Tonsilitis LR

8/18/2019 Tonsilitis LR

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Presentan : Desti Kusmardiani

Supervisor : dr. Agung Dinasti P, M.Kes, SpTHT-KL

Department of Otolaryngology - Head & Neck Surgery

Faculty of Medicine Padjadjaran Univerity

Haan Sadikin !eneral Hopital

"andung

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- Literature Reading –

Tonsillitis,Tonsilletom! AndAdenoidetom!

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'ntroduction

2

Healt( pro)lem from dieae in t(e tonil and adenoid

*eyakumar + et al, +denotonilar Dieae in .(ildren 'n Head and Neck Surgery / Otolaryngology t( ed 0ditor1 "ailey "* & *o(non 2* 3olume one 4ippincot 5illiam & 5ilkin P(iladelp(ia, #$%6 p %67$-66David H Darro8, Diorder of t(e 2onil and +denoid 'n Pediatric Otolaryngology 0ditor1 Scott 9S & David HD +merican+cademy of Pediatric, US+ , #$%# p%:%-#%7



A"AT#M$

3

PHAR$"%

Keith L. Moore. Clinically Oriented Anatomy

5th ed., 2006. p.953



A"AT#M$

+tla of Human +natomy N02209 7rd ed #$$7

6



&ALD'$'R R(")S

5

% +denoid;p(aryngeal<

# 2onil linguali

7 2onil palatina

6 4ateral faringeal)and

P(aryngeal!ranulation

= 2u)al 2onil;!erlac>(<

: 3entricel latlymp(oid tiue



6Keith L. Moore. Clinically Oriented Anatomy

5 th ed., 2006. p.958



AD'"#(D*PHAR$")'ALT#"S(LS

• 2riangular ma oflymp(oid on t(e

poterior apect oft(e )o?likenaop(aryn?

• Formed during t(e 7rd to :t( mont( ofem)ryogenei

7



L(")+AL T#"S(LS

• Uncapulated

• Mot recentdevelopment adult

• Super@cial crypte8

Keith L. Moore. Clinically Oriented Anatomy 5th ed., 2006.



PALAT("' T#"S(LS

Palatine Tonsils : 4ateral 8all of t(e orop(aryn?

+nterior 1 Pillar anterior

Poterior 1 Pillar poterior

4ateral 1 M contrictor p(aryngeu uperior

.ompoition 1 4ymp(oid tiue 9



.OMPON0N2 +ND P9OP092'0S OF

5+4D0A09 9'N!

*eyakumar + et al, +denotonilar Dieae in .(ildren 'n Head and Neck Surgery / Otolaryngology t( ed 0ditor1"ailey "* & *o(non 2* 3olume one 4ippincot 5illiam & 5ilkin P(iladelp(ia, #$%6 p %67$-66 %$



Arteries o Te Tonsils

11

o +cending palatine artery faciali artery poteroinferior

o 2onilar artery facialiartery antero inferior

o Doral lingual artery makilari interna anteromedia

o +cending p(aryngealartery e?ternal carotid

arterypotero uperior

o Palatine mayor & minorartery decendenpalatine artery anterouperior



2onilar )ranc( of 4ingual vein- t(e main drainae ytem oft(e tonillar vein

2onilar acceoria vein ple?u p(aryngeali

Peritonilar vein uperior of tonillar )ed Main )leeding ourceafter tonillectomy

(nternal ugular/eins 12



L!mpati Drainage # Te Tonsil

13

tream of 4imfe of tonilparenkim

eferen limfe in tra)ecula

gland of ervikali profunda

c(et area limfaticu nodulu

t(oraiku duktu

;No +Berent lymp(atic<



"erves o te tonsil :

14

N IX

(Glossopharyngeal)the main nerve.

Descenden branch of

N. palatine.



Anatomi and P!siologi Di0erenes1et2een Te Adenoids and Tonsils

15Brodsy, L. !o"e, C. #onsilitis, #onsillectomyand Adenoidectomy. $n %ead and &ec '(r)ery*Otolaryn)olo)y, 5 th ed.Bailey, +ol. $, 2006. p. -

Adenoids Tonsils

+natomic4ocation

- Poterior 8allnaop(aryn?

- May e?tend intopoterior c(oane

- 4ateral 8all orofaring- Occaionaly e?tend

into naop(aryn? or(ypop(aryn?

