49 Pediatric Adenotonsillar Disease, Sleep Disordered Breathing and OSA

Question 1

What is Waldeyer’s ring?

Answer 1

What is Waldeyer’s ring?

Waldeyer’s ring is the lymphoid tissue surrounding the entrance to the aerodigestive tract. The structures composing this ring are the faucial (palatine) tonsils, pharyngeal tonsils (adenoid), and the lingual tonsil located at the base of the tongue.

Question 2

Where are the adenoid and tonsils located?

Answer 2

Where are the adenoid and tonsils located?

The adenoid is located midline along the posterior aspect of the nasopharynx at the level of the posterior chonae and extend laterally to the eustachian tube orifices. The palatine tonsils lie in a fossa along the lateral walls of the oropharynx, between the anterior and posterior pillars. They extend superiorly from the soft palate down inferiorly to the tongue base. Here, they can appear to blend into the lingual tonsils. The palatine tonsils, in contrast to the lingual tonsils and adenoid, have a distinct capsule.

Question 3

Describe the blood supply to the palatine tonsils.

Answer 3

Describe the blood supply to the palatine tonsils.

The tonsils are supplied by several branches of the external carotid artery, including the tonsillar and ascending palatine branches of the facial artery, the ascending pharyngeal artery, the dorsal lingual branch of the lingual artery, and the palatine branch of the internal maxillary artery. The tonsillar branch of the facial artery provides the main blood supply.

Question 4

How is tonsillar hypertrophy graded?

Answer 4

How is tonsillar hypertrophy graded?

Tonsil size is graded as 1 to 4 according to the percentage projection from the anterior tonsillar pillar toward the midline. A 1 tonsil projects 0% to 25% from the anterior tonsillar pillar toward the midline; 2 projects 25% to 50%; 3 projects 50% to 75%; and 4 projects 75% to 100%. Tonsils graded 4 are sometimes referred to as “kissing” tonsils because they touch in the midline. The presence of enlarged tonsils does not necessarily mean that there will be disrupted breathing. Obstructive sleep apnea (OSA) arises as a combination of anatomic and neuromuscular factors.

Question 5

What is the function of the tonsils and adenoid?

Answer 5

What is the function of the tonsils and adenoid?

The tonsils and adenoid are predominantly B-cell lymphoid structures that probably play a role in secretory immunity. They are appropriately positioned for exposure to inhaled and ingested antigens, which can induce immunoglobulin and lymphokine production. Hyperplasia is thought to result from B-cell proliferation during exposure to high doses of antigen. It is generally accepted that removal of tonsils and adenoid does not produce a clinically significant immunologic deficiency. Tonsils and adenoid are immunologically most active between the ages of 4 and 10 years, and tend to involute after puberty. There are no studies to date that demonstrate significant alterations in the immune system following an adenotonsillectomy.

Question 6

What are tonsilloliths?

Answer 6

What are tonsilloliths?

Tonsillar concretions, or tonsilloliths, are whitish, cheesy, malodorous, foul-tasting lumps that can form in the tonsillar crypts. They arise from bacterial growth and retained debris, and although they are often asymptomatic, tonsilloliths can cause problems with halitosis, foreign body sensation, and otalgia. Conservative management includes gargling and expression and removal of tonsilloliths by the patient, performed with cotton swabs or a dental water jet device.

Question 7

How does bacterial tonsillitis present?

Answer 7

How does bacterial tonsillitis present?

Sudden onset of throat pain, odynophagia, enlarged erythematous tonsils with exudate, halitosis, fever, malaise, and tender cervical nodes are classic symptoms and signs of acute tonsillitis. The classic rash associated with scarlet fever appears on the neck and face and then spreads and looks like a sunburn with tiny bumps. The rash will blanch when one presses on it. Viral pharyngitis tends to be milder in presentation and usually without exudates. There may be an associated cold, cough, conjunctivitis, diarrhea, and rash. EBV is a notable exception.

