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Pediatric ENT > Pediatric Tonsil Disease > Flashcards

Pediatric Tonsil Disease Flashcards

1
Q

Indications for Total Intracapsular Tonsillectomy

A

1) Infectious/Inflammatory Conditions
- Recurrent Tonsillitis
- Peritonsillar Abscess
2) Hypertrophic/Obstructive Conditions
- Obstructive Sleep Apnea
- Hypertrophic tonsillitis
3) The same surgical technique of Total Intracapsular Tonsillectomy is used regardless of the indication

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2
Q

Complete Intracapsular Tonsillectomy - Surgical Technique

A

1) The goal of ICT is to perform a complete tonsillectomy without violating the capsule and avoiding injury to the underlying pharyngeal musculature. The intent is to remove all tonsil tissue while causing minimal injury to the underlying muscle. 2) Use the EVAC 70 HP Coblation Wand set on 8 (Coblate)/5 (Coag). 3) Use the Hurd retractor to retract the anterior pillar and then Coblate the tonsil from medial to lateral. Remove lateral tonsillar tissue until the tonsil tissue is concave btwn the tonsillar pillars. 4) Pay attention to tissue color and texture - Tonsil tissue is white - like cotton wool - Underlying muscle is brown - The tonsil capsule is yellow 5) Remove tonsil tissue until brown muscle is visualized or the yellow capsule is encountered. - The capsule has a different texture and has a more fibrous quality than tonsil tissue or muscle - If the muscle is inadvertently entered, bleeding is encountered - control bleeding with bipolar/coag function 6) Once tonsillectomy is complete, inspect the tonsil fossa - Any minimally remaining tonsil tissue adjacent to muscle is removed using either the Coblate/ablate or the Coag function of the Coblation wand 7) Tonsil tissue focally located inferiorly at the transition btwn oropharyngeal and lingual tonsil are removed by coblation using the Coag/Bipolar function or suction Electrocautery at a low setting - You can use suture to close exposed muscle

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3
Q

What are the indications for surgical tonsillectomy?

A
  1. Recurrent or chronic tonsillitis
  2. Streptococcal carriage
  3. Airway obstruction/sleep disordered breathing
  4. Peritonsillar abscess/recurrent peritonsillar abscess
  5. Cryptic tonsillitis/hemorrhagic tonsillitis
  6. Asymmetric tonsillar hypertrophy with suspicion of malignancy
  7. Effects on dental and facial growth
  8. PFAPA Syndrome (Periodic fever, aphthous stomatitis, pharyngitis, and cervical adenopathy)
  9. PANDAS Syndrome (Pediatric autoimmune neuropsychiatric d/o associated with streptococcal infections syndrome)
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4
Q

Should you give antibiotics post tonsillectomy

A

Note: Do not routinely give antibiotics post tonsillectomy:

  1. They don’t reduce pain
  2. They don’t reduce bleeding
  3. They don’t reduce the need for analgesics
  4. They may reduce post op fever
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5
Q

What are the Paradise Criteria/Surgical Indication for Recurrent Tonsillitis?

A
  1. 7 episodes of tonsillitis in one year
  2. 5 episodes of tonsillitis/year for 2 years
  3. 3 episodes of tonsillitis/year for 3 years
  4. Each episode of tonsillitis must be characterized by one of the following:
    1. Oral Temp of 101 or higher
    2. Enlarged (>2cm) or tender anterior cervical lymph nodes
    3. Tonsillar exudates
      • Culture for GABHS
  5. Notes
    1. Adequate abx tx must have been given for a proven or suspected case of step tonsillitis
    2. Each episode must have been confirmed by examinations and its qualifying features described in a clinical record at the time of occurrence
  6. A young child with recurrent viral exudative tonsillitis may suffer enough that adenotonsillectomy benefits may outweigh the risks
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6
Q

What is Grisel’s Syndrome?

