Head and Neck Diseases Rabia Shihada, MD Department of Otolaryngology – Head and Neck Surgery Bnai-Zion Medical Center
Introduction • Tonsils and adenoids can be a source of infection and obstruction for both adults and children. • Tonsillectomy and adenoidectomy remain two of the most commonly performed procedures in the history of surgery.
History • Aulus Cornelius Celsus • 1st Century AD • “the tonsils are loosened by scraping around them and then torn out” with a finger • Used vinegar and medication for postoperative hemostasis • Aetius of Amida • 6th Century AD • Hook and knife method • Mackenzie • Late 1800s • Made tonsillotome use common
Anatomy and Physiology • Waldeyer ring: • Palatine tonsils • Adenoids or Pharyngeal tonsils • Lingual tonsils • Similar histology • Similar function
Blood supply • Enters primarily at the lower pole: • Tonsillar branch of the dorsal lingual artery. • Ascending palatine artery. • Tonsillar branch of the facial artery.
Nerve supply • Tonsillar branches of the glossopharyngeal nerve and the descending branches of the lesser palatine nerves. • Referred otalgia with tonsillitis is through the tympanic branch of the glossopharyngeal nerve.
Lymphatic drainage • The lymphatic drainage courses through the upper deep cervical lymph nodes.
Adenoids or Pharyngeal tonsils • Superior posterior wall of nasopharynx. • Dramatic growth in the first years of life. • Regression at approximately age 5.
Function • Tonsils are involved in inducing secretory immunity and regulating immunoglobulin production. • The tonsils are favourably located to mediate immunologic protection of the upper aerodigestive tract as they are exposed to airborne antigens.
Function • 10 to 30 crypts in each tonsil that are ideally suited to trapping foreign material and transporting it to the lymphoid follicles. • The proliferation of ß cells in the germinal centres of the tonsils in response to antigenic signals is one of the most important tonsillar functions.
Function • Immunologically most active between the ages of 4-10. • Involution of the tonsils begins after puberty. • Decrease in the ß-cell population. • Increase in the ratio of T- to ß-cells.
Function • Although the overall immunoglobulin production is reduced, there is still considerable ß-cell activity in clinically healthy tonsils. • The immunologic consequences of tonsillectomy are unclear. • It is evident, however, that tonsillectomy does not result in a major immunologic deficiency.
Infections • Include bacteria, viruses, yeasts, and parasites. • Some are part of the normal oropharyngeal flora. • Most infections are polymicrobial.
Viral infections • Presentation • Sore throat • Difficulty swallowing • Clinical • Fever • Oropharyngeal erythema without tonsillar exudate • Treatment • Supportive • Superinfection results in more severe symptoms
EBV Infectious mononucleosis. Malaise, lymphadenopathy, hepatosplenomegaly, pharyngitis. Coxsackie Herpangina. Ulcerative vesicles over tonsils, pharynx and palate. Headache, fever, anorexia, odynophagia. Viral infections
Fungal infections • Oropharyngeal candidiasis • Immunocompromised • Prolonged antibiotic treatment • Clinical • Cottage-cheese-like plaques • Bleed if removed • Treatment • Topical nystatin
Bacterial infectionsAcute tonsillitis • Odynophagia, fever, tender cervical lymphadenopathy. • Supporting documents • Fever> 38.5 • Tonsillar Exudate • Tender cervical LAD >2cm • Positive throat culture
Bacterial infectionsAcute tonsillitis • Group A Streptococcus is the most common bacterial cause of acute pharyngitis • Two serious sequelae: • acute rheumatic fever • post-streptococcal glomerulonephritis
Bacterial infectionsAcute tonsillitis • Medical Therapy • Antibiotics for 10 days • Injectable forms for noncompliance
Bacterial infectionsRecurrent Acute tonsillitis • 6-7 of episodes of acute tonsillitis in a 1 year • 5 or more episodes for 2 consecutive years • 3 or more episodes for 3 consecutive years
Bacterial infectionsChronic tonsillitis • Persistent symptoms • Sore throat • Anorexia • Dysphagia • Pharyngotonsillar erythema • Malodorous concretions • Enlarged lymph nodes
Tonsilloliths • Stagnation of food and secretions in deep/stenotic crypts • Bacterial overgrowth and local infection • Sensation of foreign body and hard white material
Tonsilloliths • Treatment • Aggressive mouth care • Surgery may be needed
Suppurative complicationsPeritonsillar abscess • Patients with recurrent tonsillitis/chronic tonsillitis who have been inadequately treated. • The spread of infection is from the superior pole of the tonsil with pus formation between the tonsil bed and the tonsillar capsule.