Question 8

Name the most common infectious etiologic agents involved in adenotonsillar disease.

Answer 8

Name the most common infectious etiologic agents involved in adenotonsillar disease.

Group A β−hemolytic streptococcus (GABHS) is the most common cause of acute tonsillitis and can be associated with such serious sequelae as rheumatic fever and poststreptococcal glomerulonephritis. Numerous other organisms, however, are commonly associated with adenotonsillar disease, including non-GABHS bacteria, and beta-lactamase–producing organisms such as Bacteroides species, nontypable Haemophilus species, Staphylococcus aureus, and Moraxella catarrhalis. Common viral pathogens include adenovirus, coxsackievirus, parainfluenza, enteroviruses, Epstein-Barr virus (EBV), herpes simplex virus, and respiratory syncytial virus.

Question 9

Describe the otolaryngologic manifestations of mononucleosis.

Answer 9

Describe the otolaryngologic manifestations of mononucleosis.

Mononucleosis is caused by EBV and often produces an exudative tonsillitis that may appear indistinguishable from bacterial infections. Signs and symptoms of mononucleosis include high fever, malaise, generalized lymphadenopathy, enlarged tonsils with yellow-gray exudates, odynophagia, dysphagia, palatal petechiae, and hepatosplenomegaly. Useful lab results include lymphocytosis and the presence of atypical lymphocytes, as well as a positive Monospot and heterophil antibody titers. If mononucleosis is suspected, amoxicillin should be avoided because it may cause a salmon-colored rash.

Question 10

How should adenotonsillar infection be treated?

Answer 10

How should adenotonsillar infection be treated?

It can be difficult to distinguish viral from bacterial tonsillitis/pharyngitis. Most viral infections are self-limited and require only supportive care. If a bacterial infection is suspected, a rapid streptococcus detection test should be performed. If the test results are negative but suspicion for streptococcal tonsillitis is high, a throat culture should be performed. Penicillin is the initial drug of choice for culture-positive streptococcal infections. Resistance to penicillin or first-generation cephalosporins has not been reported. Tetracyclines, sulfonamides, and quinolones should not be used for treating GAS infections. If a child is a suspected strep carrier, the most effective treatment is clindamycin for 10 days.

Question 11

What is a peritonsillar abscess? How does it present?

Answer 11

What is a peritonsillar abscess? How does it present?

A peritonsillar abscess is a collection of pus in the potential space that surrounds the tonsil, between the tonsillar capsule and the superior constrictor muscle of the lateral pharyngeal wall. This process develops when infection penetrates the tonsillar capsule and enters the peritonsillar space. Over half of patients who present with peritonsillar abscess have a history of prior tonsillitis. Symptoms include throat pain, fever, dysphagia, a “hot potato” or muffled voice, trismus, and drooling. Examination reveals infected, swollen tonsils. The peritonsillar area is inflamed and swollen, usually unilaterally, with a bulge in the soft palate superior to the tonsil and displacement of the uvula toward the contralateral side.

Question 12

How is a peritonsillar abscess managed?

Answer 12

How is a peritonsillar abscess managed?

Needle aspiration with recovery of pus can be diagnostic and therapeutic and has been shown to be effective over 90% of the time. This procedure can usually be performed in the office or emergency department. After drainage, an antibiotic with strong gram-positive and anerobic coverage, such as clindamycin, is recommended. Tonsillectomy is recommended if a patient has had more than one peritonsillar abscess. It is performed after complete resolution of the infection. In selected cases, a quinsy tonsillectomy (tonsillectomy in the presence of abscess) is indicated, such as when drainage fails to adequately treat the abscess, or sometimes in children, who often require a general anesthetic for drainage anyway.

Question 13

How is obstructive sleep apnea (OSA) different from sleep disordered breathing (SDB)?

Answer 13

How is obstructive sleep apnea (OSA) different from sleep disordered breathing (SDB)?