A
  1. Definition: non traumatic atlantoaxial subluxation that results from inflammation in the superior cervical region following adenoidectomy
  2. Patients present with neck stiffness and pain
  3. The patient’s head is usually rotated away from the side where the atlas has shifted forward in unilateral subluxation
  4. The diagnosis is confirmed by CT scan of the cervical spine
  5. Treatment includes: Antibiotics, use of a Philadelphia collar or traction, pain medication, and Orthopedic or Neurosurgical consultation
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7
Q

PFAPA Syndrome - What does this acronym stand for?

A

Periodic Fever, Aphthous Stomatitis, Pharyngitis, and Adenitis Syndrome

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8
Q

PFAPA Syndrome - What are the diagnostic criteria for this condition (Modified Marshall Criteria)?

A
  1. Regularly recurring fevers with an early age of onset (< 5 years old)
  2. Constitutional symptoms in the absence of upper respiratory infection with at least one of the following clinical signs:
    1. Aphthous stomatitis
    2. Cervical lymphadenitis
    3. Pharyngitis
  3. Completely asymptomatic interval between episodes
  4. Normal growth and development
  5. Cyclic Neutropenia has been excluded
  6. Duration of symptoms is less than 7 days
  7. No atypical features
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9
Q

PFAPA Syndrome - Pharmacologic Treatment of Episodes

A
  1. Prednisone:
    1. Dose: 0.5-2mg/kg orally on first day of fever
    2. May repeat on day 2 if fever persists
  2. Betamethasone:
    1. Dose: 0.2mg/kg orally on first day of fever
    2. May repeat on day #2 if fever perssists
  3. Anakinra:
    1. Dose: 1mg/kg subcutaneously the first and second day of fever
    2. Expensive
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10
Q

PFAPA Syndrome - Pharmacologic Treatment of Each Episode

A
  1. Prednisone
    1. Dose: 0.5-2 mg/kg orally on first day of fever
    2. May repeat on day #2 if fever persists
  2. Betamethasone
    1. Dose: 0.2 mg/kg orally on the first day of fever
    2. May repeat on day #2 if fever persists
  3. Anakinra
    1. Dose: 1mg/kg subQ the first and second day of fever
    2. Expensive
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11
Q

PFAPA Syndrome - Prophylactic Treatment

A
  1. Colchicine
    1. Dose: 0.5-1 mg/day orally
    2. Side Effects: Gastrointestinal
  2. Cimetidine
    1. Dose: 20-40 mg/kg/day orally
    2. Poor efficacy
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12
Q

PFAPA Syndrome - Miscellaneous Facts

A
  1. Most common cause of periodic fever in childhood
  2. There is no evidence that medical treatment can modify the outcome
  3. NSAIDs and antipyretics are not helpful
  4. Steroids are highly effective at treating the attacks
  5. Clinical course: usually self-limiting with the resolution of fever episodes after some years
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13
Q

PFAPA Syndrome - Typical Symptoms

A
  1. Episodes of fever lasting for 3-6 days that recur regularly every 3-8 weeks
  2. Usual onset before the age of 5 years and generally resolves by adolescence
  3. Fevers are associated with at least one of three main symptoms
    1. Aphthous stomatitis
    2. Cervical adenitis
    3. Pharyngitis
  4. Patients are asymptomatic btwn episodes
  5. Patients have normal growth and development
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14
Q

PFAPA Syndrome - Cause

A
  1. PFAPA Syndrome is an immune mediated disease characterized by cytokine dysfunction
  2. Proposed contributors to pathogenesis
    1. Infection
    2. Abnormal host immune responses
    3. Combination of the two above
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15
Q

PFAPA Syndrome - Treatment

A
  1. Steroids can resolve fever attacks in a few hours
  2. Aphthous stomatitis may take longer to resolve
  3. Administration of steroids does not prevent future attacks
  4. Response to steroids may help distinguish PFAPA from the other causes of periodic fever in childhood
    1. Familial Mediterranean Fever (FMF)
    2. Other Hereditary Periodic Fever syndromes
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16
Q

What is PANDAS Syndrome?

