Cervicofacial infection in children

1. CHAPTER 37-
CERVICOFACIALINFECTIONS
PRESENTER :DR.AISWARYA
M.S PG 2nd YR
MODERATER:PROF
DR. ALAGUVADIVEL M.S
SCOTT BROWN Learning
2020
VOLUME 2
Page no: 423 - 432

2. OVERVIEW
INTRODUCTION
CLASSIFICATION OF CERVICOFACIAL INFECTIONS
AETIOLOGY OF INFLAMMATORY NECK NODES
CLINICAL APPROACH
SPECIFIC CERVICOFACIAL DISEASES

3. INTRODUCTION
Cervicofacial infections in children
usually presents as neck mass

4. BASIC TERMINOLOGIES
ABSCESS -accumulation of pus in a confined space
;inflammatory response to bac/parasite/foreign material
CELLULITIS -inflammation of s.c/connective tisue;
characterised by fever pain, redness ,warmth,& tenderness of
swelling
FASCIITIS -inflammation of fascia
NECROTISING FASCIITIS -aggressive tissue infection
,spreads rapidly, causes necrosis along path of spread

6. AETIOLOGY OF
INFLAMMATORY NECK NODES
APPROX 300 LYMPH NODES IN THE NECK
Nodes have high conc.of lymphocytes and APCs
in neonates -barely perceptible
in later childhood- due to Ag exposure ,progressively increases in
size
adolescence-starts to undergo atrophy

7. INFLAMMATORY ADENOPATHY
INFECTIVE NON INFECTIVE
CONT.....

8. CONT,.....

9. CONT.......

10. CLINICAL APPROACH
H/O TAKING
GENERAL EXAMNATION
HEAD &NECK EXAMINATION
SITE OF SWELLING
INVESTIGATION

11. HISTORY
AGE OF CHILD- mostly presents at >6 mo; if at birth ~pathological/neoplastic
DURATION OF SWELLING - acute/ chronic (>6 wks)
SIZE
ASSOCIATED SYMPTOMS -Acute swelling~URI/fever/rhinorrhea/sore
throat/malaise,Chronic swelling- wt loss,/night sweats/chronic cough/,swellings
elsewhere
CONTACTS- TB , Exposure to cats,farm animals,& ticks, Recent travel H/O
MEDICAL HISTORY - any illness , recent immunisations, regular medications(
CBZ,phenytoin,INH)
FAMILY HISTORY-H/O familial disease or congenital anomalies

12. SITE OF SWELLING
LATERAL NECK SWELLINGS
CENTRAL NECK SWELLINGS
PAROTID SWELLINGS
SUBMANDIBULAR SWELLINGS
POSTERIOR TRIANGLE SWELLINGS

13. LATERAL NECK SWELLINGS
Lymph node distribution- MC along superficial and deep cervical
chains
In upper neck~lie deep to SCM ;In lower neck -along ant border of
SCM
D/D - congenital cyst,vasoformative lesions,benign & malignant
neoplasm, secondary mets

14. CENTRAL NECK SWELLINGS
Thyroglossal duct cyst
lymph nodes
dermoid cyst
inflammatory/ neoplastic
thyroid diseases
Lymphatic malformations
Type to enter a caption.
Type to enter a caption.

15. PAROTID SWELLINGS
Parotid glands in adults ~mainly
parenchymal glandular tissue; in children
~intraparotid lymphoid tissue
Acute viral parotitis(mumps) - self
limiting,outbreaks still occur sporadically
Bacterial parotitis -recurrent,acute painful
swelling, resolves with antibiotics
chronic inflammatory swellings
Neoplasia - Rhabdomyosarcomas/ other
connective tissue tumors
Vascular malformations / hemangiomas -
MRI Useful for diagnosis Type to enter a caption.

