, and palatepharynx, and palate

Commonly in children under the age of 16. Commonly in children under the age of 16.

headache, high fever, anorexia, & odynophagia.headache, high fever, anorexia, & odynophagia.

Treatment : mostly supportive, tonsils can have a Treatment : mostly supportive, tonsils can have a

bacterial superinfection may benefit from bacterial superinfection may benefit from

systemic antibiotics.systemic antibiotics.

FUNGAL INFECTIONSFUNGAL INFECTIONS

Oropharyngeal Candida Oropharyngeal Candida (ie, thrush) mainly in (ie, thrush) mainly in

immunocompromised patients immunocompromised patients or patients who or patients who

have undergone prolonged treatment with have undergone prolonged treatment with

antibiotics. antibiotics.

white plaques over the pharyngeal mucosa, white plaques over the pharyngeal mucosa,

bleeds if removed with a tongue depressor. bleeds if removed with a tongue depressor.

topical antifungal (e.g. nystatin or clotrimazole.)topical antifungal (e.g. nystatin or clotrimazole.)

BACTERIAL INFECTIONSBACTERIAL INFECTIONS

Acute Streptococcal PharyngotonsillitisAcute Streptococcal Pharyngotonsillitis, Group A -, Group A -

hemolytic streptococcushemolytic streptococcus is the is the most commonmost common..

children aged 5–6,children aged 5–6, Presents Presents with fever, dry sore with fever, dry sore

throat, cervical adenopathy, dysphagia, and throat, cervical adenopathy, dysphagia, and

odynophagia. odynophagia.

Tonsils and pharyngeal mucosa Tonsils and pharyngeal mucosa

erythematous ,may covered with purulent erythematous ,may covered with purulent

exudate; ("strawberry tongue")exudate; ("strawberry tongue")

BACTERIAL INFECTIONSBACTERIAL INFECTIONS

Major consideration is Major consideration is preventing complications preventing complications ((acute rheumatic fever & poststreptococcal acute rheumatic fever & poststreptococcal glomerulonephritis. )glomerulonephritis. )

Suspected pharyngitis, Daignosed by Suspected pharyngitis, Daignosed by rapid strep rapid strep tests tests based on based on ELISA or latex agglutination, ELISA or latex agglutination, with with a a throat culture.throat culture.

Treatment Treatment :Mainly Penicillin, if no response (48 :Mainly Penicillin, if no response (48 hours), amoxicillin with clavulanate may be hours), amoxicillin with clavulanate may be helpful. Therapy should be for 10 days to helpful. Therapy should be for 10 days to decrease recurrencedecrease recurrence..

Other Acute Bacterial InfectionsOther Acute Bacterial Infections

Vincent angina Vincent angina is caused by Treponema vincentii is caused by Treponema vincentii and Spirochaeta denticulata.and Spirochaeta denticulata.

Patients presentPatients present with fever, unilateral pain with fever, unilateral pain (swallowing), ipsilateral cervical (swallowing), ipsilateral cervical lymphadenopathy; unilateral deep ulcer on the lymphadenopathy; unilateral deep ulcer on the upper pole of the tonsil, covered by a white upper pole of the tonsil, covered by a white exudative ulcer.exudative ulcer.

TreatmentTreatment usually with penicillin and oral usually with penicillin and oral hygiene. heals in approximately 7–10 days hygiene. heals in approximately 7–10 days membranemembrane

Other Acute Bacterial InfectionsOther Acute Bacterial Infections

Corynebacterium diphtheriae Corynebacterium diphtheriae

Usual symptoms of acute pharyngitisUsual symptoms of acute pharyngitis

Gay, firmly adherent pseudomembrane (covers the Gay, firmly adherent pseudomembrane (covers the

tonsils. 60% are localized to the pharynx; 8% spreads to tonsils. 60% are localized to the pharynx; 8% spreads to

the larynx, compromising the airway.the larynx, compromising the airway.

Diagnosis: Diagnosis: Gram stain of the pseudomembrane reveals Gram stain of the pseudomembrane reveals

gram-positive aerobic bacillusgram-positive aerobic bacillus

Treatment Treatment must started immediately, even before must started immediately, even before

confirmation with the culture. antitoxin (within 48 hours confirmation with the culture. antitoxin (within 48 hours

of the onset of symptoms), high-dose penicillin.of the onset of symptoms), high-dose penicillin.

