Adenotonsillitis New

7/28/2019 Adenotonsillitis New

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Dr.Ravikumar MS(ENT)


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Etiology : Viral followed bysecondarily invaded by

Hemolytic streptococcus

Staph aureas

H.influenza Dipl. Pneumoniae

Age : Commonest


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Spread : Droplet infection

Types:

Ac cattarhal

Ac parenchymatous

Ac follicular

Ac membranous


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Viral Infections

Bacterial Infections

Inflammatory exudates of the crypts

Epithelial keratinisation

Deep-seated multiple abscess formation

with increasing germ centers

Parenchyma destruction

Immunologic Factors

Pathophysiology


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When tonsilsare inflamed as

part of thegeneralisedinfection of theoropharyngeal

mucosa it iscalled catarrhaltonsillitis.


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Some timesexudation fromcrypts may

coalesce to forma membraneover the surfaceof tonsil, giving

rise to clinicalpicture ofmembranoustonsillitis.


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When thewhole tonsil is

uniformlycongested andswollen it is

called acuteparenchymatous tonsillitis


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SYMPTOMS Sore throat Fever Malaise Odynophagia

Thick speech Earache


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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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Rapid strep tests:latex agglutination or ELISAmethods extract antigen from swab

Throat swab:


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Bed rest : Isolation

Mouth gurgles :

Analgesics :

Antibiotics :


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First Line Penicillin/Cephalosporin for 10 days

Injectable forms for noncompliance

Macrolides Penicillin allergy Erythromycin/Clarithromycin 10 days

Azithromycin (12mg/kg/day) 5 days


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Peritonsillar abscess

Parapharyngeal abscess

Retropharyngeal abscess

Oedema of larynx

Cervical supp. Lymphadenitis


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Acute middle ear cleft infection

Chronic tonsillitis

Rheumatic heart disease

Chorea

S.B.E.

Acute nephritis


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Infectious Mononucleosis Faucial diphtheria Agranulocytosis Scarlet fever Oral thrush ALL Vincents angina Tertiary syphilis


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Differential

Diagnosis ofpseudomembranous

tonsillitis


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Infectious Mononucleosis

Cheesy exudatescovering tonsil

Lymphadenopathy ofneck, axilla & groin

Hepato/Spleenomegaly


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Oral Thrush

Painful throat White candidiasis

patches whenremoved leaveserythematous ulcer

Immunosuppressivestate


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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 or

coalesce necroticslough covered

ulcers Leucopenia H/O causative drugs

intake


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Vincents angina Fetor oris, pyrexia Tonsillar deep ulcers with

grey slough in its base

Necrotising gingivitis Enlarged tender cervical

adenitis

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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Diphtheria

Malaise, fever &headache

Greyish greenmembrane acrosstonsils to larynx

Tender bilateralcervicallymphadenopathy


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Diphtheria is an acute, toxin-mediated disease

caused by toxigenic Corynebacterium diphtheriae

Its a very contagious and potentially life-

threatening bacterial disease.


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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 via droplets or

contaminated articles

Humans are the sole carriers of theorganism

More common in children < 10 years

Rare occurrence today because of routine

vaccination


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Clinical manifestations Systemic symptoms from exotoxin

Fatigued

Lethargic

Tachycardic

toxic


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Clinical characteristics Pharynx grayish membrane (composed of

fibrin, leukocytes, and cellular debris) extends from pharynx to larynx Extensive cervical lymphadenopathy

(bull neck)


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Diagnosis Isolation of the organism

Culture from local lesion

Grows on selective media containingpotassium tellurite

Notify microbiology lab if diphtheriasuspected


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Treatment Started before culture confirmation

Airway

Resuscitation

Skin test for allergy to horse serum


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Administer diphtheria antitoxin

Have epinephrine available

Antibiotics : penicillin G is the drug

of choice Erythomycin

Pt allergic to both drugs- rifampin,

and clindamycin


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Prevention Vaccine

Trivalent vaccine diphtheria toxoid,tetanus toxoid and pertussis (DTP)

6 weeks of age, 2 more 4-8 weeksintervals, and 4th 6-12 months later.


