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Introduction

بيماريهاي لوزه، آدنوئيد و درمانهاي آن Tonsillectomy & Adenoidectomy Dr.S Sohelipour Dr.SHR Abtahi. Introduction. In 1994 140,000 U.S. children under the age of 15 had adenoidectomies and 286,000 had adenotonsillectomies This is down from a peak of over 1 million in the 1970’s

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Introduction

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  1. بيماريهاي لوزه، آدنوئيد و درمانهاي آن Tonsillectomy & AdenoidectomyDr.SSohelipourDr.SHRAbtahi

  2. Introduction • In 1994 140,000 U.S. children under the age of 15 had adenoidectomies and 286,000 had adenotonsillectomies • This is down from a peak of over 1 million in the 1970’s • These are the most common major surgical procedures in children.

  3. Anatomy Tonsils • Plicatriangularis • Gerlach’s tonsil Adenoids • Fossa of Rosenmüller • Passavant’s ridge

  4. Blood Supply Tonsils • Ascending and descending palatine arteries • Tonsillar artery • 1% aberrant ICA just deep to superior constrictor Adenoids • Ascending pharyngeal, sphenopalatine arteries

  5. Histology Tonsils • Specialized squamous • Extrafollicular • Mantle zone • Germinal center Adenoids • Ciliated pseudostratified columnar • Stratified squamous • Transitional

  6. Common Diseases of the Tonsils and Adenoids • Acute adenoiditis/tonsillitis • Recurrent/chronic adenoiditis/tonsillitis • Obstructive hyperplasia • Malignancy

  7. Acute Adenotonsillitis Etiology • 5-30% bacterial; of these 39% are beta-lactamase-producing (BLPO) • Anaerobic BLPO GABHS most important pathogen because of potential sequelae • Throat culture

  8. Microbiology of Adenotonsillitis Most common organisms cultured from patients with chronic tonsillar disease (recurrent/chronic infection, hyperplasia): • Streptococcus pyogenes (Group A beta-hemolytic streptococcus) • H.influenza • S. aureus • Streptococcus pneumoniae

  9. Acute Adenotonsillitis Differential diagnosis Infectious mononucleosisMalignancy: lymphoma, leukemia, carcinomaDiptheriaScarlet feverAgranulocytosis

  10. Medical Management • PCN is first line, even if throat culture is negative for GABHS • For acute UAO: NP airway, steroids, IV abx, and tonsillectomy for poor response • Recurrent tonsillitis: PCN injection if concerned about noncompliance or antibiotics aimed against BLPO and anaerobes • For chronic tonsillitis or obstruction, antibiotics directed against BLPO and anaerobes for 3-6 weeks will eliminate need for surgery in 17%

  11. Obstructive Hyperplasia • Adenotonsillar hypertrophy most common cause of SDB in children • Diagnosis • Indications for polysomnography • Interpretation of polysomnography • Perioperative considerations

  12. Unilateral Tonsillar Enlargement Apparent enlargement vs true enlargement Non-neoplastic: • Acute infective • Chronic infective • Hypertrophy • Congenital Neoplastic

  13. Peritonsillar Abscess

  14. ICA Aneurysm

  15. Pleomorphic Adenoma

  16. Other Tonsillar Pathology • Hyperkeratosis, mycosis leptothrica • Tonsilloliths

  17. Candidiasis

  18. Syphilis

  19. Retention Cysts

  20. Supratonsillar Cleft

  21. Indications for Tonsillectomy AAO-HNS: • 4 or more episodes/year • Hypertrophy causing malocclusion, UAO • PTA unresponsive to nonsurgical mgmt • Halitosis, not responsive to medical therapy • UTE, suspicious for malignancy • Individual considerations

  22. Indications for Adenoidectomy Obstruction: • Chronic nasal obstruction or obligate mouth breathing • OSA with FTT, cor pulmonale • Dysphagia • Speech problems • Severe orofacial/dental abnormalities Infection: • Recurrent/chronic adenoiditis (4 or more episodes/year) • Recurrent/chronic OME

  23. PreOp Evaluation ofAdenoid Disease • Triad of hyponasality, snoring, and mouth breathing • Rhinorrhea, nocturnal cough, post nasal drip • “Adenoid facies” • “Milkman” & “Micky Mouse” • Overbite, long face, crowded incisors

  24. PreOp Evaluation of Adenoid Disease Differential diagnoses • Allergic rhinitis • Sinusitis • GERD • For concomitant sinus disease, treat adenoids first

  25. PreOp Evaluation of Adenoid Disease Evaluate palate • Symptoms/FH of CP or VPI • Midline diastases of muscles, bifid uvula • CNS or neuromuscular disease • Preexisting speech disorder?