Recurrent Acute TonsillitisRecurrent Acute Tonsillitis

Episodes of acute tonsillitis with complete recovery Episodes of acute tonsillitis with complete recovery

between episodes. between episodes.

due to their location and numerous crypts and crevices, due to their location and numerous crypts and crevices,

seem to harbor bacteria. seem to harbor bacteria.

Tonsillectomy is indicated Tonsillectomy is indicated in patients with recurrent in patients with recurrent

acute tonsillitis involving 6–7 episodes of acute tonsillitis acute tonsillitis involving 6–7 episodes of acute tonsillitis

in 1 year, 5 episodes/y for 2 consecutive years, or 3 in 1 year, 5 episodes/y for 2 consecutive years, or 3

episodes/y for 3 yearsepisodes/y for 3 years

Chronic TonsillitisChronic Tonsillitis

persistent sore throat, anorexia, dysphagia, and persistent sore throat, anorexia, dysphagia, and

pharyngotonsillar erythema. pharyngotonsillar erythema.

malodorous tonsillar concretions and the malodorous tonsillar concretions and the

enlargement of jugulodigastric lymph nodes. enlargement of jugulodigastric lymph nodes.

organisms involved are usually both aerobic and organisms involved are usually both aerobic and

anaerobic mixed flora, with a predominance of anaerobic mixed flora, with a predominance of

streptococci.streptococci.

Chronic TonsillitisChronic Tonsillitis

TonsillolithsTonsilloliths deep or stenotic crypts, food and secretions stagnate, deep or stenotic crypts, food and secretions stagnate,

leading to bacterial overgrowth and a localized infection. leading to bacterial overgrowth and a localized infection.

In some patients, a sensation of a foreign body in the In some patients, a sensation of a foreign body in the throat, hard white material coming from the tonsilsthroat, hard white material coming from the tonsils

mouth care, which includes irrigation of the tonsils or mouth care, which includes irrigation of the tonsils or cleaning them with a cotton swab soaked in 3% hydrogen cleaning them with a cotton swab soaked in 3% hydrogen peroxide. peroxide.

Tonsillar surgery Tonsillar surgery and elimination of these cryptic structures and elimination of these cryptic structures may be needed to control these infections.may be needed to control these infections.

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%

Complications of Acute AdenotonsillitisComplications of Acute Adenotonsillitis

NONSUPPURATIVE COMPLICATIONSNONSUPPURATIVE COMPLICATIONS

Scarlet FeverScarlet Fever fever, severe dysphagia, diffuse erythematous rash, fever, severe dysphagia, diffuse erythematous rash,

pharyngeal symptoms.pharyngeal symptoms.

yellow membranous exudate covering the tonsils and yellow membranous exudate covering the tonsils and the pharynx, "strawberry tongue“, facial flush and the pharynx, "strawberry tongue“, facial flush and petechiae , (eruptions followed by desquamation petechiae , (eruptions followed by desquamation occur due to exotoxin produced by streptococcus. )occur due to exotoxin produced by streptococcus. )

Symptom identification and treatment planning are Symptom identification and treatment planning are important to prevent complications related to important to prevent complications related to streptococcal infection. The traditionalstreptococcal infection. The traditional treatment treatment is is with penicillin.with penicillin.


NONSUPPURATIVE COMPLICATIONS NONSUPPURATIVE COMPLICATIONS

Acute Rheumatic FeverAcute Rheumatic Fever 18 days post infection (group A -hemolytic strept.),

when the throat culture is no longer positive. Streptococcal infection results in production of cross-reactive antibodies, leading to damage of the heart tissues.

Patients should be placed on a penicillin prophylaxis or undergo tonsillectomy to eliminate the reservoir of streptococcal infection


NONSUPPURATIVE COMPLICATIONS NONSUPPURATIVE COMPLICATIONS Post-Streptococcal GlomerulonephritisPost-Streptococcal Glomerulonephritis

(12–25% incidence) (12–25% incidence) typically 10 days after a typically 10 days after a pharyngotonsillar infection pharyngotonsillar infection or or (10% incidence) as skin (10% incidence) as skin infectionsinfections with a nephrogenic strain caused by group with a nephrogenic strain caused by group A-H.S. A-H.S.

involves injury to the glomerulus by deposition of the involves injury to the glomerulus by deposition of the immune complexes & autoantibodies immune complexes & autoantibodies

Antibiotic treatment has not been shown to affect the Antibiotic treatment has not been shown to affect the incidence of the disease.incidence of the disease.


