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 TITLE:   TONSILLECTOMY AND ADENOIDECTOMY
 SOURCE:  Dept. of Otolaryngology, UTMB, Grand Rounds
 DATE:    July 12, 1994 
 FACULTY:                RONALD W. DESKIN, M.D.
 DATABASE ADMINISTRATOR: Melinda McCracken, M.S.
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 "This material was prepared for the Postgraduate Training 
 Program of the UTMB Department of Otolaryngology/Head and Neck Surgery 
 and was not intended for clinical use in its present form.  It was 
 prepared for the purpose of stimulating group discussion in a conference 
 setting.  No warranties, either express or implied, are made with respect 
 to its accuracy, completeness, or timeliness.  The material does not 
 necessarily reflect the current or past opinions of members of the UTMB 
 faculty and should not be used for purposes of diagnosis or treatment 
 without consulting appropriate literature sources and informed professional 
 opinion." 


                    TONSILLECTOMY AND ADENOIDECTOMY:
                                    
                        WHEN ARE THEY WARRANTED?


I.   T&A frequent procedure still.

     -300,000 in 1985
     -Remains controversial
     -when will child benefit?

II.  Most common indications:

     -Obstruction
     -Recurrent infections

III. What goes into your decision?

     A.   Taking the history

          1.   Sore throat
          2.   Dysphagia
          3.   Swollen cervical nodes
          4.   Sleep disturbance

          Mobile society makes hard record keeping and verifiable history.

          Begin new history and keep records.

          Questions to ask:
          
          1.   Sore throat with fever?
          2.   Swollen glands?
          3.   Difficulty swallowing?
          4.   Nasal discharge?  (Sinusitis also)
          5.   Problem breathing -- constant? periodic?
          6.   Mouth breather -- constant? periodic?
          7.   Snoring -- constant? only when ill?
          8.   Coughing at night? -- sinusitis
          9.   Enuresis?

     B.   P.E.
          
          1.   General appearance

               -Normally healthy child with acute illness
               -"Sickly child"
               -Listen to breathing at rest

          2.   Nasal exam

               -Air passage
               -Shrink nose with vasoconstrictor
               -Hyponasality vs. hypernasality
               -("99 bananas")

          3.   Palate length and movement

               -Palpate for sub-mucous cleft
               -Bifid uvula
               -Adenoidectomy contraindicated

          4.   Tonsils
     
               -Inflamed, cryptic concretions
               -Do not gag or extend tongue with exam (false impression of
                size).        

          5.   Neck Exam

               -Large cervical nodes indicate recurrent infections.

     C.   X-Ray

          -Lateral film of nasopharynx with open mouth.
          -Relative obstruction with small nasopharynx.
          -Good films will tell you when no obstruction, but large adenoids
           may not be obstructive (2 dimensional view).
          -Chest x-ray if suspect Cor pulmonale (also EKG).

     D.   Laboratory

          -Throat culture- "quick read"
          -CBC with differential
          -Monospot

IV.  Consultation

     A.   Otolaryngologist

          -Emergency for acute obstruction
          -To evaluate chronic or recurrent problem

     B.   Dental evaluation

          -Orthodontist
          -Pedodontist

          -Adenoid hypertrophy may cause obstruction and 20 palate narrowing
           and overbite.  Orthodontics ineffective without prior            
           adenoidectomy.

     C.   Speech pathologist
          
          -Tongue thrust
          -Hypernasal speech
          =Hyponasal speech

     D.   Allergist

          -If history/P.E. suggests allergy

     E.   Sleep Lab

          -Tape recorder (poor man's sleep study)

V.   Approach we recommend

     A.   Adenoidectomy or T&A -- absolute indication
     
          1.   Obstructive sleep apnea, Cor pulmonale
          2.   Peritonsillar abscess

     B.   T&A relative indications

          1.   Recurrent infection 
          
               - greater than 5/year
               - greater than 4/year x 2 yrs
               - greater than 3/year x 3 yrs

               - Consider severity of infection, school absence, family
                 stress and work absence, general health of child.
          
          2.   Persistent or Chronic Tonsillitis

               - unresolved
               - Beta lactamase producer
               - Rifampin

          3.   Dental malocclusion

     C.   Adenoidectomy - Relative indications

          1.   Nasal and upper airway obstruction with sleep disturbance.
          2.   Chronic otitis media if needs PE tubes for second time
               and/or if has nasal obstruction symptoms--usually over 3
               yrs. of age.

VI.  Weighing the risks

          -Hemorrhage 1-4%
          -Anesthesia complications
          -Severe dysphagia and readmission for hydration

VII. Daysurgery vs. In-patient

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                          BIBLIOGRAPHY 
 
     Paradise JL.  Why T&A Remains Moot.  Pediatrics 49:648-51. 1977.

     Paradise JL, Bluestone CD.  Efficacy of Tonsillectomy for Recurrent
     Throat Infection.  N Eng J Med. 310:674-83. 1984.

     Potsic, WP, Handler SD.  Primary Care Pediatric Otolaryngology. 
     MacMillan Co. 1986.
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