Chapter 49 - Pediatric Adenotonsillar disease, SDB, OSA Flashcards
“Will an adenotonsillectomy affect my immune system?”
No studies show significant alterations in immune system following this procedure
Is strep resistant to penicillin or first gen ceph?
No reported resistance with cx positive strep
Complications of SDB
social, behavioral, neurocognitive
decreased QOL, growth impairment, CV complications, systemic inflammation
Can you use ibuprofen for pain after adenotonsillectomy?
No longer contraindicated, but wait 8 hours for clot formation
Don’t give ketorolac
cochrane review 2011
Can you use tylenol with codeine after adenotonsillectomy?
contraindicated, black box
Which compound is hydrocodone converted into that explains its analgesic activity
hydromorphone
Classic scarlet fever rash
neck and face then spreads
sunburn with tiny bumps
blanches
Rash after amoxicillin for mono
Salmon-colored
Indications for tonsillectomy - two most common
SDB
then tonsillectomy
Where are the adenoids located?
midline, along posterior nasopharynx level of posterior choanae
extend laterally to ET orifices
Main blood supply of tonsils
tonsillar br of facial a
tonsillar grading scale
Brodsky 0- within tonsillar fossa 1- occupy less than 25% of distance between anterior pillars 2- 25-50% 3- 50-75% 4- 75-100%
Function of tonsils and adenoids
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
Tonsillolith: definition, sx, tx
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
Bacterial vs viral pharyngitis
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
How often is pharyngitis bacterial?
15-30%
Unique signs of EBV tonsillitis
yellow-grey membrane covering tonsils, palatal petechiae
high fever, malaise, cervicoaxillaryinguinal LAD, HSM
Causes of bacterial tonsillitis
GABHS
bacteroidits, H Flu, S Aureus, M catarrhalis
Causes of viral tonsillitis
adenovirus, coxsackie, PIV, EBV, RSV, HSV, entero
How to evaluate for cause of tonsillitis
If suspected to be bacterial, do rapid test, if negative but high suspicion, do throat cx
Most effective treatment for strep carriers
Clinda 10d
Where is a PTA located
potential space between tonsilar capsule and superior constrictor
occurs when bacteria penetrate the capsule
How many patients with PTA have prior tonsillitis?
Over 50%
How effective is needle aspiration for PTA
over 90%
ABx to give after drain PTA
Clinda (must cover gm + and anaerobes)
When to perform quinsy tonsillectomy
needle aspiration does not adequately treat it
child who needs general anesthesia to drain anyways
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
Sleep efficiency
sleep time divided by recording time
Sleep architecture
Stages.
Increased stage 1 suggests disrupted sleep
REM is where muscles are atonic –> lack of REM –> underestimate obstruction severity
Oxygen distribution and nadir
indication of gas exchange
nadir helps determine if child should be admitted following tonsillectomy
End tidal Co2
Some kids have prolonged partial obstructive hypoventilation detected by elevated end tidal CO2 rather than fully obstructive events
When to obtain PSG prior to adenotonsillectomy
obesity, downs, craniofacial abnl, neuromuscular disorders, sickle cell, mucopolysaccharidoses, or if history and PE are discordant
P crit
collapsibility of an airway
more negative p crit means airway is stiffer, less prone to collapse
How does nasal patency affect airway collapse?
More nasal patency –> more air entering pharynx –> distends upper airway, makes it less likely to collapse
Which factors make an adenotonsillectomy less likely to cure OSA, in order of influence?
age >7
elevated BMI
asthma
Preop AHI >10
Non-surgical OSA Tx
montelukast and intranasal steroid for mild OSA
PPV via nasal mask
How to treat OSA in setting of malocclusion and contracted maxilla
rapid maxillary expansion
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
Contraindications to adenotonsillectomy
bleeding, anemia, pooranesthetic risk, acute infection
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
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
Treatment of post-obst pulmonary edema
diuresis (mild)
intubate, positive pressure if more severe
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
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
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
rate of post-tonsillectomy bleed
- 2-2.2% primary (within 24 hr)
0. 1-3% secondary
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
Symptoms of adenoiditis
purulent rhinorrhea, nasal obstruction, otalgia
chronic: PND. congestion, cough, halitosis
Adenoid facies
open mouth facial elongation high arched palate open anterior bite protrusion upper incisors flattened midface
How does the adenoid contribute to AOM?
block ET
nidus for infections
Words that can demonstrate hyponasality
“my mommy made me mad”
“my nose never runs”
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
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)
Three ways to remove adenoids
curette- place high in NP against vomer then sweep inferiorly
Suction cautery
Microdebrider
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
Course and tx of VPI
most resolve spontaneously
speech tx/surgery
3 signs of submucous cleft palate
zona pellucida (thin, blue-tinged mucosa)
bifid uvula
notching posterior hard palate
How to do adenoidectomy if submucous cleft palate present
superior pole only