OSA is a diagnosis that requires an abnormal polysomnogram. SDB is a clinical diagnosis with the following features: snoring with associated gasping, labored breathing, and daytime symptoms that may include hyperactivity, inattention, poor concentration, and excessive sleepiness (Box 49-1).

Question 14

What are the indications for requesting a polysomnogram?

Answer 14

What are the indications for requesting a polysomnogram?

According to the 2011 AAO/HNS guidelines one should obtain a preoperative polysomnogram prior to an adenotonsillectomy in the following circumstances: obesity, Down syndrome, craniofacial abnormalities, neuromuscular disorders, sickle cell disease, mucopolysaccharidoses, or if history and physical examination are discordant.

Question 15

What does one assess during a sleep study?

Answer 15

What does one assess during a sleep study?

The information contained in a sleep study allows one to evaluate sleep quality, degree of obstruction, and gas exchange (Box 49-2).

Question 16

What are the criteria to diagnose OSA?

Answer 16

What are the criteria to diagnose OSA?

Most clinicians agree and recent research suggests that an obstructive apnea/hypopnea index greater than 5 events an hour is clinically relevant.

Question 17

What is the P crit?

Answer 17

What is the P crit?

The P crit is a measure of airway collapsibility. The P crit of an airway will determine whether a patient has complete airway obstruction, partial obstruction, or no obstruction. A more negative P crit is indicative of an airway that is less prone to collapse (stiffer airway).

Question 18

Does nasal patency matter?

Answer 18

Does nasal patency matter?

Yes. A more patent nasal passage allows one to move air more easily into the upper airway. With a more patent nasal airway, the higher volume of air entering the pharynx will distend the upper airway and make it less likely to collapse.

Question 19

Does an adenotonsillectomy cure OSA?

Answer 19

Does an adenotonsillectomy cure OSA?

Adenotonsillectomy is not universally curative for OSA. Studies often have differing criteria for success of resolution of OSA after surgery. A large 2010 multicenter retrospective review of treatment outcomes for OSA after adenotonsillectomy gives somes clues to success. In order of influence, the following factors were associated with less improvement: age >7 years, elevated BMI, presence of asthma, and more severe OSA preoperatively (AHI >10 events/hour).

Question 20

What are nonsurgical treatment options for residual OSA?

Answer 20

What are nonsurgical treatment options for residual OSA?

• One study in children with mild residual OSA (AHI >1 but <5 events/hour) who were treated with anti-inflammatory therapy consisting of oral montelukast and intranasal nasal steroid for 12 weeks had normalization of their AHI.
• Noninvasive ventilation is a nonsurgical treatment for OSA. Positive pressure is applied via a nasal mask to splint open the upper airway. Effectiveness is determined by how compliant the child is.
• For children who have malocclusion and a contracted maxilla, rapid maxillary expansion has resulted in a dramatic improvement.

Question 21

What diagnostic tests are available to help identify the anatomic site of obstruction of a child with OSA?

Answer 21

What diagnostic tests are available to help identify the anatomic site of obstruction of a child with OSA?

A cine MRI or drug induced sleep endoscopy will facilitate identification of sites of anatomic obstruction. Additional surgical interventions after adenotonsillectomy include an inferior turbinate reduction, lingual tonsillectomy, posterior tongue base reduction, and supraglottoplasty.

Question 22

What are the indications for performing an adenotonsillectomy?

Answer 22

What are the indications for performing an adenotonsillectomy?

The most common indication is SDB, followed by recurrent tonsillitis. Other less common indications include dypshagia due to large tonsils and suspected malignancy. AAO-HNS guidelines recommend surgical intervention for recurrent tonsillitis under the following circumstances: 7 infections in a 12-month period, 5 infections per year for 2 consecutive years, or 3 infections per year for 3 consecutive years.

Question 23

What are the clinical criteria for a throat infection to be counted as an acute tonsillitis to meet the AAO/HNS criteria for an adenotonsillectomy?