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Myocarditis.

Cardiac arrhythmias.

Acute circulatory failure.

Paralysis of soft palate,diaphragm & ocular

muscles.

Laryngeal-airway obstruction.


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Ac tonsillitis Faucialdiphtheria

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

+/- + +


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Local Complications

Respiratory obstruction Quinsy

Acute retropharyngeal abscess Parapharyngeal abscess Neck space infectionsAcute otitis media


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. Comp of acute tonsillitis ordenovo with no precedingtonsillitis

. Collection pus b/w supr

constrictor & fibrous capsule

at upper pole

.

Peritonsillar Abscess or Quinsy


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The bacteriology of acute tonsillitisand peritonsillar abscess is differentalthough one is a complication of the

other.

The bacteriology of the quinsy is

characterized by mixed flora withmultiple organisms both aerobic andanaerobic.


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repeated attacks of acute tonsillitis Fever

severe throat pain referred otalgia swelling in the neck

patients voice develops acharacteristicplummy quality


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Ill looking patient Pyrexia Often with severe

trismus

Striking asymmetrywith oedema andhyperaemia of the softpalate.

Enlarged hyperaemicand displaced tonsil Usually enlarged lymph

nodes in JD region.


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Preferably admitted to hospital and treatedwith analgesics and antibiotics.

In a patient with an early peritonsillar abscess

which is really a peritonsillar cellulitis incisionand drainage are not recommended.
http://www.mdconsult.com/das/book/body/0/0/1492/f4-u1.0-B978-1-4160-2805-5..50460-2..gr4.jpg


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Indications for I/Dinclude markedbulging of soft palate

This is undertaken atthe point ofmaximum bulge.

Interval tonsillectomy

after 6 weeks. Abscess tonsillectomy.


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Quinsy is a

potentially lethalcondition

Pharyngeal &Laryngealoedema

Parapharyngealspace abscess


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Recurrent Acute Tonsillitis

Same signs andsymptoms asacute

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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RECURRENT PAINHALITOSIS

COUGH

SNORING

SLEEP APNOEA

ASYMPTOMATIC


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LARGE TONSILS

SMALL FIBROTIC INADULTS

ANTERIOR PILLARCONGESTED

SQUEEZE IRWIN

MOORES SIGN

LYMPHADENOPATHY


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Apparent enlargement vs true enlargement

Non-neoplastic: Acute infective

Chronic infective Hypertrophy Congenital

Neoplastic


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Pleomorphic Adenoma ICAAneurysm


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Normally regress by 10 yrs

Etiology:

Age ; 3-4 years

Physiological hypertrophy

Infection

Rarely tuberculosis

Predisposing factors


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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


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Palate High arched.

Feeding difficulties.

Face - Loss of nasolabial furrow,dulllook.

Chest Pigeon shaped.

Pot belly.


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Hyponasality

Snoring Openmouthbreathing

Triad


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NASAL DISCHARGE.

SINUSITIS.

EPISTAXIS.

VOICE CHANGE.

THE DEVELOPMENT OF EXUDATIVE OTITIS


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The closing of Eustachian tube

The accumulation of exudate in

the middle ear

The lack of mobility of

eardrum


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Diagnosis :

Clinical features: clinch diagnosis

Posterior rhinoscopy:

Digital palpation :--bag of worms

X-ray nasopharynx soft tissue lateralview

Nasal endoscopy , Nasopharyngoscopy


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Lateral neck films areuseful only when

history and physical

exam are not in

agreement.

Accuracy of lateral neck

films is dependent onproper positioning

and patientcooperation.


