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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

A

over 90%

25
Q

ABx to give after drain PTA

A

Clinda (must cover gm + and anaerobes)

26
Q

When to perform quinsy tonsillectomy

A

needle aspiration does not adequately treat it

child who needs general anesthesia to drain anyways

27
Q

Define SDB

A

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
Q

Sleep efficiency

A

sleep time divided by recording time

29
Q

Sleep architecture

A

Stages.
Increased stage 1 suggests disrupted sleep
REM is where muscles are atonic –> lack of REM –> underestimate obstruction severity

30
Q

Oxygen distribution and nadir

A

indication of gas exchange

nadir helps determine if child should be admitted following tonsillectomy

31
Q

End tidal Co2

A

Some kids have prolonged partial obstructive hypoventilation detected by elevated end tidal CO2 rather than fully obstructive events

32
Q

When to obtain PSG prior to adenotonsillectomy

A

obesity, downs, craniofacial abnl, neuromuscular disorders, sickle cell, mucopolysaccharidoses, or if history and PE are discordant

33
Q

P crit

A

collapsibility of an airway

more negative p crit means airway is stiffer, less prone to collapse

34
Q

How does nasal patency affect airway collapse?

A

More nasal patency –> more air entering pharynx –> distends upper airway, makes it less likely to collapse

35
Q

Which factors make an adenotonsillectomy less likely to cure OSA, in order of influence?

A

age >7
elevated BMI
asthma
Preop AHI >10

36
Q

Non-surgical OSA Tx

A

montelukast and intranasal steroid for mild OSA

PPV via nasal mask

37
Q

How to treat OSA in setting of malocclusion and contracted maxilla

A

rapid maxillary expansion

38
Q

Tonsillectomy indications

A

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
Q

Contraindications to adenotonsillectomy

A

bleeding, anemia, pooranesthetic risk, acute infection

40
Q

Caution with adenotonsillectomy in downs

A

12% downs have A-A instability
neck extension may cause spinal cord compression, so be gentle
smaller airways for their age

41
Q

Explain post-obst pulmonary edema

A

Obstruction –> INC PEEP
Remove obst –> PEEP relieved –> fluid moves into interstitial tissue, alveoli –> pulm edema
Intraop or a few hours later

42
Q

Treatment of post-obst pulmonary edema

A

diuresis (mild)

intubate, positive pressure if more severe

43
Q

When should you admit a child postop after adenotonsillectomy

A

<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
Q

Postop instructions after adenotonsillectomy

A 
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
Q

what happens day 5-7 after tonsillectomy?

A

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
Q

rate of post-tonsillectomy bleed

A
  1. 2-2.2% primary (within 24 hr)

0. 1-3% secondary

47
Q

what to do if patient with post tonsillectomy bleed comes in if just clot no active bleeding

A

admit overnight for observation, NPO

low threshold for admission in small children, who have lower blood volume at baseline

48
Q

Symptoms of adenoiditis

A

purulent rhinorrhea, nasal obstruction, otalgia

chronic: PND. congestion, cough, halitosis

49
Q

Adenoid facies

A 
open mouth
facial elongation
high arched palate
open anterior bite
protrusion upper incisors
flattened midface
50
Q

How does the adenoid contribute to AOM?

A

block ET

nidus for infections

51
Q

Words that can demonstrate hyponasality

A

“my mommy made me mad”

“my nose never runs”

52
Q

How do you assess adenoid size?

A

If obstructive symptoms enough to necessitate tonsillectomy, then eval in OR and remove accordingly

May also use endoscopy, lateral neck XR

53
Q

Indications for adenoidectomy

A

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
Q

Three ways to remove adenoids

A

curette- place high in NP against vomer then sweep inferiorly
Suction cautery
Microdebrider

55
Q

Why adenoidectomy can lead to VPI, and rate of incidence

A

adenoids add bulk to posterior pharyngeal wall

1/1500 to 1/10,000 but higher in pts with palatal disorders

56
Q

Course and tx of VPI

A

most resolve spontaneously

speech tx/surgery

57
Q

3 signs of submucous cleft palate

A

zona pellucida (thin, blue-tinged mucosa)
bifid uvula
notching posterior hard palate

58
Q

How to do adenoidectomy if submucous cleft palate present

A

superior pole only

ENT Secrets (79 decks)

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