Suppurative complicationsPeritonsillar abscess • Clinical • Usually occurs unilaterally • Severe pain • Drooling • Odynophagia and dysphagia • Trismus • Irritation of the pterygoid musculature
Suppurative complicationsPeritonsillar abscess • Unilateral swelling of the palate and anterior pillar • Displacement of the tonsil downward and medially • Deviation of the uvula toward the opposite side
Suppurative complicationsPeritonsillar abscess • Management • Cellulitis should be differentiated from abscess in the management of peritonsillar infections • A CT scan may be needed
Suppurative complicationsPeritonsillar abscess • Management • Peritonsillar cellulitis is treated with oral or intravenous antibiotics • The use of needle aspiration and incision and drainage are the mainstay of treatment of peritonsillar abscess in the cooperative patient • A tonsillectomy is then performed 4-12 weeks later in the patient with a history of recurrent tonsillitis
Suppurative complicationsParapharyngeal abscess • Drainage of infection or pus from either the tonsils or from a peritonsillar abscess through the superior constrictor muscle • Located between the superior constrictor muscle and the deep cervical fascia and causes displacement of the tonsil on the lateral pharyngeal wall toward the midline
Suppurative complicationsParapharyngeal abscess • Involvement of the adjacent pterygoid and paraspinal muscles with the inflammatory process results in trismus and a stiff neck • Progression of the infection of the abscess may spread down the carotid sheath into the mediastinum
Suppurative complicationsParapharyngeal abscess • Clinical presentation • Irritability • Fever • Dysphagia • Muffled speech • Noisy breathing • Stiff neck • Cervical lymphadenopathy
Management Aggressive antibiotic therapy Fluid replacement Close observation Surgical intervention Transoral and external approaches may be used to drain these collections Suppurative complicationsParapharyngeal abscess
Chronic adenotonsillar hypertrophy • Symptoms • Hyponasality • Snoring • Open mouth breathing • Purulent rhinorrhea • Post nasal drip • Chronic cough • Headache
Chronic adenotonsillar hypertrophy • Obstructive airway symptoms • Snoring • Apneic episodes with gasping or choking • Daytime hypersomnolence • Nocturnal enuresis • Behavioral disturbances • Heart failure and Failure to thrive
Chronic adenotonsillar hypertrophy • Tonsils size • Grade % • 1 <25 • 2 25-50 • 3 51-75 • 4 >75
Chronic adenotonsillar hypertrophy • Kissing tonsils
Chronic adenotonsillar hypertrophy • Adenoids size
Unilateral tonsillar enlargement • Apparent enlargement vs. true enlargement • Non-neoplastic: • Acute infective • Chronic infective • Hypertrophy • Congenital • Neoplastic
Surgical indications • Recurrent acute tonsillitis • Hypertrophy • Dental malocclusion • Orofacial growth affected • Upper airway obstruction • Dysphagia • Sleep disorders • Cardiopulmonary complications • Peritonsillar abscess • Halitosis due to chronic tonsillitis • Chronic/recurrent tonsillitis with Strep carrier state • Unilateral hypertrophy, presumed neoplasm
Preoperative evaluation • Complete blood count • Coagulation studies • Lateral Neck/Adenoid films
Preoperative evaluation • Evaluate palate • Symptoms/FH of CP or VPI • Midline diastasis of muscles, bifid uvula • CNS or neuromuscular disease • Preexisting speech disorder?
Surgical techniques • Cold Dissection • Electrosurgery • Intracapsular partial tonsillectomy • Harmonic Scalpel • Radiofrequency tonsillar ablation and coblation