Acute Tonsillitis: It is one of the most common infections of childhood. Acute bacterial tonsillitis usually occurs with the addition of bacteria following a viral infection. During an acute infection, bacteria, cell debris and food residues fill the openings of the cavities called crypts on the tonsils. Along with the pain, fever increases and redness occurs due to the increase in tonsillar vascularity. Classical tonsil infection appearances occur as a result of more widespread inflammatory tissues settling in the form of spots or patches in the mouths of the closed crypts.
Pain when swallowing, painful swellings in both jaw corners (swelling of the neck lymph nodes), and fever are also frequently observed.
Viral tonsillitis (tonsil infection) is also a common condition. Although the symptoms of viral tonsillitis are more or less similar to those of bacterial tonsillitis, there may be differences in the findings. For example, the inflammatory coating on the tonsils may not be visible. Of course, there are special forms of this too. For example; A special type called Infectious Mononucleosis causes widespread whitening on the tonsils and often causes painful lymph node swelling in the neck. Malaise, fever, and severe sore throat are classical symptoms. Since it may cause liver and spleen enlargement, this aspect should also be monitored.
In case of adenovirus infection, in addition to the above-mentioned classic sore throat, fever, and white spots on the tonsils, it may also cause widespread lymph nodes in the neck and crusty eyes. While viral tonsil infections are generally treated symptomatically, appropriate medications can be added later, provided that laboratory evidence of the addition of bacteria is determined during follow-up.
Infections of the adenoid and tongue base tonsils also have similar characteristics. Frequently, these tissues may accompany bacterial or viral tonsil infection because they are tissues of the same character.
ADENOTONSILLETOMY
Adenoidectomy), Tonsil removal (Tonsillectomy), or both. (Adenotonsillectomy) and its different methods, which have been increasing over the last seventeen years with technological developments in the field of ENT, are among the most frequently performed surgeries in children. It takes its place at the top of the list.
Among the indications for adenoidectomy and tosilla intervention, the most common reason is that it causes sleep disorders. As in previous years, tonsillectomy, which is performed due to frequently recurring infections, is now being performed at decreasing rates.
Specific reasons such as advanced obstructive sleep apnea, PFAPA syndrome, chronic tonsillitis (frequently recurring) attacks, tonsil tumors, tonsil tuberculosis. It constitutes more indications.
It has been explained above that the most important or most common factor to be considered for surgical approach to tonsil and/or adenoid in childhood is sleep problems. So what are the criteria for this?
When many parents bring their children with sleep problems to the doctor, they also bring with them a video or audio recording showing their child's sleep state. What is important at the decision stage is this; 1) Does the child sleep with his mouth open and/or snore? 2) Does he turn around or change places in bed frequently? 3) Sweating occurs above the breast line, on the nape of the neck, and on the collar. If the family's answer to these three criteria is "yes", the child is affected by upper airway obstruction and the reason for this should be investigated. In children between the ages of three and six who have upper respiratory tract obstruction and obstructive sleep problems, adenoidectomy and/or tonsillectomy (or reduction methods) should be considered first. Due to; If the above three criteria are met, it is not necessary to examine the back of the nose with a camera (nasopharyngoscopy), which in my opinion is a difficult method for children. Because although the adenoid looks large, if these criteria are not met and/or there is no fluid in the ear, surgery is not necessary. However, if the adenoid appears small but is relatively small and causes the above complaints (all three) and/or fluid in the ear, it may be necessary to remove it. I am in favor of the fact that filming, which is frequently performed to see the adenoids, should be reserved for more special situations and not used only for this purpose, as it also causes radiation exposure. In conclusion, in my opinion, the criteria are important, not whether they are large or small.
To list again;
Situations requiring adenoidectomy:
Sleep disorder, apneas during sleep (In this case, intervention in the tonsils is often required)
Nasal congestion; While the enlarged adenoid causes blockage in the back holes of the nose, it sometimes grows so much that it is seen to extend into the nasal cavity in the form of finger-like extensions. Runny nose. Speaking tone as if there was a piece of food in the mouth. If allergic rhinitis is also detected, steroid nasal sprays are given to reduce the size of the nose. According to the carbon particle spraying studies I have conducted, sprays applied to the nose cannot reach the surface of the adenoid tissue. It is not possible for a molecule that may be thought to provide benefit by contact with it to shrink adenoid tissue. Or, there is no study on the duration it should be used to shrink adenoids. However, steroid sprays are necessary and used in allergic rhinitis. Some colorful drops prepared in pharmacies used against runny nose or to shrink adenoids contain substances such as Iodine (may be allergic) or Silver (a heavy metal), so I do not include these drugs in my personal practice. There is no evidence that adenoids can shrink in these applications, and it is not clear for how long they should be used. It is dangerous to take heavy metals.
