Case of E.N.

By Joel Josef Soller and Harold Nathan Tan

Objectives
At

the end of the presentation, the listener should be able to:

1. Understand the anatomy of the tonsils and its function 2. Know how to diagnose and manage common diseases affecting the tonsils, particularly hypertrophy 3. Identify indications for surgical management and properly manage the patient post-operatively

Outline
I. II. III. IV. V.

Case Presentation
Review of Normal Anatomy Infections of the Tonsils and Hypertrophy

Management of Patients with Hypertrophied Tonsils

Prevention, Prognosis and Biopsychosocial Analysis

Identifying Information

E.N. 44 year old married Male Driver Filipino Roman Catholic Taguig City

Chief Complaint: Pabalik-balik na masakit ang lalamunan (recurrent sore throat)

Source: patient

History of Present Illness

Sore throat kumikirot 4/10 severity intermittent Associated symptoms Undocumented fever Pain on swallowing Consult Diagnosed: Acute tonsillitis, given unrecalled antibiotics, resolved

37 years prior to consult (at 7 years old)

Other symptoms: No headache No rhinorrhea or nasal congestion No hoarseness No difficulty breathing No cough No hemoptysis No vomiting

History of Present Illness

Recurrence of sore throat One episode of tonsillitis/ year Given unrecalled antibiotics / episode, with resolution of symptoms

In the interim

Other symptoms: No headache No hoarseness No difficulty breathing No cough No hemoptysis No vomiting

History of Present Illness

Recurrence of sore throat kumikirot 4-5/10 severity Intermittent Associated symptoms: Undocumented fever Pain on swallowing Difficulty of breathing at night Snoring Sudden awakenings with sensation of gasping Daytime sleepiness and fatigue

3 months prior to consult

Other symptoms: No rhinoorhea or nasal congestion No headache No hoarseness No difficulty breathing No cough No hemoptysis No vomiting

ADMISSION

Review of Systems

General. No weight changes. HEENT. No dizziness, no blurring of vision. No hearing changes. Cardiorespiratory. No chest pain. No palpitations. No cough. Gastrointestinal. No abdominal pain. No changes in bowel movement. No gastrointestinal bleeding. Urinary. No dysuria. No frequency. No hematuria. Neurologic. No motor weakness. No sensory loss. No seizures. Endocrine. No temperature intolerance. No excessive sweating. No polyuria, polydipsia or polyphagia.

Past Medical History

Pulmonary tuberculosis (2006), completed 6 months of HRZE

Ureterolithotomy (1998) at East Avenue Medical Cente No history of hypertension, diabetes mellitus, cancer, thyroid disease, cardiac disease, no asthma No history of trauma. No previous hospitalizations. No other past surgeries. No history of medication use. No known allergies to food or drugs .

Family History
Family of E.N. January 2013

E.N. 56

Mother 52

Son 20

Daughter 18

Son 14

No family history of hypertension, diabetes, asthma, thyroid diseases, myocardial infarction, cardiovascular disease, stroke, allergies, cancer

Personal and Social History

High

school graduate
driver 50 pack year smoker

Family

Smoking: Alcohol: No

3-4 bottles of beer/occasion, 2 times/week

use of illicit drugs

No

exposure to environmental toxins

Stakeholder Analysis
Stakeholder Role Stand on the Issue Ally Intensity of Stand Degree of Influence Insight
Moderate Wife shows some awareness of the possible severity of the patients condition Low Children shlow awareness of the possible severity of the patients condition High High Decision making Wife regularly checks up regarding patients on the health status of health concerns is the patient largely influenced by his wife. Moderate Children occasionally checks up on the health status of the patient Low Children have low influence in decision making

Wife

Primary caregiver

Children

Emotional Support

Ally

Health Team

Health Provider

Ally

High Health team monitors and regularly checks patient

High Health team provides options and guidance for patients treatment

High Health team is highly aware of the patients course

Physical Examination
Appearance

Awake, alert, coherent, not In cardiorespiratory distress

Vital Signs

HR: 80 bpm
RR: 27 breaths per min BP: 120/80 cm Temperature 36.6 C. kg Height: 169 Weight: 83.7

Physical Examination
Skin

Normal hair distribution. No rashes. Good skin turgor. Nails without clubbing nor cyanosis.