Answer 23

What are the clinical criteria for a throat infection to be counted as an acute tonsillitis to meet the AAO/HNS criteria for an adenotonsillectomy?

See Box 49-3.

Question 24

List the contraindications for tonsillectomy and adenoidectomy.

Answer 24

List the contraindications for tonsillectomy and adenoidectomy.

1. Bleeding disorders
2. Anemia
3. Poor anesthetic risk due to uncontrolled medical illness
4. Acute infection

Question 25

**How are tonsils removed?**

Answer 25

*How are tonsils removed?* The tonsil is dissected along the plane between the tonsillar capsule and the superior constrictor muscle. Tonsillectomy can be performed using either a “cold” or “hot” technique, and the merits of one over the other are much debated. In “cold” dissection, a superior mucosal incision is created with a knife, and then blunt dissection separates the tonsil from the tonsillar bed. The tonsil is then amputated at its inferior aspect, often using a snare. The “hot” technique employs electrocautery to cut and coagulate simultaneously. Some studies suggest that “cold” dissection may lead to less postoperative pain; however, there may be less intraoperative blood loss with electrocautery. Other devices have also been introduced for tonsillectomy, including lasers and ultrasonic and radiofrequency devices. Proponents cite advantages such as less postoperative pain; however, these advantages remain to be proven.

Question 26

**Are any special precautions required in performing tonsillectomy and adenoidectomy on children with Down syndrome?**

Answer 26

*Are any special precautions required in performing tonsillectomy and adenoidectomy on children with Down syndrome?* About 12% of patients with Down syndrome have atlantoaxial instability. Cervical spine manipulations should be undertaken with the greatest of care when positioning these patients for surgery because neck extension may cause spinal cord compression. One also should be aware that these children have smaller airways so should initially be intubated with a tube that is smaller than their age-appropriate size.

Question 27

**In patients with long-standing adenotonsillar obstruction, what pulmonary problem can occur after adenotonsillectomy?**

Answer 27

*In patients with long-standing adenotonsillar obstruction, what pulmonary problem can occur after adenotonsillectomy?* Pulmonary edema. The long-term obstruction by adenotonsillar tissue produces a state of increased positive end-expiratory pressure (PEEP). With removal of the obstructing tissue, the excess PEEP is suddenly relieved and fluid moves into the interstitial and alveolar spaces, resulting in pulmonary edema with decreased blood oxygen saturation. This can occur intraoperatively or a few hours later. Treatment involves diuresis for mild cases, or intubation with reestablishment of increased PEEP in severe cases.

Question 28

**List possible complications of tonsillectomy and adenoidectomy.**

Answer 28

*List possible complications of tonsillectomy and adenoidectomy.* See Table 49-1.

Question 29

**What are the criteria to admit a child postoperatively after T&A for overnight monitoring?**

Answer 29

*What are the criteria to admit a child postoperatively after T&A for overnight monitoring?* * Younger than 3 years of age with a diagnosis of SDB * Abnormal polysomnogram with either an obstructive apnea/hypopnea index of ≥10 events per hour, or an oxygen saturation nadir \<80% * A child who has complications following the surgery, which may include hypoxemia, obstruction or poor oral intake. Social factors may also play a role, especially if there is not a reliable mode of transportation to return to the hospital or the family lives far from the hospital. * Although the AAO/HNS clinical practice guideline advocates for preoperative polysomnogram for children with certain comorbidities, if a sleep study was not performed one should strongly consider hospital observation since one would not know the severity of the obstruction. It is also reasonable to have a low threshold to observe a child with complex heart disease.

Question 30

**Should one administer perioperative antibiotics?**

Answer 30

*Should one administer perioperative antibiotics?* The AAO/HNS guidelines strongly recommend against the routine administration of antibiotics postoperatively. There is no evidence that antibiotics aid recovery and there is the risk of adverse reactions, including rash, upset stomach, allergy, and inducing bacterial resistance.