A
  1. PANDAS = Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal Infection
  2. Diagnostic Criteria
    1. Obsessive compulsive d/o
    2. Pediatric onset
    3. Episodic course of severity
    4. Associated with GABHS
    5. Association with neurological abnormalities
  3. The streptococcal infection should be confirmed with a positive culture or elevated ASO/ADB titers
  4. Note: Sydenham’s chorea is also caused by an antibody mediated mechanism
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17
Q

What is Lemierre’s Disease/Syndrome

A
  1. Septic thrombophlebitis of the internal jugular vein
  2. Lemierre’s syndrome is the most common complication of a deep space neck infection/abscess
  3. Symptoms
    1. Shaking chills
    2. Spiking fevers
    3. Tender swelling at the angle of the mandible or along the SCM
  4. Septic emboli and sepsis can frequently ensue and affect the
    1. Lungs
    2. Liver
    3. Musculoskeletal system
  5. Treatment
    1. Usually resolves with a prolonged course of antibiotics
    2. Does not usually require resection of the internal jugular vein
    3. Some advocate use of anticoagulants in treatment to prevent propagation of the IJ thrombus
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18
Q

What is Lemierre’s Disease/Syndrome

A
  1. Septic thrombophlebitis of the internal jugular vein
  2. Lemierre’s syndrome is the most common complication of a deep space neck infection/abscess
  3. Symptoms
    1. Shaking chills
    2. Spiking fevers
    3. Tender swelling at the angle of the mandible or along the SCM
  4. Septic emboli and sepsis can frequently ensue and affect the
    1. Lungs
    2. Liver
    3. Musculoskeletal system
  5. Treatment
    1. Usually resolves with a prolonged course of antibiotics
    2. Does not usually require resection of the internal jugular vein
    3. Some advocate use of anticoagulants in treatment to prevent propagation of the IJ thrombus
19
Q

What are the complications associated with Group A Beta-Hemolytic Streptococcal Infections?

A

Most GABHS infections are self-limited and benign. Abx use has decreased the incidence of non suppurative complications of GABHS, but suppurative complications of GABHS are still commonly encountered.

  1. Nonsuppurative complications of GABHS
    1. Rheumatic Fever
    2. Post streptococcal glomerulonephritis
    3. Pediatric autoimmune neuropsychiatric d/o associated with GABHS (PANDAS)
  2. Suppurative Complications of GABHS
    1. Peritonsillar abscess
    2. Parapharyngeal abscess
    3. Retropharyngeal abscess
20
Q

Post Tonsillectomy Pain Control in Children

A
  1. Give a single intraoperative dose of Decadron
  2. Alternate Tylenol and Ibuprofen Q 3 hours for the first few days post op. Have Tylenol suppositories on hand
  3. Have Oxycodone for breakthrough pain in older children
  4. Do not give NSAIDs to children with G6PD deficiency
  5. Have the patient swish/gargle with Cleocin or Sucralfate, or swallow Honey (1 tsp QID)
  6. Educate parents to frequently evaluate the patient’s pain
21
Q

Post Tonsillectomy Topical Pain Control

A
  1. Have child swallow Honey orally every 6 hours
  2. Can also swish/gargle with Cleocin or Sucralfate
22
Q

Post Tonsillectomy Pain - Oxycodone

A
  1. Oxycodone (0.1mg/kg) po every 4 hours prn breakthrough pain to older children. You can give 0.05-0.3 mg/kg/dose po Q4-6 hours prn pain to max dose of 10mg/dose.
  2. Dosage forms:
    1. Oxycodone oral solution (5mg/5mL)
    2. Do not use the 20mg/mL concentrate in children
  3. This is from the AAO-HNS clinical practice guideline
23
Q

