Tonsillitis and Adenoiditis - Upper Airway Infections

TONSILLITIS AND ADENOIDITIS

The tonsils are composed of lymphatic tissue and are situated on each side of the oropharynx. The faucial or palatine tonsils and lingual tonsils are located behind the pillars of fauces and tongue, respectively. They frequently serve as the site of acute infection (tonsillitis). Chronic tonsillitis is less common and may be mis-taken for other disorders such as allergy, asthma, and sinusitis.

The adenoids or pharyngeal tonsils consist of lymphatic tissue near the center of the posterior wall of the nasopharynx. Infec-tion of the adenoids frequently accompanies acute tonsillitis. Group A beta-streptococcus is the most common organism asso-ciated with tonsillitis and adenoiditis.

Clinical Manifestations

The symptoms of tonsillitis include sore throat, fever, snoring, and difficulty swallowing. Enlarged adenoids may cause mouth-breathing, earache, draining ears, frequent head colds, bronchi-tis, foul-smelling breath, voice impairment, and noisy respiration. Unusually enlarged adenoids fill the space behind the posterior nares, making it difficult for the air to travel from the nose to the throat and resulting in a nasal obstruction. Infection can extend to the middle ears by way of the auditory (eustachian) tubes and may result in acute otitis media, which can lead to spontaneous rupture of the eardrums and further extension of the infection into the mastoid cells, causing acute mastoiditis. The infection also may reside in the middle ear as a chronic, low-grade, smol-dering process that eventually may cause permanent deafness.

Assessment and Diagnostic Findings

A thorough physical examination is performed and a careful his-tory is obtained to rule out related or systemic conditions. The tonsillar site is cultured to determine the presence of bacterial in-fection. In adenoiditis, if recurrent episodes of suppurative otitis media result in hearing loss, the patient should be given a com-prehensive audiometric examination.

Medical Management

Tonsillectomy is usually performed for recurrent tonsillitis when medical treatment is unsuccessful and there is severe hypertrophy, asymmetry, or peritonsillar abscess that occludes the pharynx, making swallowing difficult and endangering the airway (partic-ularly during sleep). Enlargement of the tonsils is rarely an indi-cation for their removal; most children normally have large tonsils, which decrease in size with age. Despite the continuing debate over the effectiveness of many tonsillectomies, the opera-tion is still a common surgical procedure in the United States.

Tonsillectomy or adenoidectomy is indicated only if the pa-tient has had any of the following problems: repeated bouts of tonsillitis; hypertrophy of the tonsils and adenoids that could cause obstruction and obstructive sleep apnea; repeated attacks of purulent otitis media; suspected hearing loss due to serous oti-tis media that has occurred in association with enlarged tonsils and adenoids; and some other conditions, such as an exacerba-tion of asthma or rheumatic fever. Appropriate antibiotic therapy is initiated for patients undergoing tonsillectomy or adenoidec-tomy. The most common antimicrobial agent is oral penicillin, which is taken for 7 days. Amoxicillin and erythromycin are alternatives.

Nursing Management

PROVIDING POSTOPERATIVE CARE

Continuous nursing observation is required in the immediate postoperative and recovery period because of the significant risk of hemorrhage. In the immediate postoperative period, the most comfortable position is prone with the head turned to the side to allow drainage from the mouth and pharynx. The nurse must not remove the oral airway until the patient’s gag and swallowing re-flexes have returned. The nurse applies an ice collar to the neck, and a basin and tissues are provided for the expectoration of blood and mucus.

Bleeding may be bright red if the patient expectorates blood before swallowing it Often, however, the patient swallows the blood, which immediately becomes brown because of the action of the acidic gastric juice.

Hemorrhage is a potential complication after a tonsillectomy and adenoidectomy. If the patient vomits large amounts of dark blood or bright-red blood at frequent intervals, or if the pulse rate and temperature rise and the patient is restless, the nurse notifies the surgeon immediately. The nurse should have the following items ready for examination of the surgical site for bleeding: a light, a mirror, gauze, curved hemostats, and a waste basin.

Occasionally, suture or ligation of the bleeding vessel is re-quired. In such cases, the patient is taken to the operating room and given general anesthesia. After ligation, continuous nursing observation and postoperative care are required, as in the initial postoperative period.

If there is no bleeding, water and ice chips may be given to the patient as soon as desired. The patient is instructed to refrain from too much talking and coughing because these activities can produce throat pain.

TEACHING PATIENTS SELF-CARE

Tonsillectomy and adenoidectomy usually do not require hospi-talization and are performed as outpatient surgery with a short length of stay. Because the patient will be sent home soon after surgery, the patient and family must understand the signs and symptoms of hemorrhage. Hemorrhage usually occurs in the first 12 to 24 hours. The patient is instructed to report frank red bleeding to the physician.

Alkaline mouthwashes and warm saline solutions are useful in coping with the thick mucus and halitosis that may be present after surgery. It is important to explain to the patient that a sore throat, stiff neck, and vomiting may occur in the first 24 hours. A liquid or semiliquid diet is given for several days. Sherbet and gelatin are acceptable foods. The patient should avoid spicy, hot, acidic, or rough foods. Milk and milk products (ice cream and yogurt) may be restricted because they may make removal of mucus more difficult.The nurse explains to the patient that halitosis and some minor ear pain may occur for the first few days. The nurse in-structs the patient to avoid vigorous tooth brushing or gargling, since these actions could cause bleeding.