Pediatric Adenotonsillar Disease and Obstructive Sleep-disordered Breathing

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How is tonsillar hypertrophy graded?

Tonsil size is graded as 1 to 4 according to the percentage projection from the anterior tonsillar pillar toward the midline. A 1+ tonsil projects 0% to 25% from the anterior tonsillar pillar toward the midline, 2+ projects 25% to 50%, 3+ projects 50% to 75%, and 4+ projects 75% to 100%. Tonsils graded 4 are sometimes referred to as “kissing” tonsils because they touch in the midline.

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What is the function of the tonsils and adenoid?

The tonsils and adenoid are predominantly B-cell lymphoid structures that probably play a role in secretory immunity. They are appropriately positioned for exposure to inhaled and ingested antigens, which can induce immunoglobulin and lymphokine production. Hyperplasia is thought to result from B-cell proliferation during exposure to high doses of antigen. Tonsils and adenoids are immunologically most active between the ages of 4 and 10 years, and tend to involute after puberty. There are no studies to date that demonstrate significant alterations in the immune system following an adenotonsillectomy.

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What are tonsilloliths?

Tonsillar concretions, or tonsilloliths, are whitish, cheesy, malodorous, foul-tasting lumps that can form in the tonsillar crypts. They arise from bacterial growth and retained debris, and although they are often asymptomatic, tonsilloliths can cause problems with halitosis, foreign body sensation, and otalgia. Conservative management includes gargling and expression and removal of tonsilloliths by the patient using cotton swabs or a dental water jet device.

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How does bacterial tonsillitis present?

Sudden onset of throat pain, odynophagia, enlarged erythematous tonsils with exudate, halitosis, fever, malaise, and tender cervical nodes are classic symptoms and signs of acute tonsillitis. The classic rash associated with scarlet fever appears on the neck and face and then spreads and looks like sunburn with tiny bumps. The rash will blanch when one presses on it. Viral pharyngitis tends to be milder in presentation and usually without exudates. There may be an associated cold, cough, conjunctivitis, diarrhea, and rash. Epstein-Barr virus (EBV) is a notable exception.

5

Name the most common infectious etiologic agents involved in adenotonsillar disease.

Group A β-hemolytic streptococcus (GABHS) is the most common cause of acute tonsillitis and can be associated with such serious sequelae as rheumatic fever and poststreptococcal glomerulonephritis. Numerous other organisms, however, are commonly associated with adenotonsillar disease, including non-GABHS bacteria and beta-lactamase-producing organisms such as Bacteroides species, nontypeable Haemophilus species, Staphylococcus aureus , and Moraxella catarrhalis . Common viral pathogens include adenovirus, coxsackievirus, parainfluenza, enteroviruses, EBV, herpes simplex virus, and respiratory syncytial virus.

6

Describe the otolaryngologic manifestations of mononucleosis.

Mononucleosis is caused by EBV and often produces an exudative tonsillitis that may appear indistinguishable from bacterial infections. Signs and symptoms of mononucleosis include high fever, malaise, generalized lymphadenopathy, enlarged tonsils with yellow-gray exudates, odynophagia, dysphagia, palatal petechiae, and hepatosplenomegaly. Useful lab results include lymphocytosis and the presence of atypical lymphocytes, as well as a positive Monospot and heterophil antibody titers. If mononucleosis is suspected, amoxicillin should be avoided because it may cause a salmon-colored rash.

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How should adenotonsillar infection be treated?

It can be difficult to distinguish viral from bacterial tonsillitis/pharyngitis. Most viral infections are self-limited and require only supportive care. If a bacterial infection is suspected, a rapid streptococcus detection test should be performed. If the test results are negative, a throat culture should be performed. Penicillin is the initial drug of choice for culture-positive streptococcal infections. Resistance to penicillin or first-generation cephalosporins has not been reported. Tetracyclines, sulfonamides, and quinolones should not be used for treating GABHS infections. If a child is a suspected strep carrier, the most effective treatment is clindamycin for 10 days.

8

What is a peritonsillar abscess? How does it present?

A peritonsillar abscess is a collection of pus in the potential space that surrounds the tonsil, between the tonsillar capsule and the superior constrictor muscle of the lateral pharyngeal wall. This process develops when infection penetrates the tonsillar capsule and enters the peritonsillar space. Over half of patients who present with peritonsillar abscess have a history of prior tonsillitis. Symptoms include throat pain, fever, dysphagia, a “hot potato” or muffled voice, trismus, and drooling. Examination reveals infected, swollen tonsils. The peritonsillar area is inflamed and swollen, usually unilaterally, with a bulge in the soft palate superior to the tonsil and displacement of the uvula toward the contralateral side.

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How is a peritonsillar abscess managed?

Needle aspiration or incision and drainage with recovery of pus can be diagnostic and therapeutic and has been shown to be effective more than 90% of the time. This procedure can usually be performed in the office or emergency department. After drainage, an antibiotic with gram-positive and anaerobic coverage, such as amoxicillin or clindamycin, is recommended. Tonsillectomy is recommended if a patient has had more than one peritonsillar abscess. It is performed after complete resolution of the infection. In selected cases, a quinsy tonsillectomy (tonsillectomy in the presence of abscess) is indicated, such as when drainage fails to adequately treat the abscess, or sometimes in children, who often require a general anesthetic for drainage anyway.

10

How is obstructive sleep apnea (OSA) different from obstructive sleep disordered breathing?

OSA is a diagnosis that requires an abnormal polysomnogram. oSDB is a clinical diagnosis with the following features: snoring with associated gasping, labored breathing, and daytime symptoms that may include hyperactivity, inattention, poor concentration, and excessive sleepiness ( Box 51.1 ).

11

What are the indications for requesting a polysomnogram?

According to the American Academy of Otolaryngology/ Head and Neck Surgery (AAO/HNS) clinical practice guideline, one should obtain a preoperative polysomnogram prior to an adenotonsillectomy in the following circumstances: obesity, Down syndrome, craniofacial abnormalities, neuromuscular disorders, sickle cell disease, mucopolysaccharidoses, <2 years of age, or if history and physical examination are discordant.

12

What does one assess during a sleep study?

The information contained in a sleep study allows one to evaluate sleep quality, degree of obstruction, and gas exchange ( Box 51.2 ).

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