16. SUBMANDIBULAR SWELLINGS
Enlarged lymph nodes
Floor of-mouth infections
Acute sialadenitis
Plunging ranula
Lymphatic or Vascular malformations

17. POSTERIOR TRIANGLE
SWELLINGS
Lymph node enlargements
Branchial anomalies
Vascular malformations
Neoplasia

18. EXAMINATION
GENERAL EXAMINATION - fever
,tachycardia,rash,lymphadenopathy,hepatosplenomegaly
LOCAL EXAMINATION - Acute swelling~ warmth,redness,
tenderness (+);chronic swelling ~ no signs of acute inflammation ;
If abscess formed ~ cystic ,fluctuance (+)
HEAD & NECK EXAMINATION - examination of ear, nose,
pharynx,any cutaneous lesions in scalp

19. INVESTIGATIONS
Full blood count
CRP
Serological test,Monospot test for infectious mononucleosis
Mantoux /Heaf test for TB
ChestXray
Ultrasound
CT Scanning
MRI

20. SPECIFIC CERVICOFACIAL
INFECTIONS
VIRAL INFECTIONS
BACTERIAL INFECTIONS
MYCOBACTERIAL INFECTIONS
FUNGAL INFECTIONS
PARASITOSIS

21. VIRAL INFECTIONS
VIRAL UPPER RESPIRATORY INFECTIONS
INFECTIOUS MONONUCLEOSIS
HIV

22. VIRAL UPPER RESPIRATORY
INFECTIONS
ADENOVIRUS
RHINOVIRUS
ENTEROVIRUS(Coxsackie A &B)

23. INFECTIOUS MONONUCLEOSIS
An acute infection - Epstein–Barr virus (EBV).
Occurs mainly in adolescence ;Spread by close contact.
Fever, fatigue, malaise and an exudative tonsillitis are
characteristic (Figure 37.1). Cervical lymphadenopathy may
be massive
Liver & spleen may be enlarged.
Blood film - presence of atypical lymphocytes
(characteristic)
Diagnosis -Serological tests such as Monospot or Paul–
Bunnel
I.V. antibiotics -to treat any coexistent bacterial infection.
Ampicillin and amoxicillin are contraindicated as they
can cause a skin rash when used in Epstein–Barr virus
infection.
If acute tonsillitis A/w airway obstruction,-Steroids . ETT -
required to protect the airway until the swelling subsides
Splenomegaly - last at least 4 weeks ;but can take as long
as 8 weeks to settle ; refrain from contact sports.
Type to enter a caption.

25. HIV
Infection is associated with repeated opportunistic infections.
Pediatric HIV infection acquired from mother by vertical transmission.
Acute infection mimic infectious mononucleosis.
Persistent generalized lymphadenopathy ,Weight loss and recurrent fevers
occur.
Rx - Antiretroviral therapy
Investigation and management in cooperation with specialist in paediatric
infectious diseases.

26. BACTERIAL INFECTIONS
MC Causative organisms for suppuration in the neck - Group A
beta haemolytic streptococcus and Staphylococcus aureus .
Others- Anaerobes (19%); Haemophilus influenzae, Moraxella
catarrhalis & beta lactamase-positive organisms.

27. ACUTE LYMPHADENOPATHY
WITH SUPPURATION
CERVICAL ABSCESS
DENTAL ABSCESS
DEEP NECK SPACE INFECTION (DNSIs)
LUDWIGS ANGINA
LEMIERRE’S syndrome

28. CERVICAL ABSCESS. -Bacterial infection of cervical lymph node
local cellulitis. abscess formation
PHLEGMON -A solid mass of inflammatory tissue forms due to coalescence of a group
of lymph nodes
ABSCESS V/s PHLEGMON - abscesses require surgical drainage ; phlegmons settle
with i.v antibiotics. Clinically Abscesses are tender, usually reddened & cystic.
FLUCTUANCE + ve.
Management -surgical drainage. performed by a neck incision, /A wide-
bore needle aspiration may be adequate if the pus has coalesced and liquefied.
DENTAL ABSCESS - An infected molar or premolar -cause extensive swelling
extending into the face and neck