!ro 2riangular (apeC invaginated)y deep fold,fe8 crypt

!enerally ovoid(ape,ometime )ilo)ed'nvaginated )y #$-7$)ranc(ing crypt

Microcopic 7 type of epit(elium 1.illiated peudotrati@edcolumnar

Suamou 2ranitional +g proceing

No aBerent limp(atic

SpecialiEed +g proceingNo aBerent limp(atic

P(yiologic Mucocilliary clearance+g proceing'mmune urveillance

+g proceing, immuneurveillance



(MM+"#PH$S(#L#)$ 2(e tonil and adenoid involved

in /oth local immunity and in immuneurveillance for t(e development oft(e )ody> immunologic defeneytem

16

3#R'()"MAT'R(AL

4(")'ST'D*("HAL'D5

Ativation 1,T-

l!mpos

ite, AP6

Loall!presentedantigeni

stimuli

)eneratememor!

l!mposite to7e

disseminated tooter muosal

site *eyakumar + et al, +denotonilar Dieae in .(ildren 'n Head and Neck Surgery / Otolaryngology t( ed 0ditor1 "ailey "* & *o(non 2* 3olumeone 4ippincot 5illiam & 5ilkin P(iladelp(ia, #$%6 p %67$-66



.linical Preentation

;3irue<• play an important rule a initiator ofmucoal inamation, crypt o)truction,ulceration leading to )acterial uperinfection

• r(inoviru, coronaviru, adenoviru, (erpeimple? viru, parainuenEa, eptein-)arrviru, cytomegaloviru

• ymptom1 ore t(roat, odynop(agia, otalgia,(eadac(e, fever

*eyakumar + et al, +denotonilar Dieae in .(ildren 'n Head and Neck Surgery / Otolaryngology t( ed 0ditor1 "ailey "* & *o(non 2* 3olumeone 4ippincot 5illiam & 5ilkin P(iladelp(ia, #$%6 p %67$-66

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.linical Preentation;"acteriologyGMicro)iology<

• Mot infection can )e linked to t(e preence of )eta-lactamae producing organim t(at ditort t(e normalaerodigetive )acterial milieu and can caue

commenal organim to )ecome pat(ogenic

• 'nfection are often polymicro)ial in nature and ofteninclude anaero)ic pat(ogen

• O)truction of tonillar crypt can erve a a nidu for)acterial tai and can furt(er perpetuate a conditionof c(ronic infection, uppuration, and @tulae


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M(6R#1(#L#)$

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1ateria

Aero/ic ro(p A Beta %emolytic 'treptococc(s 1AB%'ro(p B, C, 'treptococc(s%emophil(s in4(ena 1tipe B dan non tipe'treptococc(s pne(moniae, 'treptococc(s epidermidisMoraella catarrhalis, 'taphyllococc(s a(re(s%emophyll(s parain4(ena&eisseria sp.Mico/acteria sp., Lacto/acill(s sp.7. colli, %elico/acter pylori

Chlamydia pne(moniae+naero)ic Bacteroides sp., !eptococc(s sp.

Microaerophillic streptococci8eillonella par+(laBido/acteri(m adolescences7(/acteri(m sp., Lacto/acill(s sp.(so/acteri(m sp., Bacteroides sp.!orphyromonas asaccharolytica!re+otella sp.

3iru 7pstein*Barr, Adeno+ir(s$n4(ena A, B%erpes simple, :espiratoy syncytial!arain4(ena

Ot(er Myco/acteri(m 1atypical nont(/erc(losisCandida al/icans

Brodsky !. "o#e $. %onsilitis %onsillectomy and &denoidectomy. In 'ead and Neck rgery*+tolaryngology , th ed. Bailey vol. I -/. p. 001/

D(33'R'"T(AL #3 AD'"#T#"S(L



D(33'R'"T(AL #3 AD'"#T#"S(L

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T#"S(LS

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'tiolog! : !+"HS, pneumococcu,tap(ylococcu, (aemop(yllu inuenEa,and 0ptein-"arr viru

Patolog! : Hyperplaia and inammaiellular tiue, leukoit, de)ri and)acteria patogen at t(e crypta

6linial Signs : Sore t(roat, dyp(agia, 8eakne, fever, tender cervical nodein t(e preence of tonil t(at are erymatou and (ave e?udate, mallodorou)reat(, otalgia

P!sial e8amination : Hypertrop(i and inamai, 8(ite ekudat, o)tructionof air8ay and muIe ign