Question 31

**What should be given for post-tonsillectomy pain?**

Answer 31

*What should be given for post-tonsillectomy pain?* Tylenol with codeine is contraindicated due to an FDA black box warning. Both codeine and hydrocodone are metabolized to a more active compound. For hydrocodone, the analgesic activity is attributed to hydromorphone not hydrocodone. Since the conversion to hydromorphone occurs via the CYP2D6 pathway (the same pathway codeine uses when converting to morphine) the concern for variability in response between ultra-rapid and poor metabolizers exists—oversedation in ultra-rapid metabolizers and minimal pain relief in poor metabolizers. The presence of ultra-rapid metabolizers is highest in the Ethiopian African population (29%) and lowest in Northern Europeans (1% to 2%). NSAID use has been controversial but since 2011 has become more acceptable. A Cochrane review demonstrated NSAID safety with the exception of ketorolac. Particularly in the immediate postoperative period, NSAIDs may theoretically induce some platelet dysfunction. One study in adults demonstrated that reversible inhibition of platelets lasted for 6 to 8 hours after administration of 400 mg of ibuprofen. It may be prudent to wait for at least 8 hours prior to ibuprofen administration after an adenotonsillectomy to allow for clot maturation. Besides medications, families need to be educated on what to expect following surgery, and to encourage good hydration, which will lessen pain.

Question 32

**What does the postoperative management of adenotonsillectomy involve?**

Answer 32

*What does the postoperative management of adenotonsillectomy involve?* Expect significant pain and fatigue for about 1 week, and often longer in teenagers and adults. Children should plan to take 7 to 10 days off from school, and strenuous activity should be avoided for 2 weeks. Pain control is important to promote oral intake of liquids and to prevent dehydration. Diet may be advanced as tolerated; many recommend a soft diet. Throat and/or ear pain (referred pain), halitosis, and low-grade fevers are normal after surgery. No further bleeding should occur. If fresh blood is seen, it should be brought to the attention of the otolaryngologist immediately. There may be some blood-tinged saliva around postoperative day 5 to 7, when the “scab” falls off the surgical site. If this does not stop within several minutes, or if it should worsen, medical attention should be sought.

Question 33

**What is the incidence of postoperative tonsillectomy bleeding?**

Answer 33

*What is the incidence of postoperative tonsillectomy bleeding?* The rate of primary hemorrhage (occurring within 24 hours of surgery) ranges from 0.2% to 2.2%. The rate of secondary hemorrhage (occurring more than 24 hours after surgery) has been quoted as anywhere from 0.1% to 3%.

Question 34

**How is postoperative bleeding managed?**

Answer 34

*How is postoperative bleeding managed?* A patient presenting to the emergency department with a post-tonsillectomy bleed should be examined by an otolaryngologist. The tonsillar fossae should be carefully examined, looking for active bleeding sites or evidence of a clot. If active bleeding is encountered, it should be controlled with cautery and/or suture ligation. If no abnormality is seen and only minimal bleeding is reported, then observation is reasonable. If a clot is present without active bleeding, the patient should be admitted for overnight observation, ready for surgery in case bleeding should reoccur. Depending on the history, a hematocrit and coagulation profile may be drawn. The threshold for admission and intervention should be lower in smaller children who have a lower blood volume to begin with.

Question 35

**What problems are caused by the adenoid?**

Answer 35

*What problems are caused by the adenoid?* Adenoid can become acutely and chronically infected. Symptoms may be difficult to differentiate from bacterial or viral upper respiratory infections and are often mislabeled as “sinusitis.” Adenoiditis commonly presents as fever, purulent rhinorrhea, nasal obstruction, and otalgia. Postnasal drip, congestion, chronic cough, and halitosis can occur during chronic infections. Adenoid hypertrophy can cause nasal obstruction, contribute to obstructive sleep apnea, and result in hyponasal speech. Chronic hypertrophy and mouth breathing can also cause alterations in craniofacial growth. “Adenoid facies” is characterized by an open mouth, facial elongation, a high arched palate, an open anterior bite with protrusion of the upper incisors, and flattened midface. It is also believed that adenoid play a role in patients with recurrent otitis media or effusions by mechanically obstructing the eustachian tubes and by providing a bacterial nidus for infection.