30. DEEP NECK SPACE INFECTION(DNSIs)
Deep neck spaces descried w.r.t hyoid bone.
Can be suprahyoid, infrahyoid or comprise the entire length of the neck
DNSIs -severe and potentially life-threatening complications[,mediastinitis, septic embolization, dural
sinus thrombosis. & intracranial abscess.]
Parapharyngeal and retropharyngeal lymph nodes - drainage pathway for adenoid and tonsillar infections
in children aged 1–5 years. Suppuration & perforation of these nodes DNSIs.
(retropharyngeal,parapharyngeal and peritonsillar spaces )
Retropharyngeal abscess - uncommon but should be recognized because of its potential to cause
fatal air- way obstruction. Child usually febrile, drooling adopt a characteristic posture with the neck
flexed and the head extended. . Imaging required to confirm suspected clinical diagnosis,CT scanning
with contrast is the modality of choice & if confirmed surgical drainage is indicated.Drainage can be via
an intraoral or external approach,

31. LUDWIGS ANGINA
Rapidly progressing cellulitis of the floor of mouth,
involving the submandibular neck space.
Secondary to dental infections also seen after
frenuloplasty
Causative organisms - Streptococcus sps
,Gram-negative rods & anaerobes.
Presentation -swelling of neck & submandibular
space, firm induration of the floor of mouth,
resulting in elevation and protrusion of the tongue.
- air-way obstruction.
Treatment - Securing the airway, f/b i.v
antibiotics. Surgical intervention if persistent or
progressive or if evidence of abscess formation.;
intraoral & external approaches to ensure drainage
of submaxillary & sublingual spaces.

32. LEMIERRE’S syndrome
Rare but potentially fatal complication of oropharyngeal
infection
Septic thrombophlebitis of the IJV.
Causative org - bacterium Fusobacterium
necrophorum. (mortality rate exceeding 50%)
Presents following an episode of upper respiratory
sepsis; patient develops high spiking fevers with
tenderness and fullness of one side of the neck.
Pulmonary emboli may occur causing lung abscess
formation.
Diagnosis -Doppler ultrasound ;CT scan with contrast
is the choice
Treatment -antibiotics (6 wks); drainage of any
abscess is usually curative.
Type to enter a caption.

33. CAT SCRATCH DISEASE
Granulomatous condn characterized by
lymphadenopathy ,fever &malaise.
Causative organism -bacteria Bartonella henselae.
Vector - flea .
Close contact with cats harboring these vectors / faeces
of cat fleas .
Transmission - inoculation with flea faeces containing
B. henselae through contaminated cat scratch wound
/ across mucosal surface
Diagnosis -Serologic testing has a high sensitivity and
specificity.
No medical treatment, but confirmation of the diagnosis ~
reassure & R/O malignancy.
Lymphadenopathy may persist for months Type to enter a caption.

34. TULAREMIA
Aka Rabbit fever or Deer fly fever.
Organism -Gram-negative bacillus Francisella tularensis.
Transmission- rabbits, ticks or contaminated drinking water.
Clinical features- Skin or mouth ulcers A/w lymphadenopathy, fevers, malaise
and headache.
Diagnosis -difficult ;organisms can be isolated from blood cultures during
periods of pyrexia. Also confirmed by rising serological titres in the
convalescent phase .
TOC is streptomycin ; Tetracycline, aminoglycosides or chloramphenicol also
used.

35. ACTINOMYCOSIS
Gram-positive non-spore forming bacteria ~Actinomyces .
MC - Actinomyces israelii
Actinomyces ~normal commensals in oral cavity
;infections arise from a breach of the mucosa (e.g. dental
extraction).
Approximately 50% of cases are cervicofacial
MC Presentation ~slow-growing painless mass near
mandible;. with or without lymphadenopathy
Untreated progresses to fibrosis & chronic suppuration with
draining sinuses.
The presence of sulphur granules is pathological.Culture of
organism -diagnostic
Rx - surgical excision f/b prolonged anti- bacterial therapy,
(penicillin -6 months.) Type to enter a caption.