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Conservative : in acute & mild cases

Antibiotics,Decongestants,Breathing exercises

Surgical : Adeoidectomy-for persistent & rec. infection

Precautions:

Grommet insertion : in case of SOM


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A. Absolute1. Recurrent infections of throat

2. Peritonsillar abscess

3. Tonsillitis causing febrile seizures

4. Hypertrophy of tonsils causing obstruction

5. Suspicion of malignancy

B. Relative1. Diphtheria carriers,

2. Streptococcal carriers

3. Chronic tonsillitis with bad taste or halitosis

4. Recurrent streptococcal tonsillitis in a patient with valvular heart disease

C. As a Part of Another Operation1. Palatopharyngoplasty

2. Glossopharyngeal neurectomy.

3. Removal of styloid process.

d d d


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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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Epidemic of polio Age below 3 years Acute infections Blood dyscrasiasis: hemophilia, purpura

Uncontrolled systemic diseases like diabetes and heartdiseases

Velopharyngeal insufficiency Overt cleft palate, submucous (covert) cleft

Neurologic or neuromuscular abnormality leading to impaired palate

function Anemia

ABSOULTECONTRAINDICATION-PULSATILE TONSILE


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Most common lab test is a CBC

Coagulation studies when the history orphysical examination suggests a bleedingdisorder.

Lateral Neck/Adenoid films

R ' iti


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Rose's position for tonsillectomy. Neck is extended by a sand bagunder the shoulders and the head is supported on a ring.

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2005 Elsevier

Rose's position


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DAVIS MOUTH GAG BOYLES TONGUE BLADE


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Set of instruments for tonsillectomy.(1) Knife in kidney tray, (2) & (3) Toothed and non-toothedWaugh's forceps, (4) Tonsil holding forceps, (5) Tonsil dissector and anterior pillar retractor, (6) Luc's

forceps, (7) Scissor, (8) Curved artery forceps, (9) Negus artery forceps, (10) Tonsillar snare, (11) BoyleDavis mouth gag with three sizes of tongue blades, (12) Doyen's mouth gag, (13) Adenoid curette, (14)

Tonsil swabs, (15) Nasopharyngeal pack, (16) Towel clips.Downloaded from: StudentConsult (on 6 December 2012 06:54 PM) 2005 Elsevier


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DISSECTION GUILLOTINE ELECTROCAUTERY

CRYOSURGERY

LASER HARMONIC

SCALPEL

COBLATION MICRODEBRIDER


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TONSILLAR DISSECTOR

EVES TONSILLAR SNARE


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(A) Tonsil being dissected from its bed. (B) The pedicle at the lower pole oftonsil being cut with a snare.

Downloaded from: StudentConsult (on 6 December 2012 06:54 PM)

2005 Elsevier


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Cold HotDissection and snare Electrocautery

Guillotine method Laser tonsillectomy (CO2

or KTP)Intracapsular (capsule

preserving) tonsillectomy

Coblation tonsillectomy

Harmonic scalpel Radio frequency

Plasma-mediated ablation

technique

Cryosurgical technique


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TONSIL GUILLOTINE GUILLOTINE TONSILLECTOMY


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HARMONIC SCALPEL

KNIFE HARMONIC SCALPEL TONSILLECTOMY


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Primary haemorrhage O t th


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Primary haemorrhage.Occurs at thetime of operation. It can be controlled by

pressure, ligation or electrocoagulation of thebleeding vessels

. Reactionary haemorrhage.Occurswithin a period of 24 hours and can be

controlled by simple measures such asremoval of the clot, application of pressure

or vasoconstrictor.

3 Injury to teeth


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3. Injury to teeth.

4. Aspiration of blood.

5. Facial oedema. Some patients get oedema of

the face particularly of the eyelids.

6. Surgical emphysema. Rarely occurs due to

injury to superior constrictor muscle.


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profuse bleeding, general anaesthesia is given

and bleeding vessel is electrocoagulated or

ligated

approximation of pillars

, external carotid ligation

Transfusion of blood or plasma

Systemic antibiotics are given for control of infection

topical application of dilute adrenaline or

hydrogen peroxide with pressure usually

suffice.

Delayed Complications cont..


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Delayed Complications cont..

1. Infection

2. Lung complications

3. Scarring in soft palate and pillars.

4. Tonsillar remnants.

5. Hypertrophy of lingual tonsil

Thank u


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Adenotonsillitis New