Ibuprofen - Pediatric Dosing

A
  1. Dose:
    1. 4-10 mg/kg/dose po Q6-8 hours.
    2. Max dose = 40mg/kg/day
  2. Dosage Forms:
    1. Infant drops: (40mg/mL)
    2. Oral Suspension (100mg/5mL)
    3. Chewtabs: 50 & 100 mg
24
Q

PFAPA Age of Onset

A
  • 90% of children with PFAPA have their first symptoms before the age of 5 years old.
  • Fewer than 3% of children with PFAPA experienced their first symptom after the age of 10 years old
  • Signs/symptoms of PFAPA syndrome are similar in children with symptom onset before vs after 5 years of age
25
Q

PFAPA Atypical Symptoms

A
  • 14% of patient’s displayed atypical features with skin rash being the most common atypical atypical feature of PFAPA
26
Q

PFAPA Symptoms

A
  1. Regular, stereotypical and self-limiting fever episodes, accompanied by signs/symptoms from the oro-pharyngeal area.
  2. Atypical symptoms of PFAPA: skin rash, arthritis, severe abdominal pain, conjunctivitis, periorbital edema, diarrhea, chest pain, episodes triggered by cold or exercise, and length of fever episodes > 7 days
  3. If Atypical symptoms are present, consider other etiologies such as mAIDs
27
Q

PFAPA Inclusion Criteria (Modified Marshall Criteria)

A
  1. Regularly recurring fevers with an early age of onset (< 5 years old)
  2. Constitutional symptoms in the absence of upper respiratory infection with >/= one of the following clinical signs:
  • Aphthous stomatitis
  • Cervical lymphadenitis
  • Pharyngitis
  1. Exclusion of cyclic neutropenia (N.B. In clinical practice, cyclic neutropenia was often excluded on clinical grounds)
  2. Completely asymptomatic interval between episodes
  3. Normal growth and development
  4. Duration of episodes < 7 days
  5. No atypical features
28
Q

What are the Modified Criteria for a First Episode of Acute Rheumatic Fever?

A

Major Criteria:

  • Carditis
  • Chorea
  • Erythema Marginatum
  • Polyarthritis
  • Subcutaneous nodules

Minor Criteria:

  • Polyarthralgia
  • Elevated ESR (>60mm/hour), CRP (>30mg/L [285.7nmol/L]
  • Fever (> 38.5 degrees centigrade)
  • Prolonged PR Interval on EKG
29
Q

How is Acute Rheumatic Fever (ARF) diagnosed?

A

Diagnosis of ARF requires 2 major or 1 major and 2 minor Jones criteria and evidence of group A streptococcal infection:

  • Elevated or rising ASO antibody titer
  • Positive throat culture
  • Positive rapid antigen test in a child with clinical manifestations suggestive of strep pharyngitis
30
Q

What are the complications of Group A Streptococcal (GAS) Tonsillitis?

A

Non Suppurative Complications of GAS:

  1. Acute Rheumatic Fever
  2. Streptococcal toxic shock syndrome
  3. Acute Glomerulonephritis - post streptococcal
  4. Pediatric autoimmune neuropsychiatric d/o associated with group A strep (PANDAS)
  5. Scarlet Fever
  6. Severe GAS infections associated with shock and organ failure

Suppurative Complications of GAS tonsillopharyngitis:

  1. Tonsillopharyngeal cellulitis or abscess
  2. Otitis media
  3. Sinusitis
  4. Necrotizing fasciitis
  5. Streptococcal bacteremia
  6. Meningitis
  7. Brain abscess
31
Q

Why do we treat Group A Streptococcal (GAS) Tonsillitis with antibiotics given that it is usually an acute self-limited disease?

A

Antibiotic therapy does the following:

  1. Reduces the duration and severity of symptoms by one to two days when begun within 48 hours of illness onset
  2. Prevents the spread of disease
  3. Reduces the risk of both suppurative and non suppurative complications of GAS
32
Q

What is Acute Rheumatic Fever?