37. BRUCELLOSIS
Zoonosis, .
Brucella (Gram- negative bacilli)
Working with livestock /consumption of unpasteurized dairy products
/infected meat products
Clinical features -Lymphadenopathy involving the neck and other body
regions A/w fever, malaise ,migratory myalgia and arthralgia.
Diagnosis ~by serology.
Rx ~tetracycline in adults ;trimethoprim-sulphamethoxazole in children.
10% ~present with relapse

38. MYCOBACTERIAL INFECTIONS
MYCOBACTERIUM
TUBERCULOSIS
[ wt loss,persistent
cough, fever,anorexia]
ATYPICAL
MYCOBACTERIA /NTM
/MOTT(18 mo - 3 yrs)
( mass with discolored
skin)
)
ubiquitous in nature
PAINLESS ,FIRM, NECK
MASS

39. Type to enter a caption.
Type to enter a caption.

40. DIAGNOSIS & MANAGEMENT
D/D - lymphoma.
Biopsy - sent for HPE & microbiology, (including staining and culture specific to mycobacterium).
HPE - caseating granuloma formation. Acid- and alcohol-fast staining bacilli may be seen ;
histopathologically difficult to distinguish tuberculous from NTM infection. Culture helps to
differentiate ;but take several weeks.
CHEST XRAY
TUBERCULOUS SKIN TEST -. A positive test in a non immunised pt - highly suggestive but not
absolutely diagnostic for tuberculosis.
MANAGEMENT OF TB LYMPHADENOPATHY - ATT
MANAGEMENT OF NONTUBERCULOUS LYMPHADENOPATHY - controversial. Complete
surgical excision / Prolonged medical therapy (with surgery there is a scar / possible injury to the
facial nerve or its branches ; untreated NTM usually resolves in 3–6 months rarely upto 1 yr )

41. SYPHILIS
Spirochete infection -Treponema pallidum.
Primary syphilis is A/w ulcer (chancre)& local lymphadenopathy.
In HIV associated pts -Early presentation with a neck mass may occur
Pediatric population ~congenital syphilis ; usually asymptomatic at birth. If untreated
late congenital syphilis.
Head and neck manifestations include neurosyphillis, saddle nose deformity and
Higoumenakis’ sign,[ sternoclavicular jt enlargement caused by periosteitis in congenital
syphilis.]
DIAGNOSIS- SEROLOGICAL [(VDRL) and (RPR) tests] ; Confirmed by treponemal-specific
tests, Treponema pallidum haemag- glutination assay (TPHA) or fluorescent treponemal anti-
body absorption (FTA-ABS) tests.
TREATMENT -single dose of i.m penicillin or oral azithromycin. ; Neurosyphilis.
high dose pencillin (10 days )

42. FUNGAL INFECTIONS
HISTOPLASMOSIS
CANDIDA & ASPERGILLUS

43. HISTOPLASMOSIS
Caused by fungus Histoplasma capsulatum.
Associated with bird droppings ;acquired via airborne spores
CentralUS ~very common and typically asymptomatic.
Pulmonary and systemic disease may occur in immunocompromised patients; common in HIV/AIDS . lesions
may mimic squamous carcinoma ; only severe infections ~lymphadenopathy.
Diagnosis ~ urine antigen testing. Serum antigen tests at > 4 weeks of the infection ; Blood cultures take 6
weeks to produce diagnostic growth
Immunocompetent patients ~no treatment required
Severe acute and chronic disseminated infections. ~ Amphotericin B & Itraconazole
CANDIDA AND ASPERGILLUS
Mucosal candidiasis common in children ;but neck masses ~ extremely rare and limited to
immunocompromised patients.