Hair

Hair of average. Scalp without lesions.

Eyes

Visual acuity 20/20. Visual fields full by confrontation. Pink palpebral conjunctiva. Anicteric sclera. Pupils 3 mm constricting to 2 mm round, regular, equally reactive to light. Extraocular movements intact.

Physical Examination
Ears

No tragal tenderness. Bilateral ear canals clear, no discharge., no masses. Tympanic membrane with good cone of light. Weber midline, AC> BC.

Nose

Mucosa pink. Septum midline. No nasal discharge/congestion. No sinus tenderness.

Oral Cavity

Oral mucosa pink. Dentition good. Tongue midline. No oral ulcers. Grade 3 tonsils, non-hyperemic. Pharynx without exudates, nor tonsilloliths noted.

Physical Examination
Nose

Septum midline. No nasal discharge.

Oral Cavity

Macroglossia. Grade 3 tonsils, non-erythematous, L>R. No exudates. No tonsiloliths.

Physical Examination
Neck

Neck supple. Trachea midline. No cervical lymphadenopathy. Nonpalpable thyroid lobes.

Pulmonary

No retractions. Symmetric chest expansion. No crackles, no wheezes, no rhonchi.

Cardiovascular

Adynamic precordium. Apex beat palpable at the 5 th intercostal space left midclavicular line. Normal rate. Regular rhythm. No murmurs.

Physical Examination
Abdomen

Flat abdomen umbilicus midline Normoactive bowel sounds Liver span: 7 cm, right midlavicular line

No splenomegaly
Tympanitic in all four quadrants No masses felt

Physical Examination

Extremities: Full and equal pulses. CRT < 2 seconds. No cyanosis. Good skin turgor. Warm and without edema.

Physical Examination

Neurologic Examination
Patient was awake, alert, coherent; GCS 15. CN 1 can smell CN2 2-3mm, round pupils, EBRTL, (-) RAPD . No papilledema. CN3, 4 and 6 intact EOMs CN 5 (+) corneal reflex, intact sensory (V1 V2 V3) functions CN 7 no facial asymmetry CN 8 Weber midline. CN9 and 10 can swallow CN 11 able to shrug shoulders, turn head side to side, good tone CN 12 tongue midline, no fasciculations

Physical Examination

Neurologic Examination

Motor: 5/5 strength on all extremities Sensory: 100% on all extremities Reflexes: 2+ on all extremities

Salient Features

SALIENT FEATURES
SUBJECTIVE OBJECTIVE

44 y/o, male Recurrent acute tonsillopharyngitis (1 episode/year) Pain on swallowing, undocumented fever. Snoring episodes, awakens at night gasping for breath, daytime sleepiness 50 pack year smoker No heartburn, no weight loss

Stable vital signs Macroglossia Grade 3 tonsils No cervical lymphadenopathy

SORE THROAT

ACUTE

CHRONIC

SORE THROAT

ACUTE

CHRONIC

Differential Diagnosis
Differential Diagnoses Chronic Hypertrophic Tonsils More Likely Less Likely

CHRONIC SORE THROAT

Enlarged tonsils, snoring, difficulty breathing at night

Gastroesophageal Reflux Disease

Can present with sore throat as gastric acid irritates pharyngeal tissue

No regurgitation, no heartburn, no gastrointestinal pain

Postnasal drip

Pulmonary tuberculosis

Can present with sore throat (via chemical irritation and repeated drying) Can present with sore throat (via irritation)

No nasal congestion, no rhinorrhea No history of chronic cough, weight loss

Primary Working Impression

Chronic Hypertrophic Tonsils Obstructive Sleep Apnea Obese Class I

Review of normal anatomy

Oral Cavity

Oral vestibule Oral cavity proper

Laterally and anteriorly: dental arches Roof: hard palate Posteriorly: communicates oropharynx Floor: tongue

Tonsils
Waldeyer

Tonsillar Ring

Palatine tonsils Adenoids/pharyngeal tonsils Lingual tonsils

Function

Induction of secretory immunity Regulating immunoglobulin production Most active from ages 4 to 10 involute after puberty

