COCLIA 91 Tonsillectomy and Adenoidectomy

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Drravikumar    on Jan 05, 2010 Says :

i think this tonsillitis ppt is very good for presentation in ug class,i request u put other topics also
mcdmanjunath    on Jul 04, 2009 Says :

I THINK THIS PRESENTATION IS MATTER PACKED WITH ALL THE FEATURES OF TONSILLITIS,,;;THANKS TO Mr.NAUSHEEN FOR SHARING US THIS SLIDE
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Slide 1 : Tonsillectomy and Adenoidectomy COCLIA Presentation Nausheen Jamal, MD May 5, 2008
Slide 2 : Tonsil Embryology Develop at the end of the fifth week Begin as aggregates of incompletely encapsulated lymphoid tissue Surface epithelium, crypt lining: second pharyngeal pouch endoderm Reticular framework: mesenchymal cells Capsule: mesenchymal condensation Lymphocytes: appear in reticulum by month 3 and form nodules
Slide 3 : What is Waldeyer’s Ring?
Slide 4 :
Slide 5 : Waldeyer’s Ring Ring of lymphoid tissue found at the entrance of the upper aerodigestive tract. Includes the palatine tonsils, pharyngeal tonsils (adenoids), and lingual tonsils Part of the mucosa-associated lymphoid tissue (MALT) system
Slide 6 : Anatomy
Slide 7 : Anatomy Adenoids (aka pharyngeal tonsils): triangular lymphoid mass on posterior nasopharynx Eustachian tubes lateral Tonsils (aka palatine or faucial tonsils): paired oval lymhoid masses on lateral oropharynx walls Lateral: attached to fascia overlying superior constrictor Anterior: palatoglossus Posterior: palatopharyngeus Inferior: may be continuous with lingual tonsil Internal carotid artery: ~2 cm postero-lateral to deep aspect
Slide 8 : Review the blood supply, lymphatics, and sensory innervation of the tonsils.
Slide 9 : Tonsillar blood supply, lymphatics, and innervation Blood supply: Arterial: highly variable; ascending pharyngeal, ascending palatine & tonsillar (facial branches), dorsal lingual branch of the lingual artery, palatine branch of the maxillary artery (all are branches of the external carotid; rarely it will supply a direct branch) Venous: tonsillar veins drain into the external palatine, pharyngeal and facial veins
Slide 10 : Tonsillar blood supply, lymphatics, and innervation Lymphatics: drain into superior deep cervical and jugular lymph nodes Sensory innervation: glossopharyngeal nerve, some branches of lesser palatine nerve via sphenopalatine ganglion
Slide 11 : Review the blood supply, lymphatics, and sensory innervation of the adenoids.
Slide 12 : Adenoid blood supply, lymphatics, and innervation Blood supply: Arterial: pharyngeal branches of the external carotid artery, some minor branches contribute from the internal maxillary (pharyngeal branch) and facial arteries (ascending palatine), ascending cervical branch of the thyrocervical trunk Venous: pharyngeal and pterygoid plexuses, flowing into the facial and internal jugular veins
Slide 13 : Adenoid blood supply, lymphatics, and innervation Lymphatics: drain into retropharyngeal nodes and superior deep cervical nodes Sensory innervation: glossopharyngeal and vagus nerves
Slide 14 : Immunology No afferent lymphatics Antigen presentation/processing Adenoid surface epithelium: deep folds with some crypts Ciliated pseudostratified columnar – mucociliary clearance Stratified squamous – antigen processing Transitional Tonsil surface epithelium: 10-30 cryptlike invaginations Squamous – antigen processing
Slide 15 : What is the effect of T&A on immune status?
Slide 16 :
Slide 17 : Effect of T&A on immune status Effects on overall immunologic integrity appear to be minimal Reports of reduced nasopharyngeal IgA production against polio vaccine after adenoidectomy? Increase in Hodgkin disease after T&A? No specific adverse effects documented, but immune function should not be readily dismissed – especially in early childhood; remove only for clearly defined clinical disease
Slide 18 : What is the most common bacterial pathogen in tonsillitis?What complications are associated with this pathogen and how do we test for it?Other pathogens?
Slide 19 :
