What are the indications and contraindications for adenotonsillectomy?
Tonsillar and adenoidal tissues are actually a part of the lymphatic system known as Waldeyer’s ring. At one time, adenotonsillectomy was the single most frequently per-formed surgical procedure. With the advent of antibiotics and more conservative thinking, its numbers have dimin-ished. The most common indications for adenotonsillec-tomy today are adenotonsillar hyperplasia in conjunction with obstructive sleep apnea, suspicion of malignant disease, hemorrhagic tonsillitis, abnormal maxillofacial growth, and failure to thrive. Indications for tonsillectomy without adenoidectomy include recurrent/chronic tonsil-litis, peritonsillar abscess, and streptococcal carriage. Indications for adenoidectomy without tonsillectomy include adenoiditis, recurrent or chronic rhinosinusitis and otitis media. Relative indications for adenotonsil-lectomy include chronic halitosis, speech impairment, dysphagia, and upper airway obstruction with relative adenotonsillar hyperplasia.
Significant contraindications to adenotonsillectomy are systemic infection, uncorrected coagulopathy, occult or frank cleft palate, and uncontrolled systemic diseases such as diabetes mellitus. Coagulopathies can be corrected pre-operatively once the diagnosis is known. In the case of occult or frank clefts, tonsillar and adenoidal tissue may contribute to intelligible speech by filling the velopharyngeal space. Once they are removed, velopharyngeal incompetence occurs, resulting in less intelligible, hypernasal speech.
A clue to the occult cleft is a bifid uvula.
In the event that adenoidectomy is necessary in the patient with a cleft, partial adenoidectomy to the level of Passavant’s ridge is performed. Passavant’s ridge is the hypertrophied portion of the posterior pharyngeal wall that is approximated by the soft palate (velum) during speech and deglutition.
Historically, severe adenotonsillar hypertrophy some-times resulted in airway obstruction and led to alveolar hypoventilation syndrome, culminating in hypoxia and hypercarbia. Secondary pulmonary artery hypertension and right ventricular hypertrophy led to cor pulmonale. This sequence of events is rare today.
Patients with Down syndrome (trisomy 21) have nar-row oral and nasal airways, predisposing to obstruction whenever tonsils and adenoids enlarge. These patients are at higher risk for cor pulmonale as a result of adenoton-sillar hypertrophy.
Patients with abnormal facies related to trisomy 21 (Down syndrome), mandibulofacial dysostosis (Treacher-Collins syndrome), acrocephaly-syndactyly (Apert syn-drome), dwarfism, or craniofacial dysostosis (Crouzon syndrome) possess abnormally small maxillary and mandibular relationships. In these patients, even normal-sized tonsillar and adenoidal tissue may be sufficient to cause airway obstruction. In these cases, adenotonsillec-tomy may be indicated even in the absence of adenoton-sillar hypertrophy.