Palatine Tonsils

Largest component of the ring Lymphoid tissue:

more compact with clearly identifiably crypts very adherent to the capsule Loose connective tissue- between the capsule and the muscles of the tonsillar fossa

Histology
B- Cell lymphocytes T cell lymphocytes Few mature plasma cells Organization: specialized endothelium-covered channels that facilitate antigen uptake directly into the tissue

Palatine Tonsils
Tonsillar

Fossa

Palatoglossus muscle- anterior tonsillar pillar Palatopharyngeus muscle- posterior tonsillar pillar Pharyngeal constrictors: base (superior constrictor)

Palatine Tonsils
Blood

Supply

Inferior Pole
Tonsillar branch of the dorsal lingual artery Ascending branch of the palatine artery Tonsillar branch of the fascial artery

Superior Pole
Ascending pharyngeal artery Lesser palatine artery (anteriorly)

Palatine Tonsils
Draininage

Venous: peritonsillar plexus lingual and pharyngeal veins Internal jugular vein Lymphatic: tonsillar lymph node or jugulodigastroc or upper cervical LNs
Innervation:

Tonsillar branch of the glossophrayngeal nerve Contributions from the descending branches of the lesser palatine nerve

Diseases of the tonsils

Approach to Sore Throat

History:

Allergy Irritation: dry heat, mouth-breathing, regurgitation, industrial pollutants, chemicals, tobacco smoke, alcohol, spicy foods, voice strain Tumors

Infections
Acute

Streptococcal Tonsillopharyngitis

Group A beta-hemolytic- most common bacterial Fever + sore throat + CLAD + dysphagia + odynophagia; Erythematous, exudative tonsils Other causes
Viruses: adenovirus, EBV, HSV, RSV influenza Vincent angina: Treponema vincentii and Spirochaeta denticulata

Infections
Recurrent Acute

Tonsillitis

Episodes of acute tonsillitis with complete recovery between episodes

Chronic

Tonsillitis

Persistent sore throat, anorexia, dysphagia, pharyngotonsillar erythema Mixed aerobic and anaerobic, predominance of streptococci

Infections
Peritonsillar

Abscess

Extension of infection beyond the capsule Between capsule and surrounding pharyngeal muscle bed High risk in recurrent infections malaise + trismus + odynophagia asymmetrically enlarged tonsils
Tonsilloliths

Stagnation of food and secretions in crypts Bacterial overgrowth Hard white material

Complications of Adenotonsillitis
Scarlet
Acute

Fever- fever + severe dysphagia, exudative tonsillopharyngitis + diffuse erythematous rash

Rheumatic Fever- when throat culture is no longer positive, cross-reactive antibodies- heart damage; ~18 days after throat infection GN- acute nephritic syndrome ~ 10 days after throat infection Adenotonsillar Hypertrophy

Poststreptococcal Chronic

Chronic Tonsillar Hypertrophy

Response to colonization with normal flora

Clinical Presentation:
Adenoid hypertrophy: Nasal obstruction, Rhinorrhea, Hyponasal voice Tonsillar enlargement: snoring, dysphagia, either hypernasal or muffled voice Upper airway obstruction- loud snoring, chronic mouth breathing, secondary enuresis

Grading of Tonsils Based on Size

Obstructive Sleep Apnea

Clinical Presentation
Apneic episodes hypersomnolence or hyperactivity frequent nighttime awakenings poor school performance general failure to thrive

Long term effects:

Pulmonary hypertension Cor pulmonare Alveolar hypoventilation- chronic CO2 retention

Management

Diagnostics

ASO Titer
Antistreptolysin O antibodies in blood plasma
Oxygen-labile hemolytic toxin hemolysis of RBCs

Positive: >200IU Found in groups A, C, and G streptococci

RADT Throat Culture- gold standard CBC, Coagulation Factors, BT, CT Sleep Studies

Therapeutic Goals
1.
2. 3.