44. PARASITOSIS
Toxoplasma gondii ~ ingestion of poorly cooked meat /oocytes
excreted in cat faeces.
Cervical adenitis in more than 90% of clinical cases
Subclinical infection and positive serology ~in asymptomatic
individuals
Detected by PCR in human blood samples .
Lymphadenopathy usually self limiting,but chronic~so R/O
malignancy
Responds to sulphonamides and pyrimethamine

45. NON INFECTIVE
INFLAMMATORY DISORDERS
SARCIODOSIS
KAWASAKI SYNDROME
KIKUCHI- FUJIMOTO DISEASE
SINUS HISTIOCYTOSIS

46. SARCOIDOSIS
Chronic multisystem disorder of unknown aetiology.
Mostly in second decade of life ;rare in children.
causes generalized and pulmonary symptoms ;also involve other parts of the body.
Neck masses, parotid masses and facial nerve paresis, often B/L
Cervical nodes - typically bilateral & non-tender.
Diagnosis - chest Xray ;confirmed by biopsy, ~shows typical non-caseating granulomas.
Angiotensin- converting enzyme blood levels used in diagnosis and monitoring of
sarcoidosis.
Treatment - CONSERVATIVE

47. KAWASAKI DISEASE
Acute multisystem vasculitis of unknown aetiology.
Affect children < 5 years of age . Diagnosis is
clinical ; children should have 4/5 following
criteria:
1. acute non purulent lymphadenopathy– usually U/L
2. erythema, oedema and desquamation of the hand
and feet
3. polymorphous exanthema
4. painless bilateral conjunctival infection
5. erythema and injection of the lips and oral cavity.

48. SINUS HISTIOCYTOSIS (ROSAI–DORFMAN DISEASE)
Simulate infectious mononucleosis or lymphoma .
Present with massive cervical lymphadenopathy ;Fever and skin nodules may be present.
abnormal histiocytic response to some precipitating cause, (possibly a herpes virus or EBV.)
Biopsy required to R/O malignancy. HPE reveals dilated sinuses, many plasma cells &marked
proliferation of histiocytes.
KIKUCHI-FUJIMOTO DISEASE
Idiopathic disorder,
Presents with lymph gland enlargement ,most typically cervical.
A /w Fever chills & weight loss .
Self limiting disease ;biopsy done R/O malignancy.
Histology shows a characteristic necrotizing lymphadenitis.

49. Other features - Thrombocytosis
& Pericardial effusion
Coronary artery aneurysms
develop in 15–20% of cases.
Management -i.v gamma
globulin therapy. . All patients
should have an initial
echocardiogram and cardiac
follow-up.

51. CHAPTER -38
DISEASES OF TONSILS,TONSILLECTOMY &
TONSILLOTOMY
SCOTT BROWN
page no: 435- 441

52. STRUCTURE OF TONSILS
Palatine tonsils -paired structures consisting of lymphoid tissue.
Located within tonsillar fossa b/w anterior & posterior tonsillar pillars
formed by palatoglossus and palatopharyngeus muscles.
Waldeyers ring - Palatine tonsils , adenoids, lingual tonsils, tubal tonsils &
aggregates of pharyngeal sub- mucosal lymphoid tissue
Histology- consist of aggregates of lymphocytes arranged in a
follicular manner & embedded in a stroma of connective tissue. Epithelial
lining is stratified squamous, invaginates into parenchyma forming
crypts.

54. FUNCTIONS OF TONSIL
The tonsils are composed of lymphoid tissue with Both T- and B-lymphocytes ( B-
lymphocytes predominate.)
Serves both cell-mediated and humoral immune function.
The B-cells synthesize specific antibodies. On exposure to antigen, immunoglobulin IgG
and IgA plasma cells are produced. Contact with allergens in URT therefore enhances
local immunity
Tonsillectomy do not result in impaired immunity ; as a result of the extensive ‘back-
up’ in immune system.
Certain latent viruses (particularly EBV , adenoviruses and HSV)sensitises pathogenic
bacteria present incidentally on the tonsils of asymptomatic individuals.

