Pedi Tonsils and Adenoids Flashcards
What is the cause of acute tonsillitis?
Viral infection often precedes bacterial infection, which can
be caused by group A β-hemolytic streptococcus (most
common), Moraxella catarrhalis, and H. influenzae.
What is the treatment of choice for culture proven
acute streptococcus pharyngotonsillitis in a patient
with no allergies?
Penicillin: Consider β-lactamase inhibitor. For patients who
have penicillin allergies, consider clindamycin.
What is required for the diagnosis of recurrent/
chronic tonsillitis?
● Seven or more episodes of tonsillitis in the past 12
months, or
● Five or more episodes per year in the past 2 years, or
● Three or more episodes per year in the past 3 years
What microbiology is associated with chronic tonsil-
litis?
Polymicrobial infection. Treatment options include long-
term β-lactamase inhibitor antibiotic or tonsillectomy.
What are tonsilliths?
Tonsiliths are tonsillar concretions of retained material and
bacterial growth in crypts within tonsil and adenoid tissue.
They are sometimes identified in patients without a clinical
history suggestive of chronic tonsil disease. Conservative
therapy includes the use of water jets, manual expression,
gargling, or cauterization of the crypts with silver nitrate.
A 5-year-old child has had 3 weeks of nasal discharge,
halitosis, recurrent serous otitis media, and nightly
snoring. What is the likely diagnosis?
Adenoiditis. Also associated with chronic mouth breathing,
“adenoid facies” (long thin face, high arched palate, malar
hypoplasia, open mouth), and hyponasal speech
In children with peripheral sleep disordered breathing
associated with tonsillar hypertrophy, which comor- bid condition(s) might improve after tonsillectomy?
Growth retardation, poor school performance, enuresis,
and behavioral problems
What polysomnogram findings indicate sleep disor-
dered breathing and obstructive sleep apnea in
children and potentially warrant tonsillectomy?
● Abnormal study: Pulse oximetry < 92% or apnea plus
hypopnea index (AHI) > 1 (more than one event in two or
more consecutive breaths per hour)
● AHI > 5 warrants consideration of tonsillectomy (no strict
cutoff, somewhat controversial); these children should be
kept in the hospital for observation after surgery.
How is tonsillar hypertrophy graded?
0: Not visible; tonsils do not reach tonsillar pillars
1 + : Less than 25% of transverse oropharyngeal space
(measured between the anterior tonsillar pillars)
2 + : 25 to 49% of transverse oropharyngeal space
3 + : 50 to 74% or transverse oropharyngeal space
4 + : 75% or more of the transverse oropharyngeal space
How is adenoid hypertrophy graded?
0: Not visible 1 + : < 25% of choanae 2 + : 25 to 49% of choanae 3 + : 50–74% of choanae 4 + : 75% of choanae
What are the boundaries of the peritonsillar space?
● Medial: Palatine tonsil
● Anterior: Anterior tonsillar pillar
● Posterior: Posterior tonsillar pillar
● Lateral: Superior pharyngeal constrictor muscle (lateral to
this is the parapharyngeal space)
● Superior: Confluence of the anterior and posterior
tonsillar pillars with the soft palate
A patient in the emergency department has drooling, stertor, muffled voice, fever, leukocytosis, odyno-
phagia, and unilateral otalgia. She has a history of recurrent tonsillitis and on examination is noted to have uvular deviation and pharyngotonsillar asymmetry. What is the best treatment?
Treatment consists of incision and drainage of this
presumed peritonsillar abscess, along with antibiotics, pain
management, and consideration for steroids. Quinsy
tonsillectomy should be considered in a child with recurrent
tonsillitis undergoing incision and drainage of a peritonsillar
abscess under anesthesia.
If the tonsillar bed is violated inferiorly during
tonsillectomy, what nerve is at risk?
The glossopharyngeal nerve runs just lateral to the superior
constrictor muscle in the floor of the tonsillar bed. Injury or
postoperative edema may result in altered taste to the
posterior third of the tongue and referred otalgia resulting
from irritation of the tympanic nerve, a branch of cranial
nerve IX.
What is the immunologic risk of
adenotonsillectomy?
Although this tissue offers active immunologic protection
via B and T cell activity, there appears to be no clinically
relevant immunologic sequelae associated with performing
adenotonsillectomy,
What are the absolute indications for
tonsillectomy?
● Tonsillar hypertrophy resulting in upper airway obstruc-
tion, severe dysphagia, sleep disordered breathing, cor
pulmonale
● Unilateral tonsillar hypertrophy, or other concern for
possible malignancy
● Tonsillitis resulting in febrile convulsions
● Persistent or recurrent tonsillar hemorrhage
