Literature Reading

Tonsillitis, Tonsillectomy, And

Adenoidectomy

Darmastuti

Bekti

Department of Otolaryngology - Head & Neck Surgery

Faculty of Medicine Padjadjaran University
Hasan Sadikin General Hospital

Introduction

Brodsky, L Poje, C. Tonsillitis, Tonsillectomy and Adenoidectomy. In Head and Neck Surgery Otolaryngology. 5 th ed.
Editor: Bailey B.J. & Johnson T.J. Volume one. Lippincot Williams & Wilkins. Philadelphia, 2006. p. 1184 - 99

DEFINITION
TONSILITIS
TONSILEKTOMI
TONSILOADENOIDEKTOMI

ANATOMY
PHARYN
X

Keith L. Moore. Clinically Oriented Anatomy

5th ed., 2006. p.953

ANATOMY
PHARYN
X
Posterior View

Keith L. Moore. Clinically Oriented Anatomy

5th ed., 2006. p.953

WALDEYER RINGS

1. Adenoid (pharyngeal)
2. Tonsil lingualis
3. Tonsil palatina
4. Lateral faringeal band
5. Pharyngeal
Granulation
6. Tubal Tonsil
(Gerlach)
7. Ventricel lat lymphoid
tissue
6

ADENOIDS
Adenoid
( pharyngeal
tonsils)
Triangular mass of
lymphoid on the
posterior aspect of
the boxlike
nasopharynx
Formed during the
3rd to 7th months of
embryogenesis

 Adenoid have 3 types

epithelium

Ciliated pseudostratified
columnar, squamous,
Blood
is supplied to the adenoids
trantitional
via the pharyngeal branches of the
Stratified
squamous
external
carotid artery;
some minor
branches
contribute from the
Transitional
internal maxillary and facial
arteries.

Sensory innervation is received from

both the glossopharyngeal and
vagus nerves.
8

LINGUAL TONSILS

Uncapsulated
Most recent
development
adult.
Superficial crypte
Detritus
Probst,
R,
et
al.
Basic
Otorhinolaryngology, A Step-by-Step
Learning Guide, Thieme, 2006. p. 98

10

PALATINE TONSILS

Growth of the head & neck

after 5 weeks of
pregnancy.
Anterior and posterior
tonsillar pillar
arcus
brachialis 2 and 3.
Crypta
third until
sixth months of pregnancy
Tonsillar capsul
from
5 months of pregnancy.

11

PALATINE TONSILS
Palatine Tonsils :
Lateral wall of the
oropharynx
Fossa tonsilaris
oval.
Anterior : Pillar
anterior
Posterior : Pillar
posterior
Lateral
: M.
constrictor pharyngeus
superior
Composition
Lymphoid tissue.

Bull, RT. Color Atlas of ENT Diagnosis,4th ed. 2003. p. 196

12

PALATINE TONSILS

1. Squamous epithelium
2. Reticular epithelium
3. Secondary nodes with zones of light
and dark zones containing small
lymphocytes
4. Lymphoid tissue base
5. Arterioles and venules
6. Postkapiler vein

a) Adenoid s
b) Palatine Tonsils
1) Lacuna 2)Crypt 3) Abscess

Becker, W. Naumann, HH. Pfalttz, RC. Ear,

Nose and Throat Disease. A Pocket
Reference, 2nd ed, Thieme, 1994. p. 31224, 344-61.

13

Arteries of The Tonsils

Ascending palatine artery facialis

artery postero inferior
Tonsilar artery facialis artery
antero inferior
Dorsal lingual artery maksilaris
interna antero media
Ascending pharyngeal artery
external carotid artery postero
superior
Palatine mayor & minor artery
descendens palatine artery
anterosuperior

14

Tonsilar branch of Lingual veins- the main

drainase system of the tonsillar veins.
Tonsilar accesoria veins plexus pharyngealis
Peritonsilar veins superior of tonsillar bed.
Main bleeding source after tonsillectomy.