Slide 20 : Group A Beta-Hemolytic Strep Complications cervical adenitis with abscess, PTA, poststreptococcal glomerulonephritis, Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcus (PANDAS), rheumatic fever Tests Rapid strep, throat culture, anti-streptolysin O titers (ASOT), anti-DNAse B serologies
Slide 21 : Other Tonsillitis Pathogens Bacteria aerobic: Group B/C/F strep, H. influenza, S. pneumoniae, S. epidermidis, M. catarrhalis, S. aureus, H. parainfluenza, Neisseria spp, Mycobacteria spp, Lactobacillus spp, etc. Anaerobic: Bacteroides, Peptococcus, Peptostreptococcus, Actinomycosis, etc. Viruses : EBV, adeno, Influenza, HSV, RSV, Parainfluenza Other : Candida albicans
Slide 22 : What antibiotics are commonly used for treatment of tonsillitis?What are the goals of therapy?
Slide 23 : Tonsillitis: Treatment Acute tonsillitis: PCN (amoxicillin) Chronic tonsillitis, Obstructive tonsillar hyperplasia: antibiotic against beta-lactamase-producing microorganisms or encapsulated anaerobes (Augmentin or clindamycin) for 3-6 weeks Obviates need for tonsillectomy in 15% of children Antibiotic prophylaxis rarely used unless undue surgical risk present Goals of therapy: treatment of infection, small reduction in size of tonsils
Slide 24 : Describe the signs and symptoms of adenoid hypertrophy.
Slide 25 : Adenoid Hypertrophy Difficult to differentiate from sinus infections Symptoms Rhinorrhea, chronic cough (especially nocturnal), postnasal drip
Slide 26 : Adenoid Hypertrophy Signs Obligate mouth breathing (awake and asleep), snoring/sleep-disordered breathing, hyponasal speech Adenoid facies: open mouth appearance, flattened midface, dark circles under the eyes; abnormalities in maxillo-mandibular relationship
Slide 27 : Adenoid Hypertrophy
Slide 28 : Adenoid Hypertrophy Diagnosis Nasopharyngoscopy Lateral neck radiograph Possible coronal/sagittal CT
Slide 29 : List the indications for T&A.
Slide 30 : T&A: Indications Indications for adenoidectomy: Obstruction: hyperplasia with chronic nasal congestion/mouth breathing, sleep-related disordered breathing (OSA/UARS/OHS), FTT, cor pulmonale, swallowing/speech/orofacial/dental abnormalities, lymphoproliferative disorder Infection: recurrent/chronic adenoiditis/OME, COM, chronic sinusitis Neoplasia: suspected benign/malignant neoplasia
Slide 31 : T&A: Indications Indications for tonsillectomy: Obstruction: tonsillar hypertrophy with obstruction, otherwise same as adenoidectomy Infection: recurrent/chronic tonsillitis, tonsillitis with abscessed cervical nodes/acute airway obstruction/cardiac valve disease, persistent tonsillitis with persistent sore throat/tender cervical nodes/halitosis, tonsillolithiasis, streptococcal carrier state (unresponsive to medical therapy in a child/household at risk), PTA unresponsive to medical therapy/recurrent abscess Neoplasia: same as adenoidectomy
Slide 32 :
Slide 33 : Should we screen all kids for bleeding disorders prior to tonsillectomy?What is the most common bleeding disorder?
Slide 34 : Bleeding Disorders No – only when a suspicious history is present (bleeding history in child or family) Most common bleeding disorder Thrombocytopenia Most common inherited bleeding disorders Due to defects of the Factor VIII macromolecule (1) Factor VIII:C deficient in Hemophilia A (2) Factor VIII:VW deficient in Von Willebrand’s disease Factor IX deficiency Hemophilia C
Slide 35 : Discuss the complications of T&A and how to avoid them. Discuss the surgical options for correcting complications of T&A.
Slide 36 : T&A: Complications Hemorrhage Presentation: bleeding from mouth/nose Management: local control (cautery/vasoconstriction), control in OR (topical vs. ligation/embolization), selective hematologic evaluation Avoidance: good operative technique
Slide 37 : T&A: Complications Airway obstruction Presentation: in first 4-24 hours, palatal swelling, hypopharyngeal secretions Management: Nasopharyngeal airway, steroids (IV), gentle suctioning Avoidance: intraoperative steroids, gentle intraoperative suctioning, limited use of cautery intraop
Slide 38 : T&A: Complications Dehydration Presentation: poor oral intake, dry mucous membranes, lethargy Management: control emesis if present, IV hydration, parental education, prn pain medication Avoidance: anti-emetics (intra- and post-op), IV hydration until pt is tolerating adequate po, pain control
