Chapter 96 Tonsillectomy with/without Adenoidectomy
PATHOPHYSIOLOGY
A tonsillectomy with and a tonsillectomy without an adenoidectomy are considered two of the most frequent major surgical procedures among children today in the United States, second only to myringotomy with tube insertion. In the past, adenotonsillectomy (T and A) was performed by general surgeons. Today, because of surgical specialization related to ear, nose, and throat (ENT) disorders, the T and A procedures are primarily performed by otolaryngologists.
In the twentieth century, the tonsillectomy was performed because of infectious etiologies. Today the tonsillectomy is primarily performed because of tonsillar hyperplasia causing sleep apnea related to airway obstruction, and cardiopulmonary complications such as failure to thrive, tonsillitis resulting in febrile seizures, developmental delays, learning and behavior disorders, and chronic infection syndromes. The adenoidectomy is performed because of chronic throat infections, otitis media, dental abnormalities, snoring, speech delays, and perceptions of low intelligence. Continued clinical trials and attitudes demonstrate through clinical experience and treatment modalities the efficacy of the T and A.
The tonsils and adenoids are a group of lymphoid tissue called Waldeyer’s ring in the oral cavity and the nasopharynx; they begin growth in the third month of fetal development. The term tonsil typically refers to the palatine tonsil, which is located on both sides of the pharynx and bound anteriorly by the palatopharyngeus muscle (anterior tonsillar pillar) and posteriorly by the palatopharyngeus muscle (posterior tonsillar pillar). The palatine tonsils form the lateral aspects of Waldeyer’s ring. The lingual tonsil is located at the base of the tongue and forms the inferior aspect of Waldeyer’s ring.
The tonsils and adenoids are considered part of the immune system and primarily induce secretory immunity and regulate the production of secretory immunoglobulins. Their anatomic positioning provides a primary defense against foreign matter. The lymphoid defenses of Waldeyer’s ring are most immunologically active between the ages of 4 to 10 years and decrease in efficiency after puberty. No major immunologic deficiency has been noted after either a tonsillectomy or an adenoidectomy.
Acute inflammation, intermittent or endemic, of the lymphatic tissue of the pharynx involves the palatine or facial tonsils. Inflammation is primarily due to infection by group A beta-hemolytic streptococci found in school-aged children and can cause sequelae such as rheumatic fever, carditis, or nephritis. Other responsible infectious organisms include Epstein-Barr virus, Staphylococcus species (in particular, S. aureus), Streptococcus pyogenes, Haemophilus influenzae, Moraxella catarrhalis, and Streptococcus pneumoniae and are identified by throat culture and/or serology testing. However, the etiology of the condition is largely irrelevant in determining whether a tonsillectomy is indicated.
INCIDENCE
1. Approximately 67% of children with sinus disease and failed medical therapy respond well to an adenoidectomy alone.
2. The prevalence of obstructive sleep apnea in pre–school-aged children is approximately 1% to 3% and is related to the increased size of the adenoids and the tonsils compared with the child’s airway.
3. Adenotonsillectomy is the first-line treatment for obstructive sleep apnea, and the cure rate runs between 75% and 100%.
4. Adenotonsillectomy is considered a generally safe procedure; it has a reported mortality rate of up to 1 in 16,000.
CLINICAL MANIFESTATIONS
Preceding Tonsillectomy
Children who manifest abnormalities of the tonsils typically have problems related to obstruction, infection, or malignancy. The following are general manifestations.
General Malaise
COMPLICATIONS
The most vulnerable group appears to be children under the age of 3 years associated with the following:
1. Cardiorespiratory: respiratory compromise related to a narrow oropharynx, potential for circulatory collapse, airway obstruction due to general edema or pulmonary edema, hematoma formation, or central apnea
2. Oral cavity: aspiration, severe pain causing reduced oral intake, difficulty swallowing, bleeding leading to increased hospital stays, nasal pharyngeal stenosis, velopharyngeal insufficiency (characterized by hypernasal speech and regurgitation of fluids through the nasal cavity)
3. Fluid and electrolyte balance: dehydration and facial edema
4. Muscular: refractory torticollis, Grissel’s syndrome (a result of laxity, infection, or possible positioning of the transverse ligament of the axial vertebral body)
5. Hematologic: hemorrhage—complication that is most feared by physicians, patients, and parents; defined in two ways: primary—occurs in the first 24 hours, and secondary—which can occur 24 hours thereafter
7. Psychologic: Emotional trauma
8. Eagle’s syndrome—can occur when the elongated styloid process is in contact with the tonsillar fossa. Once the tonsils are removed postoperative edema and inflammation can cause scarring around the process, leading to chronic pain syndrome
9. Anesthesia risks: malignant hyperthermia, cardiac arrhythmias, vocal cord trauma, aspiration resulting in bronchopulmonary obstruction and/or infection; residual anesthesia causing potential hypothermia, hypoxemia, acid-base imbalance, hypocarbia, hypercarbia, and hypovolemia, and prolonged muscular paralysis
10. Velopharyngeal insufficiency—complication of adenoidectomy, characterized by hypernasal speech and regurgitation of fluids through the nasal cavity
LABORATORY AND DIAGNOSTIC TESTING
1. Throat culture—to identify causative agent(s)
2. Complete blood count (CBC)—to identify anemia or platelet abnormalities
3. Chemistry panel—performed as general baseline panel suggested by American Academy of Otolaryngology (AAO)
4. Coagulation studies—these tests include bleeding time, prothrombin time, and/or partial thrombin time—to investigate suspected coagulation disorders (basic coagulation panel recommended by the AAO)
