TREATMENT OF ADENOIDS
When symptoms are not marked ,
breathing exercises, decongestant
nasal drops and antihistaminics for
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any co-existent nasal allergy can curethe condition without resort to surgery
When symptoms are marked,
adenoidectomy is done.
Adenoidectomy
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Adenoidectomy may be indicatedalone or in combination with
tonsillectomy
Adenoids are removed first and the
nasopharynx packed before starting
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tonsillectomyINDICATIONS
1. Adenoid hypertrophy causing snoring, mouth
breathing, sleep apnoea syndrome or speech
abnormalities, i.e. (rhinolalia clausa)
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2. Recurrent rhinosinusitis3. Chronic otitis media with effusion associated
with adenoid hyperplasia
4. Recurrent ear discharge in benign CSOM
associated with adenoiditis/adenoid hyperplasia.
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5. Dental malocclusion. Adenoidectomy does notcorrect dental abnormalities but will prevent its
recurrence after orthodontic treatment.
CONTRAINDICATIONS
1. Cleft palate or submucous palate.
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2. Haemorrhagic diathesis.3. Acute infection of upper respiratory
tract.
ANAESTHESIA
Always general, with oral endotracheal
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intubationPOSITION
Rose's position
Patient lies supine with head extended by
placing a pillow under the shoulders. A rubber
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ring is placed under the head to stabilizeit.Hyperextension should always be avoided
STEPS OF OPERATION
Boyle?Davis mouth gag is inserted
Before actual removal of adenoids, nasopharynx
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should always be examined by retracting the softpalate with curved end of the tongue depressor and by
digital palpation, to confirm the diagnosis, to assess
the size of adenoids mass and to push the lateral
adenoid masses towards the midline
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A laryngeal mirror helps to assess the size and extentof adenoid mass
Proper size of "adenoid curette with guard" is
introduced into the nasopharynx till its free
edge touches the posterior border of nasal
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septum and is then pressed backwards toengage the adenoids.
At this level, head should be slightly flexed to
avoid injury to the odontoid process
With gentle sweeping movement, adenoids are
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shaved offLateral masses are similarly removed with
smaller curettes; small tags of lymphoid tissue
left behind are removed with punch forceps
Haemostasis is achieved by packing the area for
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sometime.Persistent bleeders are electrocoagulated under vision
COMPLICATIONS
Haemorrhage
Injury to eustachian tube opening
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Injury to pharyngeal musculature and vertebrae.Grisel syndrome.
Velopharyngeal insufficiency
Nasopharyngeal stenosis
Recurrence
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TREATMENT OF ACUTE TONSILLITIS
Patient is put to bed and encouraged to take plenty of
fluids
Analgesics (aspirin or paracetamol) are given
according to the age of the patient to relieve local pain
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and bring down the fever.Antimicrobial therapy. Most of the infections are due
to Streptococcus and penicillin is the drug of choice.
Patients allergic to penicillin can be treated with
erythromycin. Antibiotics should be continued for 7?
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10 days.TREATMENT OF CHRONIC
TONSILLITIS
Conservative treatment consists of attention to
general health, diet, treatment of coexistent infection
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of teeth, nose and sinusesTonsillectomy is indicated when tonsils interfere with
speech, deglutition and respiration or cause recurrent
attacks
Tonsillectomy
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INDICATIONSABSOLUTE
? Recurrent infections of throat.
? Peritonsillar abscess
? Tonsillitis
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? Hypertrophy of tonsils? Suspicion of malignancy
RELATIVE
oDiphtheria carriers, who do not respond to
antibiotics.
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oStreptococcal carriersoChronic tonsillitis with bad taste or halitosis
which is unresponsive to medical
treatment.
oRecurrent streptococcal tonsillitis in a
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patient with valvular heart disease.AS A PART OF ANOTHER OPERATION
Palatopharyngoplasty which is done for
sleep apnoea syndrome.
Glossopharyngeal neurectomy. Tonsil
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is removed first and then IX nerve issevered in the bed of tonsil.
Removal of styloid process.
CONTRAINDICATIONS
Haemoglobin level less than 10 g%.
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Presence of acute infection in upper respiratorytract, even acute tonsillitis
Children under 3 years of age
Overt or submucous cleft palate
Bleeding disorders, e.g. leukaemia, purpura,
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aplastic anaemia or haemophilia.At the time of epidemic of polio.
Uncontrolled systemic disease, e.g. diabetes,
cardiac disease, hypertension or asthma.
Tonsillectomy is avoided during the period of
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mensesANAESTHESIA
Usually done under general anaesthesia with
endotracheal intubation. In adults, it may be done
under local anaesthesia.
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POSITION? Rose's position, i.e. patient lies supine with head
extended by placing a pillow under the shoulders.
A rubber ring is placed under the head to stabilize
it .Hyperextension should always be avoided
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STEPS OF OPERATION (DISSECTION
AND SNARE METHOD)
. Boyle?Davis mouth gag is introduced and opened. It
is held in place by Draffin's bipods or a string over a
pulley
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Tonsil is grasped with tonsil-holding forceps andpulled medially.
Incision is made in the mucous membrane where it
reflects from the tonsil to anterior pillar. It may be
extended along the upper pole to mucous membrane
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between the tonsil and posterior pillarA blunt curved scissor may be used to dissect the
tonsil from the peritonsillar tissue and separate its
upper pole
Now the tonsil is held at its upper pole and traction
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applied downwards and medially. Dissection iscontinued with tonsillar dissector or scissors until
lower pole is reached
Now wire loop of tonsillar snare is threaded over the
tonsil on to its pedicle, tightened, and the pedicle cut
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and the tonsil removed.A gauze sponge is placed in the fossa and pressure
applied for a few minutes
Bleeding points are tied with silk. Procedure is
repeated on the other side.
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COMPLICATIONS
IMMEDIATE
Primary haemorrhage
Reactionary haemorrhage
Injury to tonsillar pillars, uvula, soft palate,
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tongue or superior constrictor muscle due to badsurgical technique
Injury to teeth.
Aspiration of blood.
Facial oedema.
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Surgical emphysema.DELAYED
Secondary haemorrhage.
Infection- parapharyngeal abscess or otitis
media
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Lung complicationsScarring in soft palate and pillars
Tonsillar remnants.
Hypertrophy of lingual tonsil.
THANK YOU
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