55. INFLAMMATORY DISORDERS
OF TONSILS
ACUTE TONSILLITIS
INFECTIOUS MONONUCLEOSIS
OTHER INFECTIVE CONDITIONS

56. ACUTE TONSILLITIS
Acute tonsillitis- can be localized , in A/w an URI or as a part of
generalized systemic infection such as infectious mono- nucleosis.
Predominantly a disease of children & young adults ; peak
incidence ~5-7 yrs of age & young teens.
The most commonly identified causative organism usually is
GABHS ;other organisms -H.influenza,S.aureus,alpha hemolytic
Streptococci,Brahnamella spp,Mycoplasma, Chlamydia,
Anaerobes & respiratory viruses.

57. DIAGNOSIS & MANAGEMENT
Acute H/O sore throat, fever and pain on swallowing.
O/E reveals erythema of the tonsils and posterior
pharyngeal wall, with exudates on the tonsils
occasionally.
Tender jugulodigastric lymph node enlargement. .
Management - mainly symptomatic i.e. using
analgesia & hydration . Antibiotics ; benzyl-
penicillin being the drug of choice.
In severe cases corticosteroids found to provide
symptomatic relief of pain in sore throat, in
addition to antibiotic therapy.

58. COMPLICATIONS OF ACUTE
TONSILLITIS
PERITONSILLAR ABSCESS (QUINSY)
PARAPHARYNGEAL ABSCESS
RETROPHARYNGEAL ABSCESS
LEMIERRE’S SYNDROME
IMMUNE COMPLEX DISORDERS
TONSILLITIS AND PSORIASIS
RECURRENT TONSILLITIS
CHRONIC TONSILLITIS

59. PERITONSILLAR ABSCESS
Defn - Collection of pus lateral to the tonsil.
Symptoms ~ severe ,U/L sore throat, odynophagia,
trismus and lymphadenopathy.
Treatment ~ Antibiotics(i.v high-dose penicillin or a
cephalosporin) , needle aspiration of pus or incision and
drainage.
The initial management of choice is aspiration of
the abscess using a wide-bore needle along with
intravenous antibiotics, usually high-dose penicillin
or cephalosporin.
Indication for interval tonsillectomy ~ any previous
history of tonsillitis or more than one episode of quinsy
on the same side.
Tonsillectomy not advised during acute attack ,
as the release of pus into the oral cavity either
spontaneously or therapeutically carries with it the
risk of aspiration in severely ill patients.

61. RETROPHARYNGEAL ABSCESS
A rare but serious complication of acute tonsillitis,
; mainly in infants and children < 5 yrs of age .
Infection tracks into the lymphoid tissue b/w
posterior pharyngeal wall & the pre- vertebral
fascia.
Child usually systemically unwell & there may be
evidence of airway compromise or an associated
neck abscess.
Diagnosis ~ confirmed by CT scanning.
Treatment ~ high-dose i.v antibiotics. If pus
collection suspected, ~urgent incision and
drainage is done under a general anaesthetic The
drainage is done perorally but occasionally
external drainage via neck also done .Very rarely,
tracheostomy is necessary.

63. PARAPHARYNGEAL ABSCESS
Occassionaly, peritonsillar and
retropharyngeal abscess may spread to
parapharygeal space .
Presents with severe trismus ; possibly
an airway compromise .
Diagnosis ~confirmed by ultrasound or CT
scanning.
Treatment ~ high-dose broad-spectrum i.v
antibiotics and drainage of the abscess.
Complication ~ may progresses to life-
threatening infections including
mediastinitis or retroperitoneal sepsis.