  26. PreOp 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 patientcooperation.

  27. PreOp Evaluation of Adenoid Disease

  28. PreOp Evaluation of Tonsillar Disease History • Documentation of episodes by physician • FTT • Cor pulmonale • Poststreptococcal GN • Rheumatic fever

  29. PreOp Evaluation of Tonsillar Disease TONSIL SIZE • 0 in fossa • +1 <25% occupation of oropharynx • +2 25-50% • +3 50-75% • +4 >75% Avoid gagging the patient

  30. Complications 0.1-8.1% Postoperative bleeding Other: • Sore throat, otalgia, uvular swelling • Respiratory compromise • Dehydration • Burns and iatrogenic trauma

  31. Rare Complications • Velopharyngeal Insufficiency • Nasopharyngeal stenosis • Atlantoaxial subluxation/ Grisel’s syndrome • Regrowth • Eustachian tube injury • Depression • Laceration of ICA/ pseudoaneursym of ICA

  32. Questions?

  33. DEFINITION • Adenoid =pharyngeal tonsil = Nasopharyngeal • Mass of sub – epithelial lympoid tissue situated posterior to the nasal cavity in the roof of the nasopharynx • In children it forms a soft mound in the roof and posterior wall of the nasopharynx, above and behind the uvula. • Age – enlargement from less than a year old to 12 years.

  34. HISTOLOGY OF ADENOID • Unlike other types of tonsils. • Has pseudostratified columnar ciliated epithelium. • Lack crypts (opening or outlet) but has a capsule • It drains to the jugulodigastric lymph nodes below the angle of the mandible.

  35. IMPORTANCE OF ADENOID AND TONSILLAR TISSUE. • Part of lymphoid tissue of Waldeyer’s ring • Its size increases progressively until puberty, then diminishes until about the age of 20 years and from this time onwards, maintains its adult size.

  36. Protective Functions • Formation of lymphocytes • Formation of antibodies • Acquisition of immunity • Localization of infection – “filters” to the upper respiratory passages.

  37. PATHOLOGY • An enlarged adenoid or adenoid hypertrophy, can become nearly the size of a ping pong ball. • Completely block airflow through the nasal passages or block the back of the nose. • Breathing through the nose requiring an uncomfortable amount of work. • Inhalation occurs instead through an open mouth. • Affects voice mechanism (speech hyponasality) • Recurrent upper respiratory tract infection.

  38. CLINICAL FEATURES OF ADENOID FACES IN CHILDREN. • It causes an atypical appearance of the face (adenoid face) • Features of adenoid faces include • Mouth breathing • Elongated face • Prominent incisors • Hypoplastic maxilla • Short upper lip • Elevated nostril • High Arched palate

  39. TONSILLITIS & ADENOID

  40. Symptoms • Bilateral NasalObstruction • Mouth Breathing • Snoring & OSA • Speech hyponasality • Difficult suckling • Bilateral Nasal discharge • Mucoid or mucopurulent discharge WHY? Due to blockage of the choanae • Excoriation of the nasal vestibule & upper lip • Post nasal discharge causing frequent nocturnal cough Rhinolalia clausa (speech hyponasality)

  41. Signs • Posterior Rhinoscopy difficult • Digital palpation not pleasant • Endoscopic examination the best

  42. Investigations • Lateral soft tisue X ray of the nasopharynx It is not the size of the nasopharyngeal tonsil which is important but the size of the mass in relation to the nasopharyngeal space

  43. Complications Restless sleep, Night mare, Nocturnal eneuresis 1- OSAS: • During Sleep: • During day time 2- Descending infection 3-ِ Adenoid Facies Morning headache Impaired concentration Excessive day-time sleepiness Recurrent OM Pharyngitis, Laryngitis, bronchitis Idiot look Pinched nostril Short upper lip Prominent incisor High arched palate

  44. Removal • Adenoidectomy – procedure of surgical removal of the adenoid • Studies have shown that adenoid regrowth occurs in as many as 20% of the cases after removal. Why? • Adenoid tissue is not encompassed by a capsule like the tonsils. Complete removal of all adenoid tissue is nearly impossible and thus recurrent hypertrophy or infection is possible.

  45. Indications for Adenoidectomy Paradise study (1984) • 28-35% fewer acute episodes of OM with adenoidectomy in kids with previous tube placement • Adenoidectomy or T & A not indicated in children with recurrent OM who had not undergone previous tube placement Gates et al (1994) • Recommend adenoidectomy with M & T as the initial surgical treatment for children with MEE > 90 days and CHL > 20 dB

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