Improve Quality of Life

Prevent recurrence of infection Prevent long-term complications

Medical Management
Antibiotics

Penicillin and derivatives Amoxiclav/Claunvunamic Acid Cephalosporins Clindamycin

Supportive

Medications

Anti-pyretics Pain relievers

Modified Centor Scoring

SURGICAL: Tonsillectomy

Paradise Criteria

Frequency:
At least 7 episodes in the previous year At least 5 episodes in each of the 2 previous yrs At least 3 episodes in each of the 3 previous yrs

Clinical features: sore throat+ at least one

T>38.3oC CLAD (tender lymph nodes/ size > 2cm) Tonsillar exudate Culture (+) for A B-hemolytic Strep

Treatment: antibiotics given in conventional dosage

Documentation: on medical records

AAO-HNS Guidelines for Tonsillectomy in Children and Adolescents. 2011. http://www.aafp.org/afp/2011/0901/p566.html

Surgical Indications for Tonsillectomy and Adenoidectomy

Infectious

Diseases

Recurrent, acute tonsillitis

Philippine Guidelines: 4x/year Scottish Guidelines: 5/year AO-ENT: 3/year Paradise Criteria

Recurrent, acute tonsillitis, with recurrent febrile seizures or cardiac valvular disease Chronic tonsillitis, unresponsive to medical therapy or local measures Peritonsillar abscess with history of tonsillar infections

Surgical Indications for Tonsillectomy and Adenoidectomy

Obstructive

Disease

Snoring with chronic mouth breathing Obstructive sleep apnea or sleep disturbances Adenotonsillar hypertrophy with dysphagia or speech abdnormalities Adenotonsillar hypertrophy with craniofacial growth or occlusive abnormalities Mononucleoisis with obstructive tonsillar hypertrophy, unresponsive to steroids

Surgical Indications for Tonsillectomy and Adenoidectomy

Neoplastic

Disease

Asymmetric growth or tonsillar lesion suspicious for neoplasm

Surgical Indications
STRONG Cor-pulmonale due to hypertrophied tonsils Upper airway obstruction OSA Complications: RF, PSGN Dysphagia due to hypertrophied tonsils Peritonsillar abscenss Unilateral tonsillar hypertrophy RELATIVE Recurrent tonsillitis Chronic tonsillitis with halitosis or sore throat Tonsillar hypertrophy with speech distortion or snoring

Operation
Subcapsular

dissection and total removal of the

tonsils
Incision

of mucosa adjacent to the tonsil to find the of blood vessels

capsule
Cauterization Tonsillar

bed is examined for bleeders

Suturing

is avoided

Post-Operation
Post-op

changes

Odynophagia, change of diet, decreased activity

Recovery:

Children 4 days-1 week Adults- up to 2 weeks

Complications: Medications:

hemorrhage

high-dose steroids, antibiotics, local

anesthetics

Post-Operative Plan

Diet:
First 4-7 days: soft, cold diet 5th-8th day onwards: regular food as long as swallowing is comfortable

Activity
Avoid strenuous activities, rest at home Avoid exposure to extreme temperatures, void people with cough and colds Take multivitamins Avoid smoking and drinking alcohol

Watch out For

Persistence of pain Fever, malaise, dysphagia Vomiting occurs after discharge, with gross blood or dark material

Clinical Practice Guidelines

Acute and Chronic Tonsillopharyngitis and Obstructive Adenoidal Hypertrophy
Philippine Society of Otolaryngology-Head and Neck Surgery

Definitions

Acute Tonsillopharyngitis Erythematous and/or exudative tonsils with any one of the ff: sore throat, dysphagia, odynophagia, fever and accompanying tender, enlarged cervical lymph nodes

Viral tonsillopharyngitis Inflammatory condition of tonsils caused by respiratory viruses (adenovirus, influenza, parainfluenza, RSV)

Bacterial tonsillopharyngitis Inflammatory conditionof pharynx and/or tonsils caused by GABHS, H. influenzae, and Moraxhella catarrhalis.

Definitions

Chronic Tonsillopharyngitis Tonsillar inflammation resulting from recurrent clinically documented attacks of acute tonsillitis occurring 4 times per year.

Obstructive Tonsillar Hypertrophy Presence of enlarged tonsils enough to cause symptoms of functional obstruction of the air and food passages such as snoring and dysphagia.