65. IMMUNE COMPLEX DISORDERS
Acute tonsillitis caused by GABHS occasionally lead to diseases related
to immune complex formation, i.e; generated as a response to the
infection.
2 important diseases resulting from this phenomenon are acute
rheumatic fever and acute gomerulonephritis.
TONSILLITIS AND PSORIASIS
There is possibly some association between GABHS tonsillitis and
exacerbations of psoriasis, as a result of an immune phenomenon.
Treatment ~TONSILLECTOMY ???

66. RECURRENT TONSILLITIS
The predominant organisms ~ Haemophilus influenzae and S.
aureus including (MRSA), mixed flora being common.
Significant numbers of patients suffer from recurring episodes of
acute tonsillitis.
Episodes may gradually settle or may continue for several years.
Treatment depends on severity of each episode.

67. CHRONIC TONSILLITIS
Some patients get chronic throat discomfort A /w production of
smelly white debris from tonsillar crypts.
Occasionally DEBRIS CALCIFY TONSILLOLITH

68. OTHER INFECTIVE CONDITIONS
Syphilis & tuberculosis infections in the tonsils ~ potentially difficult
to diagnose.
In syphilis ~ lesion classically takes the form of a punched-out ulcer
But in Tuberculosis ~ variable appearence
D/D of a neoplasm should be R/O ;final diagnosis made by biopsy of
lesion.

69. NON INFLAMMATORY CONDITIONS
TONSILLAR ASYMMETRY
Asymmetry of tonsils ~ not an absolute indication for tonsillectomy, but R/O the possibility
of neoplasia(lymphoma).
Tonsils tend to involute during late childhood, but this is variable between individuals & can
vary between the two tonsils, which can at times give an asymmetrical appearance.
SPONTANEOUS TONSILLAR BLEEDING
May occur with inflamed tonsils ; may also occur secondary to minor trauma.
topical cautery under local anaesthetic used. If persists ~ do tonsillectomy
NEOPLASIA
Asymmetrical tonsils /if the surface of one of the tonsils is irregular or ulcerated.
~suspect neoplasia . Lymphoma can occur within the tonsils in adults as well as children.
In adults, SCC is the most common malignancy.

71. TONSILLECTOMY
According to SIGN (Scottish Intercollegiate Guidelines Network ), patients for tonsillectomy for
both adults and children should meet all the following criteria:
sore throats are due to tonsillitis
the episodes of sore throat are disabling and prevent normal functioning
seven or more well-documented, clinically significant, adequately treated sore throats in the
preceding year,
five or more such episodes in each of the preceding 2 years, or
three or more such episodes in each of the preceding 3 years.

72. TONSILLECTOMY TECHNIQUES
COLD STEEL TONSILLECTOMY
DIATHERMY TONSILLECTOMY
COBLATION TONSILLECTOMY
ULTRASONIC DISSECTION
LASER TONSILLECTOMY

74. COLD STEEL TONSILLECTOMY
DISSECTION TECHNIQUE - most common method of cold steel
tonsillectomy.
In this technique, tonsil is pulled medially and mucosa overlying the tonsil
capsule is incised.
Dissection continues in the plane of loose areolar tissue b/w tonsil tissue
& pharyngeal muscles using a dissector or gauze, and the tonsil is excised
completely.
The bleeding vessels dealt using diathermy or ligatures as required.
GUILLOTINE TECHNIQUE - involves using a specially designed
guillotine to excise the tonsil.

75. GUILLOTINE TECHNIQUE -
involves using a specially designed
guillotine to excise the tonsil

77. Hemmorrhage rates for various techniques
HEMORRHAGE defined as a
bleed that prolonged the patient’s
stay in hospital, required blood
transfusion or return to the operating
theatre or for secondary
haemorrhage readmission to
hospital.
The Swedish registry gives similar
results, cold steel dissection and ties
having a significantly lower bleed
rate and less post-operative pain
than any of the other techniques.