Diagnosis : 2(roat culture or rapid trep antigen tet for !+"HS

Terap! : )edret, (ydration, diet, +nalgetik and +nti)iotik

Aute Tonsilitis



90.U990N2 +cute 2oniliti

9ecurrent acute infection (a )eenvaria)ly

de@ned a 1

% Four to even epiode of acutetonilliti in one year

# Five epiode for t8o conecutive

year7 2(ree epiode per year for 7

conecutive year

22



.H9ON'. P09S'S20N2 2oniliti

6linial Signs :

.(ronic ore t(roat, malodorou )reat(, e?ceive tonillarde)ri ;tonillolit(<, peritonillar eryt(ema, and peritent,tender cervical adenopat(y, foreign )ody enation

P!sial '8amination :

Hypertrop(i

.icatric of t(e tonil

Stenoi of t(e crypta

Purulent e?udat

Terap! :

Hydration, +nti)iotik and 2onillectomy

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O"S29U.2'30 2ONS'44+9HAP09P4+S'+

6linial Signs : Snoring 8it( o)tructive ditur)ance ;aleep anda8ake<, dyp(agia, voice c(ange ;muIing or (yponaality<,c(ange )e(aviour and emotion

P!sial e8amination : Hyperplaia tonil 8it( (ealt(y crypta

Terap! :

Paliatif, Preventif and 2onillectomy

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"ull, 92 .olot +tla of 0N2 Diagnoi

6t( ed, 2(ieme, #$$7 p %J=-#%$



AD'"#(DS

DiKcult to diBerentiate from a generaliEed virallyinduce U9' or a true )acterial r(inoinuiti

6linial Signs :

Purulent r(inorr(ea

Naal o)truction

Fever

Otiti media

4oud noring

25

Aute Adenoiditis



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“Presence of four or greater discrete episodesof acute adenoiditis during of a 6-month

period”• Treatment :

+ntimicro)ial prop(yla?i

aymptomatic )et8eeninfection, epecially ifcomor)idity occur ;reactiveair8ay dieae, recurrent otiti<

daily lo8 doe ;one (alf to

one t(ird t(e full doe< epiodic prop(yla?i ;(ortcoure of +" 8it( t(e onetof U9'<

• Di0erential Diagnosis:

9ecurrent acute inuiti

0?traeop(ageal reu?;009<-induced

adenoiditi

Reurrent Aute Adenoiditis



.H9ON'. ;P09S'S20N2< +denoiditi

Often aociated 8it( c(ronic inuiti and otiti media 6linial Signs :

Peritent naal dic(arge,

malodorou )reat(,

potnaal drip, and

c(ronic congetion

27

- 2(e role of 009 a contri)utory to c(ronic adenoidinammation, epecially in younger c(ildren

- +lt(oug( initially adenoidectomy may )e c(oen fortreatment of adenoiditi andGor inuiti, prognoi forimprovement after t(e urgery could diBerigni@cantly ;unpu)li(ed data<



O"S29U.2'30 +denoidHAP09P4+S'+

-'tiolog! :0nlarge adenoid

Naop(aryngeal o)truction

-Te triad os!mptoms :c(ronic naal o)truction

;aociated 8it( noring ando)ligate mout( )reat(ing<,

r(inorr(ea, and

a (yponaal voice

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6linial 'valuation• P(yical e?amination (ould )e performed 8it(

t(e c(ildL mout( open and t(e tongue on t(eoor of t(e mout( 8it(in t(e oral cavity

• Having t(e c(ild ay aa( 8ill allo8 aement

of palatal integrity and motion

• 2onillar (ypertrop(y i uually de@ned a falling8it(in t(e 7 to 6 range

• 2(e otolaryngologit mut )e cogniEant of ign ofc(ronic dieae, uc( a peritonillar eryt(ema,tender cervical lymp(adenopat(y, tonillolit(,moot( glitening tonil, or e?ceively ayptic

tonil 29 *eyakumar + et al, +denotonilar Dieae in .(ildren 'n Head and Neck Surgery / Otolaryngology t( ed 0ditor1 "ailey "* & *o(non 2* 3olumeone 4ippincot 5illiam & 5ilkin P(iladelp(ia, #$%6 p %67$-66