SUPPURATIVE COMPLICATIONSSUPPURATIVE COMPLICATIONS

Peritonsillar AbscessPeritonsillar Abscess Lies in the potential space between the tonsillar Lies in the potential space between the tonsillar

capsule and surrounding pharyngeal muscle bed.capsule and surrounding pharyngeal muscle bed.

SymptomsSymptoms include malaise, severe odynophagia include malaise, severe odynophagia leads to dehydration & trismus.leads to dehydration & trismus.

O/E O/E a bulging palate with the corresponding tonsil a bulging palate with the corresponding tonsil displaced to the midline or beyond. displaced to the midline or beyond.



Peritonsillar AbscessPeritonsillar Abscess Needle aspiration confirmsNeedle aspiration confirms

diagnosis and ocate the abscess. diagnosis and ocate the abscess.

Definitive Treatment incision and drainageDefinitive Treatment incision and drainage recurrence rate for peritonsillar abscess indicate recurrence rate for peritonsillar abscess indicate

tonsillectomy. some surgeons favor a "Quincy tonsillectomy. some surgeons favor a "Quincy tonsillectomy”, most surgeons prefer either to surgery tonsillectomy”, most surgeons prefer either to surgery after all the acute infection has resolved or to perform after all the acute infection has resolved or to perform an interval tonsillectomyan interval tonsillectomy. .



Deep Neck InfectionsDeep Neck Infections common cause of parapharyngeal abscesses is common cause of parapharyngeal abscesses is

bacterial pharyngitis or tonsillitis. bacterial pharyngitis or tonsillitis. odynophagia, trismus, and shortness of breath.odynophagia, trismus, and shortness of breath. asymmetric pharyngeal swelling, including the palate, asymmetric pharyngeal swelling, including the palate,

extends more inferiorly than the tonsil, into the extends more inferiorly than the tonsil, into the hypopharynx.hypopharynx.

Ultrasound may be helpful, a definitive diagnosis Ultrasound may be helpful, a definitive diagnosis requires (CT) scan of the neck. requires (CT) scan of the neck.

managementmanagement includes control of the airway, includes control of the airway, intravenous antibiotics, I&D of the abscess.intravenous antibiotics, I&D of the abscess.

Chronic Adenotonsillar HypertrophyChronic Adenotonsillar Hypertrophy

Hypertrophy occurs in response to colonization with Hypertrophy occurs in response to colonization with

normal flora, pathogenic microorganisms & Second-normal flora, pathogenic microorganisms & Second-

hand smoke .hand smoke .

SymptomsSymptoms: (adenoid hypertrophy) Nasal obstruction, : (adenoid hypertrophy) Nasal obstruction,

rhinorrhea, hyponasal voice. (tonsillar enlargement) rhinorrhea, hyponasal voice. (tonsillar enlargement)

snoring, dysphagia, and hypernasal or a muffled voice. snoring, dysphagia, and hypernasal or a muffled voice.

Chronic adenotonsillar hypertrophy is the Chronic adenotonsillar hypertrophy is the most most

common cause of sleep-disordered common cause of sleep-disordered breathing in breathing in

childrenchildren

Chronic Adenotonsillar HypertrophyChronic Adenotonsillar Hypertrophy

Adenotonsillar hypertrophy and chronic mouth Adenotonsillar hypertrophy and chronic mouth

breathing due to nasal obstruction is associated with breathing due to nasal obstruction is associated with

craniofacial growth abnormalities (increased anterior craniofacial growth abnormalities (increased anterior

facial height and a retrognathic mandible, with facial height and a retrognathic mandible, with

subsequent malocclusion.) subsequent malocclusion.)

Flexible endoscopy is helpful in diagnosing adenoid Flexible endoscopy is helpful in diagnosing adenoid

hypertrophy and forruling out other causes of nasal hypertrophy and forruling out other causes of nasal

obstruction. obstruction.

Lateral neck soft-tissue radiography can be helpful if Lateral neck soft-tissue radiography can be helpful if

endoscopy is not performed. endoscopy is not performed.