1 Lingual veins
Internal Jugular Veins

2, 3 Plexus pharyngealis

15

Lymphatic Drainage Of The Tonsil

stream of Limfe of tonsil
parenkim
eferen limfe in trabecula
gland of servikalis profunda
chest area limfaticus nodulus
thorasikus duktus
(No Afferent lymphatic)

16

PALATINE TONSILS

Nerves of the
tonsil :

N IX
(Glossopharyngeal)
the main nerve.
Descenden branch of
N. palatine.

17

Anatomic and Physiologic

Differences Between The
Adenoids and Tonsils

Brodsky, L. Poje, C. Tonsilitis, Tonsillectomyand Adenoidectomy. In Head and Neck Surgery-Otolaryngology, 5 th ed.
Bailey, vol. I, 2006. p. 1184

18

IMMUNOLOGY
The immunology of the tonsils and
adenoids is a complex.
The tonsils and adenoids involved in
both local immunity and in immune
surveillance for the development of the
bodys immunologic defense system.

Antigen
-Bacteria
- Virus
-Food
- Irritans

increase in
the serum
immunoglob
ulin levels

Activati
on B
and T cell

production of
local abd
systemic
antibody,

Interleukin

19

FUNCTIONS OF TONSIL
Tonsils have two main functions:

1) capture and effectively collect foreign

material
2) as the main organ of the production of
antibodies and sensitized cells with
antigen specific T lymphocytes

20

FUNCTIONS OF TONSIL
PHYSIOLOGY TONSILS
Plays an important role in early life
against mucosal infection
Plays a role in the production of IgA
Developed after maternal antibodies
depleted, involution after puberty

21

FUNCTIONS OF TONSIL
Defense mechanisms
a. Non-specific defense
Destroy the mucosal lining of the tonsil
m.o
Germs mu cosal lining of phagocytic
cells (elements tonsils) opsonization
phagosome digestion and kill bacteria

22

FUNCTIONS OF TONSIL
b. Specific defense
Tonsils IgA production jar of local
resistance against pathogenic organisms
Tonsil and adenoid tissue cells IgE
basophils & mastosit
Allergens react with IgE cell surface
membrane processes stimulated
degranulation (histamine + rx.
Hypersensitivity type I)
Mechanism of IgA prevent substance
entered immunological processe

23

Pathogenesis of
Adenotonsillar
Disease
Mechanism of the initiation
The
pathogenesis influenced
of chronic disease :
by:

Has its basis in their anatomic

location
Their inherent function as
organs of immunity
Processing infectious material
& other antigens
Paradoxically becoming focus
infection/inflammation

Viral infection with

secondary bacterial
invasion
Environment
Host factors
Widespread use of
antibiotics
Ecological consideration
Diet

23

MICROBIOLOGY

24

Brodsky, L. Poje, C. Tonsilitis, Tonsillectomy

and Adenoidectomy. In Head and Neck SurgeryOtolaryngology, 5th ed. Bailey, vol. I, 2006. p. 1186

Brodsky, L Poje, C. Tonsillitis, Tonsillectomy and Adenoidectomy. In Head and Neck Surgery Otolaryngology. 5 th ed.
Editor: Bailey B.J. & Johnson T.J. Volume one. Lippincot Williams & Wilkins. Philadelphia, 2006. p. 1184 - 99

26

ADENOIDS
Acute Adenoiditis
Difficult to differentiate from a generalized virally
induce URI or a true bacterial rhinosinusitis.
Clinical Signs :
Purulent rhinorrhea
Nasal obstruction
Fever
Otitis media
Loud snoring

27

Recurrent Acute Adenoiditis

Presence of four or greater discrete episodes
of acute adenoiditis during of a 6-month
period

Treatment :
Antimicrobial prophylaxis
asymptomatic between
infection, especially if
comorbidity occurs (reactive
airway disease, recurrent otitis)
daily low dose (one half to
one third the full dose)
episodic prophylaxis (short
course of AB with the onset
of URI)