•



1rods9! gradingo tonsil sie

- !rade $urglcally a)ent ;+<

- !rade %8it(in t(e tonillar pillar ;"< ;$to # air8ay o)truction<

-!rade # jut toG)eyond t(e tonillar pillar;.< ;# to $ air8ayo)truction<

-!rade 7

)eyond t(e tonillar pillar, )ut notto midline ;D< ;$ to : air8ayo)truction<

-!rade 6touc(lng 'n t(e midline ;0< ;: to%$$ air8ay o)truction<


7$



6linial 'valuation

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AD'"#(D

Histor! r(inorr(ea c(ronic coug(

potnaal drip o)ligate mout( )reat(ing noring (yponaal peec(

P!sial '8amination•

open mout( appearance•attened mid face claic “adenoid facies”• dark circle under t(e eye

Assessed "asalit! Spee

emp(aiEe naal emiion milman or micey mo(se pinc( t(e noe during anaality tranmitted p(rae anterior and poteriorr(inocopy direct e?i)le @)eropticnaop(aryngocopy ;QQ 7yo<•a)normalitie in t(e

ma?illary- mandi)ularrelation(ip palate evaluation



32

T#"S(LS

2(e Firt-line anti)iotic in acute tonilliti due to !+"HS peniciillin

+nti)iotic eBective againt R-lactamae-producing mo orencapulated anaero)e ;7-= 8eek< in c(ronic tonilliti oro)tructive (yperplaia +mo?-clavulanat orclyndamicin

+cute upper air8ay o)truction 1 Naop(aryngeal air8ay

'mmediate tonillectomy 1-P2+ coe?it 8it( infection of mononucleoi-c(ild 8it( poor clinical repone to medical t(erapy



'ndication of 2onillectomy

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#7strution 2onillar (yperplaia 8it( c(ronico)tructionSleep-related diordered )reat(ing

O)tructive leep apnea yndrome

Upper air8ay reitance yndrome O)tructive (ypoventilationyndrome Failure to t(rive .or pulmonale S8allo8ing a)normalitie Speec( a)normalitie

OrofacialGdental a)normalitie 4ymp(oproliferative diorder

(netion 9ecurrentGc(ronic tonilliti 2onilliti 8it( 1 +)ceed cervical node +cute air8ay o)truction

.ardiac valve dieae Peritent tonilliti 8it( 1

Peritent ore t(roat 2ender cervical node Halitoi 2onilolit(iai

Streptococcal carrier tateunreponive

to medical t(erapy in a c(ild of(oue(old

at rik Peritonillar a)ce unreponive to medical t(erapy or in a patient 8it(

recurrent tonilliti or recurrent

"rodky, 4 Poje, . 2oniliti, 2onillectomy and+denoidectomy 'n Head and Neck Surgery-Otolaryngology, t( ed "ailey, vol ', #$$= p

%%



P+9+D'S0 .9'209'+ FO9

2ONS'440.2OMA


76



Tonsilletom!

Teni;ue o Tonsilletom! :

% Diection and Snare Met(od# 2onil !uillotine ;Sluder< 2ec(niue

7 2onillectomy 8it( 4ocal +net(eia

6 .ryogenic 2onillectomy 0lectroteriliEation of 2(e 2onil

= 4aer 2onillectomy

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36

2ec(niue of 2onillectomy



2ec(niue of 2onillectomy

37

etode Dissetion-Snare



Pot Operative .are

% Maintain air8ay

# .ontrolled of )leeding

7 Maintenance in general

6 Diet tage1

- %-# day1 liuid food and cold

- 7- day1 train porridge or train

food- =- day1 regular porridge

- J-%$ day1 2eam rice

- %% day 1 9iceGregular food38



39

AD'"#(D+ntimicro)ial eBective againt R-lactamae-producingmo 1 recurrent G c(ronic adenoiditi

'ntra naal teroid ;=-to- 8eek< 1 adenoid (yperplaia

Surgical tec(niue 1 mirror viualiEation of t(enaop(aryn? and removal of t(e tiue 8it( (arpcurette, adenotome, po8ered microde)rider, or 8it(cauter

Hemotai 1 'ntraoperative packing, application of

)imut( u)galleate, electrocoagulation of adenoi )ed



Management

40

#7strution +denoid (yperplaia 8it( c(ronic naalo)truction or o)ligate mout( )reat(ing Sleep-related diordered )reat(ing O)tructive leep apnea yndrome Upper air8ay reitance yndrome O)tructive (ypoventilationyndrome Failure to t(rive .or pulmonale