78. DIATHERMY TONSILLECTOMY
Bipolar dissection ~
1. an alternative method to traditional cold steel tonsillectomy.
2. Reduced intra-operative bleeding but increased pain in the diathermy
3. Post - operative bleeding more frequent with diathermy than with cold
steel alone,
Monopolar dissection ~a/w more post-operative pain than other
techniques;post op bleeding is particularly worse with monopolar
diathermy.

79. COBLATION TONSILLECTOMY
Uses a specially designed probe which coagulates and cuts the tissues. Post-
operative bleeding rates were unacceptably high but post-operative pain is
less
ULTRASONIC DISSECTION
Uses an oscillating blade, which acts as both a cutting and a coagulating device.
Some studies claim reduced pain
LASER TONSILLECTOMY
Laser used to dissect out the tonsils ;have advantages in terms of reduced
bleeding

80. TONSILLOTOMY
Involves removing a part of tonsil lymphoid tissue, leaving the capsule
intact.
The technique is reminiscent guillotine tonsillectomy. Techniques include
microdebrider, laser, or radiofrequency ablation (using the instrument from
medial to lateral.)
The amount of tissue removed can be from just the lymphoid tissue up to the
anterior tonsillar pillar, to leaving a cuff of tonsil tissue lining the tonsillar fossa, to
taking the tissue all the way back to the capsule (sometimes called intracapsular
tonsillectomy).
For children with obstructive sleep apnoea intracapsular tonsillotomy is
better than total tonsillectomy ;leaving behind some functioning lymphoid tissue is
better
Postop pain is less (the muscle disturbed is less)

81. TONSILLECTOMY MORBIDITIES
PAIN. Post-tonsillectomy sore throat normal for at least 1 week ;return to school or work may take 1–2
weeks.
PERIOPERATIVE COMPLICATIONS
1. If mouth opened too widely during tonsillectomy operation ~TMJ dysfunction.
2. Dissection beyond pharyngeal musculature can lead to injury to the glossopharyngeal nerve and
rarely the carotid sheath.
3. Non-traumatic atlantoaxial subluxation (GRISEL syndrome) can occur secondary to any inflammatory
process in the neck.
BLEEDING Can be
1. PRIMARY (within 24 hours after the operation) or
2. SECONDARY (after 24 hours until 2 weeks). The readmission rate for bleeding was 4.57%, with 1.44%
requiring return to theatre. Most likely explanation is infection with Streptococcus .Treatment depends on
severity and potential cause of bleed. Antibiotics advised for secondary bleeding. Severe bleeds
~controlled in theatre.
INFECTION. The first symptoms of infection are fever and halitosis. Treatment according to the
severity.

82. PERIOPERATIVE MANAGEMENT
ANAESTHESIA . ~. Total intravenous anaesthesia (TIVA) with propofol and remifentanil leads to
fast wake-up,. inhalational agents for in tuba- tion preferred; obviates need for muscle relaxants
& speeds up the reversal process.
ANALGESIA is important in the immediate post- operative period. Paracetamol is the drug of
choice as it is safe and efficacious. NSAIDs ~effect of these drugs on platelet adhesion might
increase bleeding from the tonsil bed.. Codeine should not be used in children after tonsillectomy .
Aspirin ~not to be used because of the risk of Reye syndrome. No significant benefit from
injecting long- and short-acting local anaesthetic pre- or post-operatively into the tonsil beds.
STEROID TREATMENT. A single preoperative i.v dose of dexamethasone is effective &
relatively safe treatment for reducing morbidity from paediatric tonsillectomy & also reduces early
incidence of nausea, vomiting and level of pain post-operatively.
POSTOP ANTIBIOTICS ~ Cochrane review of studies published in 2012 advocate against
routine use of antibiotics after tonsillectomy.
DAY - CASE SURGERY. Tonsillectomy as a day-case procedure is gaining popularity. Studies
prove it to be a safe alternative to surgery as an inpatient.. The main reasons for patients to stay
overnight are the risk of bleeding and associated morbidity from pain and vomiting.