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)
5. Urinalysis—to determine baseline kidney function
6. Pregnancy screening—performed for menstruating females
7. Full-night polysomnography (PSG)—to diagnose severe obstructive sleep apnea; this diagnostic test is expensive and use of it is limited owing to availability and access to sleep laboratory
MEDICAL AND SURGICAL MANAGEMENT
Preoperative screening and evaluation procedures are used to eliminate risks factors based on diagnosis, type of procedure required or available, preexistent medical problems, family history, and potential anesthesia risks, and to complete a physical examination.
According to the AAO—Head and Neck Surgery, “Children with three or more infections of the tonsils or adenoids per year despite adequate medical therapy are candidates for tonsillectomy.” Tonsil infections are typically identified by the following criteria: dysphagia, fever >101° F, cervical adenopathy, positive group A beta-hemolytic streptococci culture, and tonsil exudates. Children considered candidates for tonsillectomy are those who have adenotonsillar hypertrophy related to obstructive sleep apnea, tonsil hyperplasia, and peritonsillar abscess unresponsive to medical management, symptomatic infectious mononucleosis, or tonsillitis resulting in febrile seizures. Tonsillectomy is indicated for children with inherited or immunodeficiency diseases such as acquired immunodeficiency syndrome (AIDS), X-linked lymphoproliferative disorder, posttransplant immunosuppression, and various lymphomas related to significant airway obstruction from adenotonsillar hyperplasia that occur in a large number of individuals infected with the Epstein-Barr virus.
Children are also considered candidates for adenoidectomy who have chronic or persistent otitis media (typically children 4 years old or younger); sinusitis, either recurrent or chronic; speech problems; or severe orofacial or dental abnormalities from adenoid hyperplasia, chronic otitis media, or suspected neoplasia.
There are a variety of effective and safe techniques available for the tonsillectomy and adenoidectomy procedures (Box 96-1). Surgical techniques are based on postoperative criteria such as pain and return to normal diet and activity, preoperative and postoperative hemorrhage, operating room time, and cost. Children who have tonsillectomies and adenoidectomies require intensive postanesthesia care associated with the potential for organ system dysfunction. Airway obstruction focus is on respiratory, circulatory, or neurologic compromise, and can result from surgical manipulation and/or bleeding.
Box 96-1 Surgical Techniques for Tonsillectomy and Adenoidectomy
1. Traditional cold-knife (steel) dissection—Involves the removal of the tonsils by the use of a scalpel. The tonsils are completely removed with minimal postoperative bleeding.
2. Electrocautery—Electrocautery burns the tonsillar tissue and thus assists in the reduction of postoperative blood loss. Research has found the heat of the electrocautery (400° C) can result in thermal injury to the adjacent tissues. This may result in increased postoperative pain. Currently this is the most popular technique to decrease intraoperative time and blood loss.
3. CO2 or potassium titanyl phosphate (KTP) laser-assisted surgical procedures—Tonsils are removed using laser. Studies have demonstrated less postoperative pain, decreased healing time, less blood loss, and shorter intraoperative time using the CO2 or KTP laser.
4. Harmonic scalpel dissection—The ultrasonic technology is used to cut and coagulate at lower temperatures than with electrocautery. Energy is created by vibratory rather than electrical current. Studies have found significant improvements in pain management.
5. Tonsillar ablation and coblation—This technique uses a combination of radio frequency energy and a electrolyte solution to create a plasma field to liquefy or excise the tonsils at low temperatures (between 40° to 70° C), thereby preserving the integrity of the healthy tissue adjacent to the tonsils.
6. Intracapsular power-assisted partial tonsillectomy—Studies have shown that if the tonsil capsule is left intact, the underlying pharyngeal musculature is undisturbed and isolated from secretions; however, tonsil regrowth is a potential side effect. Chronic tonsillitis is a contraindication for this technique. Less postoperative pain and speedier recovery is associated with the use of this procedure.
Tonsillectomy or adenoidectomy is contraindicated in children who are at risk for anesthesia-related complications owing to uncontrolled medical illness. Other contraindications can include anemia, high fever, severe bleeding disorder, velopharyngeal insufficiency, and children with Down syndrome who have atlantoaxial laxity.
Postoperative pain and nausea are common following a tonsillectomy. Currently, some physicians are using local anesthetics to reduce postoperative pain and intraoperative and/or postoperative dexamethasone to reduce surgical site edema or respiratory compromise, and also as an antiemetic. Adjuvant antibiotic therapy has been shown to decrease inflammation of pharyngeal tissues following a tonsillectomy due to bacterial colonization. In addition, the benefits can include pain reduction, increased oral intake and, possibly, reduced postoperative bleeding.