Slide 39 : T&A: Complications Persistent VPI after adenoidectomy Presentation: hypernasal speech (lasting beyond 2 mos post-op), nasal regurgitation of fluids Management: speech therapy, palate surgery, palatal prosthesis Avoidance: evaluate for bifid uvula/submucous cleft palate, leave inferior tuft of adenoid tissue
Slide 40 : T&A: Complications Pulmonary edema after relief of airway obstruction Presentation: difficulty with oxygenation, frothy pink secretions from endotracheal tube Management: positive end expiratory ventilation, lasix, morphine Avoidance: leave inferior tuft of adenoid tissue
Slide 41 : What are the indications for Quinsy tonsillectomy?
Slide 42 : Quinsy Tonsillectomy Controversial – routinely practiced in Europe as standard management of PTA’s In the US, aspiration/I&D is accepted as standard of care for PTA, with tonsillectomy only indicted for recurrent tonsillitis/PTA
Slide 43 : How do you diagnose and manage a patient with mononucleosis?
Slide 44 : The Face of Mono
Slide 45 : Mononucleosis: Diagnosis Clinical diagnosis: fever, sore throat, swollen cervical lymphadenopathy, patient age (peak 15-19, rare >35) Laboratory tests: leukocytosis, monocytosis, (+) monospot, Paul-Bunnell heterophile antibody test Rule-out CMV, adenovirus, Toxoplasma gondii infections
Slide 46 : Mononucleosis: Management Manage symptomatically, steroids reported to help shorten course of illness Tonsillectomy indicated for life-threatening upper airway obstruction if steroids are not effective
Slide 47 : Your first case in private practice is a pediatric tonsillectomy. Your partners are surprised that you are not admitting the patient. Educate them.
Slide 48 : Rothschild, et al Ambulatory pediatric tonsillectomy and the identification of high-risk subgroups 1994 paper: retrospective chart review of pediatric tonsillectomies at Mt. Sinai between 1989-1990 statistically significant differences in time to PO intake/discharge for two high-risk subgroups: (1) children under the age of 4, (2) children with a preoperative diagnosis of OSA no post-operative bleeding
Slide 49 : Current “High Risk” Admission Guidelines OSA craniofacial syndromes involving the airway vomiting/hemorrhage younger than age 3 live >60 minutes from hospital socioeconomic environment with inadvertent neglect that may lead to complications other medical problems that may lead to complications if not closely managed
Slide 50 : You suspect OSA in a pediatric patient. Describe the most common presenting symptom in pediatric OSA. When should you order a sleep study in children?
Slide 51 : Pediatric OSA Pediatric OSA Syndrome more than one event per hour with O2 saturation below 92% Most common presenting symptom: snoring, accompanied by sleep disruption, increased work of breathing, apneas/hypopneas Sleep study, or multichannel polysomnography, is indicated for children in whom the diagnosis is unclear or if there is an unusual risk for surgery
Slide 52 : Potsic Assessment and Treatment of Adenotonsillar Hypertrophy in Children in addition to snoring and irregular respiratory patterns while sleeping, patients may Have chronic (purulent) rhinorrhea due to chronic NP obstruction prefer soft foods chew with their mouths open slow/picky eaters, reduced appetite occasional choking may be FTT poor oral hygiene changes in craniofacial development
Slide 53 : Potsic Assessment and Treatment of Adenotonsillar Hypertrophy in Children PSG = most complete way to characterize obstruction/OSA, central vs. obstructive; obtain only in children with severe apneas only to confirm diagnosis
Slide 54 : Compare and contrast pediatric vs. adult OSA.
Slide 55 : Pediatric vs. Adult OSA
Slide 56 : On the first day of your pediatric fellowship, you get to perform a T&A with your director. He wants to know your thoughts on peri-operative drugs.
Slide 57 : April, et al The effect of intravenous dexamethasone in pediatric adenotonsillectomy Preop IV dexamethasone (1 mg/kg up to 16 mg for electrocautery tonsillectomy): increased po intake, less trismus/vomiting/fever Decreased morbidity without significant increase in risk
Slide 58 : The End

 


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