Otitis with Effusion: It is a condition of fluid accumulation in the middle ear. It needs follow up. If left untreated, it can lead to hearing loss and extensive surgery in the future. It is a condition that requires attention in untreated adenoid enlargements.
Chronic sinusitis: Recurrent rhinosinusitis occurs when airflow in the nose is impaired (due to blockage in the posterior nostrils).
Situations requiring tonsillectomy;
Sleep disorder, sleep apneas (usually in this case, intervention in adenoids is also required).
Recurrent tonsillitis. attacks (there are different criteria), In my personal practice, I accept as a criterion to have seven febrile tonsillitis attacks in the last year, or five tonsillitis attacks in each year in the last two years, or having had a febrile tonsillitis attack three times a year in the last three years. .
Sudden unilateral tonsillar enlargement or shape change.
Tonsil surroundings abscess (peritonsillar abscess),
Pediatric autoimmune neuropsychiatric disorders (PANDAS) related to streptococcal infections.
Periodic fever, oral sores (aphthous stomatitis), pharyngitis, cervical lymphadenitis (PFAPA) syndrome
Bad breath due to accumulations on the tonsils (in this case, shrinking the tonsil tissue with radio waves may also be sufficient) .
Surgical techniques, applications.
I was introduced to tonsillectomy adenoidectomy procedures for the first time in 1985, when I was an ENT elective trainee. Gone are the days when, following minimal throat anesthesia with spray, a child was held in a sitting position, most of the time by experienced clinical staff, and the child's mouth was opened and the adenoid curetted, and then both tonsils were removed using the Sluder guillotine technique in a total of 50 seconds. Later, during our specialization period, we learned and performed tonsillectomies and adenoidectomies with curettage performed in adults with local injection anesthesia and in children with general anesthesia. These are classical methods and were a bit time consuming. They continued (and continue to be) technically sound methods that are still in use. Adenoid tissue was removed visually with a device called a curette. After this, relapses were also seen to a considerable extent. Because the possibility of leaving a piece behind in an application performed blindly was high even in the most experienced hand, and it was not possible to get enough for adenoid growths extending into the nose because they were outside the reach of the instrument. Over the years, adenoidectomy and tonsillectomy techniques have developed on healing patterns and their effects on post-operative pain. Hundreds of studies have been published with the influence of technology. During this process, while the only procedure in our field of practice was tonsillectomy (removal of the tonsil), methods of reducing the size of the tonsil with various tools (LASER; Cautery, Thermal velding, Coblation) were also developed. From the LASER method; It was partially abandoned or could not be widely used due to the fact that it caused severe pain, had significant bleeding, and required expensive equipment.
The methods used for adenoidectomy tonsillectomy or tonsil reduction should be listed, including my own experience. e;
Sluder guillotine technique and curettage. It is a method performed with local anesthesia or regional anesthesia applied with a spray. The process is completed in a very short time. Its psychological effects on the child may continue for many years. It is an almost completely abandoned method.
Classical adenoidectomy, Tonsillectomy; It is the classical and most widely used method. It is unthinkable to abandon it. Adenoidectomy is performed by curettage and tonsillectomy is performed with cold steel instruments. Its different variations are; It is a technique of pulling the tonsil tissue with a holding tool and then making an incision using a hot method, similar to using a scalpel, with a tool called cautery, which is also used to burn, cut and stop blood. The aftermath of the procedure is the same as in the classical method. Heat may reach partially deeper into the tissue and cause bleeding. Tonsil reduction can also be performed with monopolar cautery.
Bilpolar diathermy dissection. It is similar to the method described in article two, but heat is applied more localized. Cautery methods may cause some pain. Tonsil reduction can be performed. Adenoidectomy cannot be performed.
LASER's high heat causes severe pain. Bleeding has been reported afterwards, and considering the cost-benefit ratio, it has no superiority for tonsillectomy compared to other methods. Adenoidectomy is still performed with classical curettage in this method. Tonsil reduction can be performed.
Thermal Welding: As with bipolar cautery, tonsillectomy or tonsil reduction can be performed. In my opinion, it has no superiority over bipolar cautery. It is necessary to resort to other methods for adenoidectomy.
Plasmacoblation method: In this technique; The specially engraved application tip allows us to perform the operation by creating ionized plasma that breaks the chemical bonds between cells in a cold saline environment. The heat generated in this method is much lower than other methods (except the cold steel method), and is further reduced by using cold serum.
Microdebrider method: Adenoidectomy can also be performed safely by visualizing. Bleeding during surgery may take time to control, partly because it is close to the classical curettage method. If tonsil reduction is also applied with this method, bleeding control is as difficult as the classical method.
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