TONSILLAR NEOPLASMSTONSILLAR NEOPLASMS

Asymmetric tonsillar hypertrophy, if accompanied by a Asymmetric tonsillar hypertrophy, if accompanied by a

suspicious clinical course or history, a tonsillectomy suspicious clinical course or history, a tonsillectomy

should be performed for biopsy. should be performed for biopsy.

Lymphoma and squamous cell carcinoma are the most Lymphoma and squamous cell carcinoma are the most

common primary tonsillar neoplasms. common primary tonsillar neoplasms.

Many primary malignant neoplasms metastasize to Many primary malignant neoplasms metastasize to

tonsils tonsils (eg, melanoma, renal, lung, breast, gastric and colon ca) (eg, melanoma, renal, lung, breast, gastric and colon ca)

Benign tumors are rare, include lipomas, fibromas and Benign tumors are rare, include lipomas, fibromas and

schwannomas.schwannomas.

TONSILLAR NEOPLASMSTONSILLAR NEOPLASMS

Parapharyngeal space tumors are important to consider, Parapharyngeal space tumors are important to consider, may present with similar signs and symptoms.may present with similar signs and symptoms.

Risk Factors for Malignanency include tonsillar Risk Factors for Malignanency include tonsillar asymmetry associated with rapid enlargement, asymmetry associated with rapid enlargement, constitutional symptoms, atypical tonsillar appearance, constitutional symptoms, atypical tonsillar appearance, ipsilateral cervical lymphadenopathy, and Hx of previous ipsilateral cervical lymphadenopathy, and Hx of previous tumers.tumers.

Unilateral tonsillar enlargement in asymptomatic Unilateral tonsillar enlargement in asymptomatic children is rarely of neoplastic , However, the diagnosis children is rarely of neoplastic , However, the diagnosis of tonsillar lymphoma should be considered when of tonsillar lymphoma should be considered when unilateral tonsillar enlargement is present either in an unilateral tonsillar enlargement is present either in an immunocompromised child or when acute tonsillitis is immunocompromised child or when acute tonsillitis is asymmetric and unresponsive to medical therapy.asymmetric and unresponsive to medical therapy.

ADENOTONSILLAR DISEASES : RefrencesADENOTONSILLAR DISEASES : Refrences

Current Diagnosis & Treatment in Otolaryngology—Head & Neck Surgery, 2nd Edition Copyright © 2008

Harley EH. Asymmetric tonsil size in children. Arch Otolaryngol Head Neck Surg. 2002;128(7):767. Harley EH. Asymmetric tonsil size in children. Arch Otolaryngol Head Neck Surg. 2002;128(7):767.

(Prospective controlled study of the implication of pediatric tonsillar asymmetry.) [PMID: 12117331](Prospective controlled study of the implication of pediatric tonsillar asymmetry.) [PMID: 12117331]

Syms MJ, Birkmire-Peters DP, Holtel MR. Incidence of carcinoma in incidental tonsil asymmetry. Syms MJ, Birkmire-Peters DP, Holtel MR. Incidence of carcinoma in incidental tonsil asymmetry.

Laryngoscope. 2000;110(11):1807. (Retrospective review examining the incidence of malignant Laryngoscope. 2000;110(11):1807. (Retrospective review examining the incidence of malignant

neoplasms in incidentally discovered unilateral tonsillar enlargement.) [PMID: 11081589neoplasms in incidentally discovered unilateral tonsillar enlargement.) [PMID: 11081589

Darrow DH, Siemens C. Indications for tonsillectomy and adenoidectomy. Laryngoscope. Darrow DH, Siemens C. Indications for tonsillectomy and adenoidectomy. Laryngoscope.

2002;112:6. (A thorough review of the indications for tonsillectomy and adenoidectomy based on 2002;112:6. (A thorough review of the indications for tonsillectomy and adenoidectomy based on

evidence in the medical literature.) [PMID: 12172229]evidence in the medical literature.) [PMID: 12172229]

Krisha P, Lee D. Post-tonsillectomy bleeding: A meta-analysis, Laryngoscope. 2001;111:1358. (A Krisha P, Lee D. Post-tonsillectomy bleeding: A meta-analysis, Laryngoscope. 2001;111:1358. (A

review of reports on post-tonsillectomy bleeding, the major complication of tonsillectomy.) [PMID: review of reports on post-tonsillectomy bleeding, the major complication of tonsillectomy.) [PMID:

11568568]11568568]

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