Question 36

**How is the adenoid evaluated?**

Answer 36

*How is the adenoid evaluated?* In patients with suspected adenoid hypertrophy, breathing and speech should be assessed. Words that emphasize nasal emission such as “mommy” can be useful in demonstrating hyponasality. The nose should be examined for other causes of obstruction such as enlarged turbinates. The adenoid cannot be seen by looking in the mouth or the anterior nose, but it is generally assumed that children with significant obstructive symptoms who require tonsillectomy will have enlarged adenoid as well. The adenoid is visualized at the time of surgery and removed accordingly. Lateral neck radiography and fiber-optic endoscopy can be used to assess the adenoid if there is diagnostic uncertainty.

Question 37

**What nonsurgical therapies are available for adenoiditis or adenoid hypertrophy?**

Answer 37

*What nonsurgical therapies are available for adenoiditis or adenoid hypertrophy?* 1. Antibiotics are used to treat infectious adenoiditis. 2. Nasal steroid sprays can improve adenoidal hypertrophy.

Question 38

**List the indications for adenoidectomy.**

Answer 38

*List the indications for adenoidectomy.* 1. Recurrent acute or chronic adenoiditis 2. Nasal obstruction with chronic mouth breathing 3. Hyponasal speech 4. Craniofacial growth abnormalities 5. Obstructive sleep apnea 6. Recurrent otitis media or persistent effusion in patients who have undergone prior tympanostomy tube placement (adenoidectomy usually performed in conjunction with a subsequent tube placement procedure)

Question 39

**How is the adenoid removed?**

Answer 39

*How is the adenoid removed?* Adenoidectomy is performed transorally, and the nasopharynx is visualized using a laryngeal mirror. Tissue can be removed by the following methods: 1. Curetting is the traditional method for adenoidectomy. The curette is positioned high in the nasopharynx against the septal vomer and then swept inferiorly, thereby cutting out the adenoid tissue. Hemostasis is achieved by packing followed by suction cautery. 2. Suction cautery can be used to fulgurate the adenoid tissue. This method is associated with less intraoperative blood loss and is ideal for smaller adenoid, although it can be used routinely as well. 3. The microdebrider can be used to shave away adenoid tissue. Care must be taken to avoid injury to surrounding structures with powered instrumentation.

Question 40

**Why can velopharyngeal insufficiency (VPI) occur after adenoidectomy?**

Answer 40

*Why can velopharyngeal insufficiency (VPI) occur after adenoidectomy?* VPI occurs when there is incomplete closure of the soft palate against the posterior pharyngeal wall during speech and swallowing. VPI results in hypernasal speech and nasopharyngeal regurgitation. In children, adenoid tissue significantly adds to the bulk of the posterior pharyngeal wall. An adenoidectomy reduces this bulk and can lead to incomplete closure. Most cases are temporary, but persistent or severe cases may require speech therapy and/or surgical treatment. The incidence of VPI after adenoidectomy ranges from 1/1500 to 1/10,000 in healthy patients. The incidence is much higher in patients with palatal disorders.

Question 41

**Why should one always inspect and palpate the palate prior to adenoidectomy?**

Answer 41

*Why should one always inspect and palpate the palate prior to adenoidectomy?* A submucous cleft palate is associated with a higher incidence of postadenoidectomy VPI. Signs of a submucous cleft include a bifid uvula, zona pellucida, and notching of the posterior hard palate. In the presence of these findings, a superior pole adenoidectomy is recommended. This procedure removes obstructing tissue from the choanal area but preserves bulk in the posterior pharyngeal wall.