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ENT Secrets > Chapter 49 - Pediatric Adenotonsillar disease, SDB, OSA > Flashcards

Chapter 49 - Pediatric Adenotonsillar disease, SDB, OSA Flashcards

1
Q

“Will an adenotonsillectomy affect my immune system?”

A

No studies show significant alterations in immune system following this procedure

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2
Q

Is strep resistant to penicillin or first gen ceph?

A

No reported resistance with cx positive strep

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3
Q

Complications of SDB

A

social, behavioral, neurocognitive

decreased QOL, growth impairment, CV complications, systemic inflammation

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4
Q

Can you use ibuprofen for pain after adenotonsillectomy?

A

No longer contraindicated, but wait 8 hours for clot formation
Don’t give ketorolac
cochrane review 2011

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5
Q

Can you use tylenol with codeine after adenotonsillectomy?

A

contraindicated, black box

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6
Q

Which compound is hydrocodone converted into that explains its analgesic activity

A

hydromorphone

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7
Q

Classic scarlet fever rash

A

neck and face then spreads
sunburn with tiny bumps
blanches

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8
Q

Rash after amoxicillin for mono

A

Salmon-colored

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9
Q

Indications for tonsillectomy - two most common

A

SDB

then tonsillectomy

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10
Q

Where are the adenoids located?

A

midline, along posterior nasopharynx level of posterior choanae
extend laterally to ET orifices

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11
Q

Main blood supply of tonsils

A

tonsillar br of facial a

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12
Q

tonsillar grading scale

A 
Brodsky
0- within tonsillar fossa
1- occupy less than 25% of distance between anterior pillars
2- 25-50%
3- 50-75%
4- 75-100%
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13
Q

Function of tonsils and adenoids

A

predominately B lymphoid structures - secretory immunity
exposure to inhaled and ingested pathogens
induce immunoglobulin and cytokine production
hyperplastic when B-cells proliferate during exposure to high doses of antigen
active between ages 4-10, involute after puberty

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14
Q

Tonsillolith: definition, sx, tx

A

white, cheesy malodorous lump, from bacterial growth/retained debris
halitosis, FB sensation, otalgia, or ASx
Gargling and removal with cotton swab/dental jet device, or surgery

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15
Q

Bacterial vs viral pharyngitis

A

bacterial: more likely to be severe and with exudate. Sudden onset throat pain, odynophagia, enlarged/red tonsils, halitosis, fever, malaise, tender cervical nodes
viral: milder, less often with exudate, associated cold, conjunctivitis, diarrhea, rash

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16
Q

How often is pharyngitis bacterial?

A

15-30%

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17
Q

Unique signs of EBV tonsillitis

A

yellow-grey membrane covering tonsils, palatal petechiae

high fever, malaise, cervicoaxillaryinguinal LAD, HSM

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18
Q

Causes of bacterial tonsillitis

A

GABHS

bacteroidits, H Flu, S Aureus, M catarrhalis

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19
Q

Causes of viral tonsillitis

A

adenovirus, coxsackie, PIV, EBV, RSV, HSV, entero

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20
Q

How to evaluate for cause of tonsillitis

A

If suspected to be bacterial, do rapid test, if negative but high suspicion, do throat cx

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21
Q

Most effective treatment for strep carriers

A

Clinda 10d

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22
Q

Where is a PTA located

A

potential space between tonsilar capsule and superior constrictor
occurs when bacteria penetrate the capsule

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23
Q

How many patients with PTA have prior tonsillitis?