Differential Diagnosis
:
Recurrent acute sinusitis
Extraesophageal reflux
(EER)-induced
adenoiditis

28

Chronic Adenoiditis
Often associated with chronic sinusitis and otitis media.
Clinical Signs :
Persistent nasal discharge,
malodorous breath,
postnasal drip, and
chronic congestion

- The role of EER as contributory to chronic adenoid

inflammation, especially in younger children.
- Although initially adenoidectomy may be chosen for
treatment of adenoiditis and/or sinusitis, prognosis for
improvement after the surgery could differ
significantly (unpublished data).

Obstructive Adenoid
Hyperplasia
-Etiology :
Enlarge adenoids
Nasopharyngeal obstruction

-The triad of
symptoms :
chronic nasal obstruction
(associated with snoring
and obligate mouth
breathing),
rhinorrhea, and
a hyponasal voice.
29

TONSILS
Acute Tonsillitis
Etiology : GABHS, pneumococcus,

staphylococcus, haemophyllus influenza,

and Epstein-Barr virus.

Pathology : Hyperplasia and inflammasi

sellular tissue, leukosit, debris and
bacteria patogen at the crypta.

Clinical Signs : Sore throat, dysphagia, weakness, fever, tender cervical nodes
in the presence of tonsil that are erymatous and have exudates, mallodorous
breath, otalgia.
Physical examination : Hypertrophi and inflamasi, white eksudat, obstruction
of airway and muffle sign.
Diagnosis : Throat culture or rapid strep antigen test for GABHS.
Therapy : bedrest, hydration, diet, Analgetik and Antibiotik.

31

Recurrent Acute Tonsillitis

Recurrent acute infection has been variably
defined as :
1. Four to seven episodes of acute tonsillitis in
one year
2. Five episodes for two consecutive years
3. Three episodes per year for 3 consecutive
years

Chronic Persistent
Tonsillitis
Clinical Signs :
Chronic sore throat, malodorous breath, excessive tonsillar
debris (tonsilloliths), peritonsillar erythema, and persistent,
tender cervical adenopathy, foreign body sensation.
Physical Examination :
Hypertrophi
Cicatric of the tonsil
Stenosis of the crypta
Purulent exudat
Therapy :
Hydration, Antibiotik and Tonsillectomy
32

33

Obstructive Tonsillar Hyperplasia

Clinical Signs : Snoring with obstructive disturbances (asleep and

awake), dysphagia, voice changes (muffling or hyponasality),
change behaviour and emotion
Physical examination : Hyperplasia tonsil with healthy crypta
Therapy :
Paliatif, Preventif and Tonsillectomy

Bull, RT. Colot Atlas of ENT Diagnosis.

4th ed., Thieme, 2003. p. 196-210

34

Clinical Evaluation
ADENOID
History
*
*
*
*
*
*

rhinorrhea
chronic cough
postnasal drip
obligate mouth breathing
snoring
hyponasal speech

Physical Examination
open mouth appearance
flattened mid face dark circles under
the eye
classic adenoid facies

Assessed Nasality Speech

* emphasize nasal emission
milkman or mickey mouse
* pinch the nose during a
nasality transmitted phrase
* anterior and posterior
rhinoscopy
* direct flexible fiberoptic
nasopharyngoscopy (>> 3.5
y.o)
abnormalities in the
maxillary- mandibular
relationship
* palate evaluation

35

Classic Adenoid Facies

Adenoid
Hyperplasia
Probst,
R,

et
al.
Basic
Otorhinolaryngology, A Step-by-Step
Learning Guide, Thieme, 2006. p. 98

36

Clinical Evaluation
TONSILS
History
sore throat
Dysphagia, fever
tender cervical adenopathy
erythematous tonsils with or without
enlargement
exudated tonsils
crypts will reveal inspissated
obstructed material
loud snoring
nocturnal choking & coughing
frequent awakening w/ restless sleep
daytime hypersomnolence
behavioral changes
failure to thrive
cor pulmonale
congestive heart failure

Children at particularly risk for the

development of obstructive
disturbances secondary to tonsillar
hyperplasia :
Craniofacial anomalies
Down syndrome
Neuromuscular or
CNS abnormalities

Ancillary test :
multichannel
polysomnography (PSG)
measures the peak end tidal
CO2
audiotape/videotape of the
childs sleep recorder.