S8allo8ing a)normalitie Speec( a)normalitie OrofacialGdental a)normalitie 4ymp(oproliferative diorder(netion 9ecurrentGc(ronic adenoiditi 9ecurrentGc(ronic otiti media 8it(

eBuion .(ronic otiti media .(ronic inuiti"eoplasia Supected neoplaia, )enign ormalignant

"rodky, 4 Poje, . 2oniliti, 2onillectomy and+denoidectomy 'n Head and Neck Surgery-Otolaryngology, t( ed "ailey, vol ', #$$= p%%

'ND'.+2'ONSOF

+D0NO'D0.2OMA



6ompliations

• Naop(aryngealtenoi

• "leeding

• 2orticolli

• .-pine lu?ation;rare<

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Teni;ue o Adenoidetom!

% .uretae adenoidectomy

- Prepare of curetae

- .uretae

- 0?amination

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a +denoidectomy 8it( (eade?tenion poition

) "eckmann> ring curette



Teni;ue oAdenoidetom!

# +denoidectomy 8it( endocopy

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Helal, =-0ndocopic Po8ered+denoidectomy(ttp1GG888googleerar(GimageGendocopicadenoidectomy



.ON29+'ND'.+2'ON

• .ontraindication to 2&+ includecoagulation a)normalitie t(at (ould )eaddreed prior to urgery, and often reuirea multidiciplinary approac( including(ematology involvement and coordination

• .(ildren 8it( acute illnee t(at mig(timpair t(e a)ility to maintain adeuate

potoperative (ydration or afely undergogeneral anet(eia (ould defer electiveurgery


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Peritonillar a)ce Sore t(roatGdyp(agia +nti)iotic ;iv<

P(aryngotonillar )ulge Needle apirationG' & D in O9

2rimu

Drooling 'mmediate tonillectomy+cute air8ay o)truction Stridor Naop(aryngeal air8ay

econdary to 2 & + MuIedG(yponaal voice Steroid ;iv<

(yperplaia Drooling +nti)iotic ;iv<

0nlarged tonil ;and adenoid<

Hemorr(age pot- "leeding from mout( or noe 4ocal control ;cauteryor

tonillectomy Freuent 8allo8ing vaocontriction<

.ontrol in O9

0valuate for coagulopat(y in

elected cae

6ompliations o adenotonsillar disease

and adenoidetom! and tonsilletom!

6ompliation Presentation Management



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Pot 2 & + air8ay o)truction Occur in @rt 6/#6 ( Naop(aryngeal air8ay

Palatal 8elling Suction gently

Hypop(aryngeal ecretion Steroid ;iv<

De(ydration pot 2 & + Poor oral intake .ontrol emei if preent

Dry mucou mem)rane iv Hydration

4et(argy Parental education

Pain control prn

Peritent 3P' after Hypernaal peec( ;lating Speec( t(erapy

+denoidectomy )eyond # mo potop< Palate urgery

Naal regurgitation of uid

Pulmonary edema after DiKculty 8it( o?ygenation Poitive and e?piratoryventilation

relief of air8ay o)truction noted

)y anet(eiologit

Frot(y pink ecretion from 4ai?

endotrac(eal tu)e Morp(ine

Hitory of o)tructiona

ManagementPresentation6ompliation



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#$%$ .4'N'.+4 P9+.2'.0 !U'D04'N0S


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H()HL()HT

• +denotonillar dieae uually preent inc(ildren 8it( eit(er recurrent t(roatinfection or SD" Preently t(e motcommon indication for 2&+ i SD"

• +ppro?imately 7$ of )acterial cae ofacute tonillop(aryngiti are caued )y!+"+, 8it( a varying contri)ution from

ot(er pat(ogen, including group . )eta-(emolytic treptococci, N g$%%$%2(oeae,. dip(t(eria, . pneumoniae, and Mpneumuniae

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H'!H4'!H2

• 2(e +merican +cademy of Otolaryngology-Head and Neck Surgery pu)li(ed a.linical Practice !uideline on t(e

indication for tonillectomy )aed on ane?tenive literature revie8 and an e?pertpanel t(at included )ot( otolaryngologitand nonotolaryngologit 2(ey made

recommendation to addre t(e t8o motcommon indication for tonillectomy1recurrent tonilliti and SD"

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Tan9 $ou

Tonsilitis LR

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