A

Over 50%

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24
Q

How effective is needle aspiration for PTA

25
ABx to give after drain PTA
Clinda (must cover gm + and anaerobes)
26
When to perform quinsy tonsillectomy
needle aspiration does not adequately treat it | child who needs general anesthesia to drain anyways
27
Define SDB
Snoring plus: Night Sx: gasping, pauses, labored breathing, night terrors, sleep walk, enuresis Day Sx: unrefreshed after sleep, ADHD, emotional lability, temperomental behavior, poor weight gain, daytime fatigue, daytime mouth breathing, dysphagia
28
Sleep efficiency
sleep time divided by recording time
29
Sleep architecture
Stages. Increased stage 1 suggests disrupted sleep REM is where muscles are atonic --> lack of REM --> underestimate obstruction severity
30
Oxygen distribution and nadir
indication of gas exchange | nadir helps determine if child should be admitted following tonsillectomy
31
End tidal Co2
Some kids have prolonged partial obstructive hypoventilation detected by elevated end tidal CO2 rather than fully obstructive events
32
When to obtain PSG prior to adenotonsillectomy
obesity, downs, craniofacial abnl, neuromuscular disorders, sickle cell, mucopolysaccharidoses, or if history and PE are discordant
33
P crit
collapsibility of an airway | more negative p crit means airway is stiffer, less prone to collapse
34
How does nasal patency affect airway collapse?
More nasal patency --> more air entering pharynx --> distends upper airway, makes it less likely to collapse
35
Which factors make an adenotonsillectomy less likely to cure OSA, in order of influence?
age >7 elevated BMI asthma Preop AHI >10
36
Non-surgical OSA Tx
montelukast and intranasal steroid for mild OSA | PPV via nasal mask
37
How to treat OSA in setting of malocclusion and contracted maxilla
rapid maxillary expansion
38
Tonsillectomy indications
7 in 1, 5 in 2, 3 in 3 (each episode has sore throat plus either cervical ad, exudate, + test, or T >101 Consider if PFAPA, abx allergy/intolerance, h/o PTA Consider for SDB + large tonsils
39
Contraindications to adenotonsillectomy
bleeding, anemia, pooranesthetic risk, acute infection
40
Caution with adenotonsillectomy in downs
12% downs have A-A instability neck extension may cause spinal cord compression, so be gentle smaller airways for their age
41
Explain post-obst pulmonary edema
Obstruction --> INC PEEP Remove obst --> PEEP relieved --> fluid moves into interstitial tissue, alveoli --> pulm edema Intraop or a few hours later
42
Treatment of post-obst pulmonary edema
diuresis (mild) | intubate, positive pressure if more severe
43
When should you admit a child postop after adenotonsillectomy
<3 and SDB AHI >10 or nadir <80% postop complications (hypoxemia, obstruction, poor PO intake, no suitable mode of transportation back to hospital, lives far away) complex heart disease
44
Postop instructions after adenotonsillectomy
``` pain/fatigue 1-2 wk, worse for teenage/adult halitosis, low grade fevers expected 7-10d off from school avoid stenuous activity for 2wk soft diet pain control, hydration ```
45
what happens day 5-7 after tonsillectomy?
scab falls of surgical site may see blood tinged saliva here If bleeding doesn't stop within several minutes, or if it worsens, go to ED
46
rate of post-tonsillectomy bleed
0. 2-2.2% primary (within 24 hr) | 0. 1-3% secondary
47
what to do if patient with post tonsillectomy bleed comes in if just clot no active bleeding
admit overnight for observation, NPO | low threshold for admission in small children, who have lower blood volume at baseline
48
Symptoms of adenoiditis
purulent rhinorrhea, nasal obstruction, otalgia | chronic: PND. congestion, cough, halitosis
49
Adenoid facies
``` open mouth facial elongation high arched palate open anterior bite protrusion upper incisors flattened midface ```
50
How does the adenoid contribute to AOM?
block ET | nidus for infections
51
Words that can demonstrate hyponasality
"my mommy made me mad" | "my nose never runs"
52
How do you assess adenoid size?
If obstructive symptoms enough to necessitate tonsillectomy, then eval in OR and remove accordingly May also use endoscopy, lateral neck XR
53
Indications for adenoidectomy
recurrent acute/chronic adenoiditis, nasal obstruction w/ chronic mouth breathing, hyponasal speech, craniofacial growth abnormalities, OSA, recurrent AOM or persistent effusion in pts who have undergone prior tube placement (second set of tubes do adenoidectomy also)
54
Three ways to remove adenoids
curette- place high in NP against vomer then sweep inferiorly Suction cautery Microdebrider
55
Why adenoidectomy can lead to VPI, and rate of incidence
adenoids add bulk to posterior pharyngeal wall | 1/1500 to 1/10,000 but higher in pts with palatal disorders
56
Course and tx of VPI
most resolve spontaneously | speech tx/surgery
57
3 signs of submucous cleft palate
zona pellucida (thin, blue-tinged mucosa) bifid uvula notching posterior hard palate
58
How to do adenoidectomy if submucous cleft palate present
superior pole only

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