Physical
Examination

Classification system for tonsil size

37

38

MANAGEMENT OF DISEASES OF
THE ADENOIDS AND TONSILS
ADENOID

Antimicrobial effective against -lactamase-producing m.o

: recurrent / chronic adenoiditis
Intra nasal steroid (6-to-8 weeks) : adenoid hyperplasia
Surgical techniques : mirror visualization of the
nasopharynx and removal of the tissue with sharp curette,
adenotome, powered microdebrider, or with cauter
Hemostasis : Intraoperative packing, application of
bismuth subgalleate, electrocoagulation of adenois bed

Complications
Nasopharyngeal
stenosis
Bleeding
Torticollis
C-spine luxation
(rare)

39

40

Management
Obstruction
Adenoid hyperplasia with chronic nasal
obstruction or
obligate mouth breathing
Sleep-related disordered breathing
Obstructive sleep apnea syndrome
Upper airway resistance syndrome
Obstructive hypoventilation
syndrome
Failure to thrive
Cor pulmonale
Swallowing abnormalities
Speech abnormalities
Orofacial/dental abnormalities
Lymphoproliferative disorder
Infection
Recurrent/chronic adenoiditis
Recurrent/chronic otitis media with
effusion
Chronic otitis media
Chronic sinusitis
Neoplasia
Suspected neoplasia, benign or
malignant

Indication of
Adenoidecto
my

Brodsky, L. Poje, C. Tonsilitis,

Tonsillectomy and
Adenoidectomy. In Head and
Neck Surgery-Otolaryngology, 5th
ed. Bailey, vol. I, 2006. p. 1188

Technique of Adenoidectomy
1. Curetase adenoidectomy
- Prepare of curetase
- Curetase
- Examination
a. Adenoidectomy with head
extension position
b. Beckmanns ring curette

41

Technique of
Adenoidectomy
2.

42

Adenoidectomy with endoscopy

Helal, Z. 6-Endoscopic Powered

Adenoidectomy.
http://www.googleserarh/image/endoscopic
adenoidectomy

43

TONSILS
The First-line antibiotic in acute tonsillitis due to GABHS
penissillin
Antibiotic effective against -lactamase-producing m.o or
encapsulated anaerobes (3-6 weeks) in chronic tonsillitis or
obstructive hyperplasia
Amox-clavulanat or clyndamicin
Acute upper airway obstruction : Nasopharyngeal airway
Immediate tonsillectomy :
-PTA coexist with infections of mononucleosis
-child with poor clinical response to medical therapy

44

Indication of Tonsillectomy
Obstruction
Tonsillar hyperplasia with chronic
obstruction
Sleep-related disordered breathing
Obstructive sleep apnea syndrome
Upper airway resistance syndrome
Obstructive hypoventilation
syndrome
Failure to thrive
Cor pulmonale
Swallowing abnormalities
Speech abnormalities
Orofacial/dental abnormalities
Lymphoproliferative disorder
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
Tonsilolithiasis
Streptococcal carrier state
unresponsive to
medical therapy in a child of
household at risk
Peritonsillar abscess unresponsive to
medical therapy or in a patient with
recurrent tonsillitis or recurrent
abscess
Neoplasia
Suspected neoplasia, benign or
Brodsky, L. Poje, C. Tonsilitis, Tonsillectomy and
malignant
Adenoidectomy. In Head and Neck SurgeryOtolaryngology, 5th ed. Bailey, vol. I, 2006. p.
1188

45

Absolut Indication

(paparella &
Shmrick)
Tonsilektomi :