A
  1. ARF is a delayed, non suppurative sequela of a pharyngeal infection with GAS
  2. There is a latent period of 2-3 weeks before the first symptoms of ARF appear
  3. The disease presents with various manifestations that may include
    1. Arthritis
    2. Carditis
    3. Chorea
    4. Subcutaneous nodules
    5. Erythema marginatum
33
Q

What is Post Streptococcal Reactive Arthritis?

A

This is a reactive arthritis with inflammation involving one or more joints that develops within a month following a pharyngeal GAS infection.

34
Q

What is Scarlet Fever?

A
  1. Also known as scarlatina
  2. SF is a diffuse erythematous skin eruption that generally occurs in association with pharyngitis.
  3. Development of the SF rash requires prior exposure to S. pyogenes and occurs as a result of delayed-type skin reactivity to pyrogenic exotoxin (erythrogenic toxin, usually types A, B, or C) produced by the organism.
  4. The rash of SF is a diffuse erythema that blanches with pressure with numerous small (1-2mm) papular elevations giving a ‘sandpaper’ quality to the skin.
    1. The rash usually starts in the groin and armpits and is accompanied by a circumoral pallor and a strawberry tongue
    2. Subsequently, the rash expands rapidly to cover the trunk followed by the extremities and ultimately desquamates
    3. The palms and soles of the feet are usually spared
35
Q

What are Pastia’s Lines?

A

This is a linear petechial rash in the antecubital fossae and axillary folds

36
Q

Does pharyngitis with Scarlet Fever predispose the patient to Acute Rheumatic Fever?

A

Yes

37
Q

How is Scarlet Fever treated?

A
  1. The treatment of Scarlet Fever is the same as that of streptococcal pharyngitis - no additional treatment is warranted for the rash
38
Q

When may a child return to daycare or school after initiation of treatment of GAS pharyngitis/Scarlet fever?

A

A child may return to school/daycare 24 hours after the initiation of treatment for SF/GAS pharyngitis

39
Q

What is Streptococcal toxic shock syndrome (STSS)?

A
  1. STSS is a rare complication of Streptococcal pharyngitis.
  2. This presents as a severe GAS infection associated with shock and organ failure
40
Q

What is post streptococcal glomerulonephritis (PSGN) and how does it present?

A
  1. PSGN is induced by specific nephritogenic strains of GAS (such as type 12 and type 49)
  2. PSGN can occur in sporadic cases or during an epidemic
  3. The incidence of glomerulonephritis in children infected during an epidemic is about 5-10% with pharyngitis and 25% with skin infections
    1. Children below the age of 7 years are at greatest risk
  4. Clinical presentation varies - it can be:
    1. Asymptomatic
    2. Microscopic hematuria
    3. Full-blown acute nephritic syndrome with red to brown urine, proteinuria (which can reach the nephrotic range, edema, hypertension, and acute renal failure
41
Q

How to prevent complications of acute streptococcal tonsillopharyngitis

A

1) Administration of antibiotics within 10 days of the onset of pharyngeal infection reduces the incidence of acute rheumatic fever
2) Antibiotics also prevent other delayed complications of acute pharyngitis such as:
- Acute glomerulonephritis
- Reactive arthritis
- PANDAS

42
Q

What are the clinical features of Toxic Shock-Like Syndrome caused by Group A Streptococci?

A

1) Fever
2) Hypotension
3) Altered mental status
4) Coma
5) Signs of soft tissue infection that usually progresses to necrotizing fasciitis or myositis
6) Active varicella with secondary infection
7) Multiorgan dysfunction, often with acute respiratory distress syndrome
8) Bacteremia present in 60% of patients
9) Case-fatality rate: 30%-60%

43
Q
A

Pediatric ENT (3 decks)

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