Obstructive adenoidal hypertrophy

Presence of enlarged adenoids enough to cause symptoms of chronic mouth breathing, snoring, hyponasal speech and Eustachian tube dysfunction

Epidemiology

PGH Outpatient Department ORL Clinic (From Jan-May 2005) 10 consults for Acute Tonsillitis 4 consults for Acute Pharyngitis 21 consults for Acute Tonsillopharyngitis 76 consults for Chronic Hypertrophic Tonsils

Prevalence rate: 56 out of 1000 patients seen in PGH have Chronic Hypertrophic Tonsils

Recommendations on Diagnosis

Diagnosis of acute tonsillopharyngitis may be made clinically for both children and adults (grade B)
Differentiate whether infection is viral or bacterial in etiology

Diagnosis of chronic tonsillitis can be made by a history of medically documented episodes of acute tonsillitis for at least 4 times a year (grade C).

Diagnosis of obstructive adenoidal hypertrophy should be made on the basis of enlarged adenoids and a persistent difficulty in breathing and/or swallowing (grade C)
Symptomatic treatment is an integral part in the management of children and adults with sore throat. This includes maintaining adequate fluid intake, warm saline gargle, bed rest, use of analgesics and antipyretics and maintaining good oral hygiene (grade B)

Recommendations on Management

Surgical treatment (tonsillectomy with or without adenoidectomy) tonsillectomy may be recommended in patients with the following conditions:
Tonsillar hyperplasia accompanied by any of the following: upper airway obstruction, dysphagia, speech impairment or halitosis Recurrent or chronic tonsillitis (4 episodes of tonsillitis within a year) Peritonsillar abscess occurring in the background of chronic tonsillitis

Patients with obstructive adenoidal hypertrophy may benefit from adenoidectomy

New surgical modalities for tonsillectomy may be available but are not recommended as routine procedures because of unproven effectiveness and higher expense (radiofrequency, ultrasonic harmonic scalpel

COURSE IN THE WARDS

Course in the Wards

Admitted to the 6th Floor of TMC Monitor vital signs every 4 hours Monitor input and urine output every 4 hours Diet as tolerated and appropriate for age

Diagnostics:
Creatinine: 94 umol/L (N) PT: 13 seconds (N)

aPTT: 29 seconds (N)

Chest xray: Residual fibrosis, right upper lobe Patient is scheduled for tonsillectomy

DAY 1 of Hospitalization
Subjective Awake, comfortable Still with sore throat No fever Noted difficulty breathing at night
Objective Stable vital signs No nasal discharge Grade 3 tonsils No CLADs Clear breath sounds Normal rate, regular rhythm Full and equal pulses

Assessment Chronic Hypertrophic Tonsils Obstructive Sleep Apnea Obese Clas I

Plan
Monitor vital signs Monitor input and output For tonsillectomy

Operative Technique

Placed on general anesthesia Patient placed in Rose position Asepsis and antisepsis. Sterile drapes placed Mouth gag positioned. Right tonsil grasped with Allis forceps. Mucosa of the superior tonsillar pillar infiltrated with 1:100,000 lidocaine + epinephrine solution

Mucosa of the superior tonsillar pillar was incised sing Blade 12

Blunt dissection done at the superior pole going to the inferior pole using unipolar cautery to separate the capsule of the tonsil from its fossa.

Operative Technique

Right tonsil removed. Bleeders controlled using unipolar cautery and Chromic 3-0 suture. Same procedure was done on the left tonsil. Patient tolerated the procedure well.

Operative findings: (+) Grade 3 tonsils without tonsilloliths, no exudates No reportable events

Complications

Blockage of airway from swollen tonsils Dehydration from difficulty swallowing fluids Peritonsillar abscess formation For tonsillectomy: hemorrhage

Prognosis

Good prognosis with prompt treatment and monitoring of patients condition In patients who have undergone tonsillectomy, studies have shown that it produces a positive an durable increase in health related quality of life measures.

Prevention

Adequate hydration Lifestyle changes (refrain from smoking) Avoidance of contact with individuals who are ill or patients who are immunocompromised is useful.

Biopsychosocial Perspective

Medications
HEALTH CARE TEAM FAMILY AND FRIENDS

Psychosocial support

PATIENT

Surgical Management