Acute recurrent tonsillitis>

3x/years
Chronic tonsillitis who is
the focal infection
Post peritonsiler abscess
career diphtheria
Tonsillitis that cause
febrile seizures
Upper Respiratory
Obstruction and
swallowing disorders
suspicious of malignancy

Relatif Indication
Tonsiloadenoidektomi:
Recurrent sore throat

Otalgia repeated

chronic rhinitis

Upper Respiratory recurrent

infections

Large tonsils / dg debris

cervical lymphadenopathy

Tonsillitis / TB adenitis

Systemic disease caused by betahemolytic streptococci (rheumatic

fever, RHD)

46

PREPARATION OPERATION
Clinical Inspection
Blood tests, urine routine, radiological,
ECG
Special examination of OtolaryngologyKL
preoperative treatment
preparation tool

47

Tonsillectomy
1.
2.
3.
4.
5.
6.

Technique of Tonsillectomy :
Dissection and Snare Method
Tonsil Guillotine (Sluder) Technique
Tonsillectomy with Local Anesthesia
Cryogenic Tonsillectomy
Electrosterilization of The Tonsil
Laser Tonsillectomy

48

49

Technique of Tonsillectomy
Metode Dissection-Snare

50

Dissection-snare

51

Coblation

52

Post Operative Care

1.
2.
3.
4.

Maintain airway
Controlled of bleeding
Maintenance in general
Diet stages:
- 1-2 day: liquid food and cold
- 3-5 day: strain porridge or strain
foods
- 6-8 day: regular porridge
- 9-10 day: Team rice
- 11 day : Rice/regular food

Complications of adenotonsillar disease

and adenoidectomy and tonsillectomy
Complication

Presentation

Peritonsillar abscess

Management

Sore throat/dysphagia
Pharyngotonsillar bulge

Antibiotics (i.v.)

Needle aspiration/I & D in

OR
Trismus
Acute airway obstruction

Drooling

Immediate tonsillectomy

Stridor

Nasopharyngeal airway

secondary to T & A
hyperplasia

Muffled/hyponasal voice
Drooling

Steroids (i.v.)

Antibiotics (i.v.)

Enlarged tonsils (and adenoids)

Hemorrhage postcontrol (cautery or
tonsillectomy

Bleeding from mouth or nose

Frequent swallowing

Local

vasoconstriction)
Control in OR
Evaluate for coagulopathy

53

Complication

Presentation

Post T & A airway obstruction

airway

Management

Occurs in first 424 h

Palatal swelling

Suction gently

Hypopharyngeal secretions
Dehydration post T & A

Nasopharyngeal

Steroids (i.v.)

Poor oral intake

Control emesis if present

Dry mucous membranes

i.v. Hydration

Lethargy

Parental education
Pain control prn

Persistent VPI after

therapy
Adenoidectomy

Hypernasal speech (lasting

beyond 2 mo postop)

Speech

Palate surgery

Nasal regurgitation of fluids

Pulmonary edema after
expiratory ventilation

Difficulty with oxygenation

Positive and

relief of airway obstruction noted

by anesthesiologist
Frothy pink secretions from

Lasix

endotracheal tube

Morphine

54

HIGHLIGHTS
The adenoids and tonsils, by virtue of their unique
anatomic locations and differential functions have
characteristic clinical presentations. Therefore, they
must be evaluated as two separate organs
Understanding the basic pathophysiology of the
diseases of the tonsils and adenoids will lead the
clinician to explore new avenues of medical
management before consideration is given to
tonsillectomy
Tonsillectomy and adenoidectomy are major
surgical procedures. They require the diligence of
the physician to be aware of all the possible
complications and treat them with care and respect

HIGHLIGHTS
Identification of higher risk patients
preoperatively, with appropriate
perioperative and postoperative
management, will increase the safety of
these procedures
Several methods of tonsillectomy exist,
but all require careful dissection in the
subcapsular plane and meticulous
hemostasis