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Head and Neck Diseases

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  1. Head and Neck Diseases Rabia Shihada, MD Department of Otolaryngology – Head and Neck Surgery Bnai-Zion Medical Center

  2. Tonsils and Adenoids

  3. 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.

  4. 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

  5. Anatomy and Physiology • Waldeyer ring: • Palatine tonsils • Adenoids or Pharyngeal tonsils • Lingual tonsils • Similar histology • Similar function

  6. Blood supply • Enters primarily at the lower pole: • Tonsillar branch of the dorsal lingual artery. • Ascending palatine artery. • Tonsillar branch of the facial artery.

  7. 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.

  8. Lymphatic drainage • The lymphatic drainage courses through the upper deep cervical lymph nodes.

  9. Adenoids or Pharyngeal tonsils • Superior posterior wall of nasopharynx. • Dramatic growth in the first years of life. • Regression at approximately age 5.

  10. 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.

  11. 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.

  12. 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.

  13. 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.

  14. Infections • Include bacteria, viruses, yeasts, and parasites. • Some are part of the normal oropharyngeal flora. • Most infections are polymicrobial.

  15. Viral infections • Presentation • Sore throat • Difficulty swallowing • Clinical • Fever • Oropharyngeal erythema without tonsillar exudate • Treatment • Supportive • Superinfection results in more severe symptoms

  16. EBV Infectious mononucleosis. Malaise, lymphadenopathy, hepatosplenomegaly, pharyngitis. Coxsackie Herpangina. Ulcerative vesicles over tonsils, pharynx and palate. Headache, fever, anorexia, odynophagia. Viral infections

  17. Viral infections

  18. Fungal infections • Oropharyngeal candidiasis • Immunocompromised • Prolonged antibiotic treatment • Clinical • Cottage-cheese-like plaques • Bleed if removed • Treatment • Topical nystatin

  19. Bacterial infectionsAcute tonsillitis • Odynophagia, fever, tender cervical lymphadenopathy. • Supporting documents • Fever> 38.5 • Tonsillar Exudate • Tender cervical LAD >2cm • Positive throat culture

  20. Bacterial vs Viral

  21. Bacterial infectionsAcute tonsillitis • Group A Streptococcus is the most common bacterial cause of acute pharyngitis • Two serious sequelae: • acute rheumatic fever • post-streptococcal glomerulonephritis

  22. Bacterial infectionsAcute tonsillitis • Medical Therapy • Antibiotics for 10 days • Injectable forms for noncompliance

  23. 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

  24. Bacterial infectionsChronic tonsillitis • Persistent symptoms • Sore throat • Anorexia • Dysphagia • Pharyngotonsillar erythema • Malodorous concretions • Enlarged lymph nodes

  25. Tonsilloliths • Stagnation of food and secretions in deep/stenotic crypts • Bacterial overgrowth and local infection • Sensation of foreign body and hard white material

  26. Tonsilloliths • Treatment • Aggressive mouth care • Surgery may be needed

  27. Complications of Acute Adenotonsillitis

  28. 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.

  29. Suppurative complicationsPeritonsillar abscess • Clinical • Usually occurs unilaterally • Severe pain • Drooling • Odynophagia and dysphagia • Trismus • Irritation of the pterygoid musculature

  30. 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

  31. Suppurative complicationsPeritonsillar abscess • Management • Cellulitis should be differentiated from abscess in the management of peritonsillar infections • A CT scan may be needed

  32. Suppurative complicationsPeritonsillar abscess

  33. 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

  34. 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

  35. 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

  36. Suppurative complicationsParapharyngeal abscess

  37. Suppurative complicationsParapharyngeal abscess • Clinical presentation • Irritability • Fever • Dysphagia • Muffled speech • Noisy breathing • Stiff neck • Cervical lymphadenopathy

  38. Management Aggressive antibiotic therapy Fluid replacement Close observation Surgical intervention Transoral and external approaches may be used to drain these collections Suppurative complicationsParapharyngeal abscess

  39. Chronic adenotonsillar hypertrophy • Symptoms • Hyponasality • Snoring • Open mouth breathing • Purulent rhinorrhea • Post nasal drip • Chronic cough • Headache

  40. 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

  41. Chronic adenotonsillar hypertrophy • Tonsils size • Grade % • 1 <25 • 2 25-50 • 3 51-75 • 4 >75

  42. Chronic adenotonsillar hypertrophy • Kissing tonsils

  43. Chronic adenotonsillar hypertrophy • Adenoids size

  44. Unilateral tonsillar enlargement • Apparent enlargement vs. true enlargement • Non-neoplastic: • Acute infective • Chronic infective • Hypertrophy • Congenital • Neoplastic

  45. 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

  46. Preoperative evaluation • Complete blood count • Coagulation studies • Lateral Neck/Adenoid films

  47. Preoperative evaluation • Evaluate palate • Symptoms/FH of CP or VPI • Midline diastasis of muscles, bifid uvula • CNS or neuromuscular disease • Preexisting speech disorder?

  48. Surgical techniques • Cold Dissection • Electrosurgery • Intracapsular partial tonsillectomy • Harmonic Scalpel • Radiofrequency tonsillar ablation and coblation