NURSING ASSESSMENT
1. Obtain baseline health assessment including vital signs.
4. Ensure that necessary preoperative laboratory testing and imaging has been conducted.
5. Ensure child’s nothing-by-mouth (NPO) status.
6. Assess child’s and parents’ understanding of the surgical procedure and sequence of recovery events.
NURSING INTERVENTIONS
Preoperative Care
1. Encourage parents to communicate their concerns over surgical procedures, risks and benefits, and age-related anesthesia risks.
2. Carry out psychologic preparation for both the child and the family (refer to Appendix F). Preparation techniques include interactive books, Internet visits to associated facilities, and interventions by child-life specialists who facilitate preoperative visits to the hospital and offer interactive play focusing on the surgical procedure (see specific facility for availability of presurgical visits or online interactive modalities).
3. Inform parents of fasting requirements, based on the specific facility or anesthesia criteria. Typically most facilities require NPO status after midnight the night before surgery for children over the age of 2 years.
4. Inform parents of the registration process before the day of surgery to decrease anxiety and facilitate intake procedures (required insurance cards and driver’s license or picture identification for all children must be available). In the case of adoption or temporary custody, court-approved papers must be available.
5. Inform parents of the preoperative, postoperative, and discharge course to reduce anxiety and instill confidence in associated health care providers.
Postoperative Recovery Care
1. Conduct initial patient assessment according to diagnosis, surgical procedure, intraoperative status, and patient history. Patient assessment, level of consciousness, and vital signs are taken every 15 minutes.
3. Elevate head of bed 45 degrees or place child in tonsillar position (on side with face down).
4. Encourage child to expectorate secretions and to limit coughing, clearing the throat, blowing the nose, or talking excessively.
5. Monitor fluid and electrolyte balance.
6. Use pharmacologic and nonpharmacologic interventions (see Appendix I).
7. Apply ice collar (if tolerated, to decrease pain and swelling to surgical site).
8. Administer and monitor child’s response to antiemetics for nausea and vomiting.
9. Transfer child to the pediatric unit or outpatient unit to be monitored and discharged according to surgeon and anesthesia discharge criteria.
Discharge Planning and Home Care
1. Inform parents both verbally and with postoperative, written instructions that follow-up care with the surgeon should be 5 to 10 days postoperatively unless otherwise indicated by physician.
2. Inform parents that 7 to 11 days postoperatively scabs begin to slough from surgical site, and parents may see minimal bleeding. If bleeding continues or if blood is bright red, they are to notify their physician immediately (in the case of tonsillectomy).
3. Inform parents that after a tonsillectomy, a white shaggy eschar forms in the tonsillar fossae (surgical site of tonsils) that may last from 3 to 4 weeks.
4. Children who have persistent pain, fever of 101° F or greater, bleeding, inability to take oral fluids, and signs of dehydration (i.e., pallor, lethargy, rapid pulse rate) should be evaluated by a physician.
5. Inform parents with children at risk for velopharyngeal insufficiency (see section in this chapter on Complications following a tonsillectomy and/or adenoidectomy) that they must use caution with feedings and be aware of the signs and symptoms: hypernasal speech and regurgitation of fluids through nasal cavity. This is rare following a tonsillectomy.
6. Teach about tonsillectomy diet—soft foods, puddings, eggs, noodles, ice cream, and so on, to minimize pain and risk of bleeding. Diet’s duration varies from several days to 2 weeks or more.
7. Teach about adenoidectomy diet—soft to regular as tolerated.
8. Inform parents that oral fluid intake (hydration) is essential to prevent the vicious cycle of poor fluid intake, dehydration, and throat pain. Fluids include water, apple juice, Gatorade, Popsicles. Avoid citrus juices, since they may cause operative site pain; colas and other red liquids may be mistaken for blood.
9. Review pain management—oral acetaminophen with/without codeine, Vicodin, and/or physician preference, in keeping with any history of allergies and sensitivities.
10. Review nonpharmacologic pain management therapeutic modalities such as deep breathing and diversional activities such as TV, drawing, assisting with care, and puzzles.
11. Antibiotics are usually prescribed (amoxicillin for 7 to 10 days unless contraindicated related to allergies, history, or physician preference).
12. Teach about ear drops—as indicated per physician (adenoidectomy).
13. Recommended activity level is light; no active sports should be played for 2 weeks.
14. Inform parents that children after tonsillectomies have sore throats, halitosis, otalgia.
15. Provide parents with physician name and number for follow-up and/or emergencies.
CLIENT OUTCOMES
1. Child will have reduction in frequency or elimination of ear, nose, and throat infections.
2. Child’s pain will be reduced and eventually alleviated.
3. Child will have fewer school absences and improved school performance.
4. Child will have fewer physician visits and sick days.
5. Child will experience good sleep at night.
6. Child will experience sense of mastery related to the surgical experience.
7. Child’s daily activities will return to those typical for age.
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