T&A/PETS—-DANIEL TODD, MD TONSILS ARE HIGH IN B-CELLS AND LOW IN T-CELLS TOSILLAR HYPERTROPHY CAN LEAD TO APERTOGNATHIA ADENOID HYPERTROPHY AND NAO—–CAN LEAD TO MOUTH BREATHING AND FACIAL ELONGATION (ADENOID FACIES) RECURRENT ADENOTONSILLITIS/PHARYNGOTONSILLITIS—BETA HEMOLYTIC STREP ADENOTONSILLAR HYPERTROPHY—-H. INF PROBABLY SHOULD DO AN ADENOIDECTOMY WITH EVERY TONSILLECTOMY AND NOT VICE VERSA—ALTHOUGH YOU CERTAINLY CAN HAVE A POST OP NP BLEED INDICATIONS: RECURRENT TONSILLOPHARYNGITIS, OSA, PTA OR DNSI, SYMPTOMATIC CRYPTIC TONSILLITIS, CHRONIC GABHS, AND UNILATERAL HYPERTROPHY—-FOR SYMPTOMATIC CRYPTIC TONSILLOLITHIASIS—-ATTEMPT WATER PIK, AGNO3, ECT…BEFORE SURGERY NEVER DO ANY PALATAL WORK WITH AN ADENOIDECTOMY—–DO NOT COMBINE UPPP WITH ADENOIDECTOMY! PROBABLY REASONABLE TO DO ADENOIDECTOMY WITH EVERY 2ND SET OF PET’S (80% OF KIDS GET BY WITH 1 SET OF PET’S) AND IN CHILDREN >4 WITH PETS AND <10 WITH CHRONIC RHINOSINUSITIS AS A 1ST PROCEDURE ONLY INDICATION FOR NP EUA IS TO CHECK FOR REGROWTH AND NEED FOR REVISION—-OTHERWISE SIZE DOES NOT MATTER IN EITHER OSA NOR AOM PROBABLY IMPORTANT TO GET GERLACHE’S (TUBAL) TONSIL AND POST CHOANAL ADENOID HUMMER MAY BENEFIT HERE IF YOU HAVE EXTRA TIME AND MONEY RARE COMPLICATION OF POST ADENOID TORTICOLLIS—CAN EVEN CAUSE C1-C2 SUBLUXATION—MORE COMMON IN DOWNS—GRIESEL’S SYNDROME—MUST R/O MENINGISMUS—MAY NEED TO CONSULT NEUROSURG PREOP CBC AND COAGS?(NO EVIDENCE THAT COAGS OFFER ANY BENEFIT OVER BLEEDING HISTORY) BRUISABILITY, EPISTAXIS, ORAL BLEEDING, POST TRAUMATIC BLEEDING, EXCESSIVE CIRCUMCISION BLEEDING, POST OP OR DENTAL HEMORRAGE, PMHX OF LIVER DZ, RENAL DZ, HEMATOLOGIC DZ, OR FAMILY HX OF SUCH PE—PETICHIAE, TELANGIECTASIA, OR H-S MEGALLY CAN GET CBC, PT, PTT, BLEEDING TIME (BT)—–BEST JUST TO GET WHAT YOUR COLLEGUES GET NO ASA OR NSAIDS FOR 2 WEEKS PRIMARY CAUSE FOR AN ISOLATED HIGH PTT IS A LUPUS ANTIBODY ANTICOAGULANT STIMULATED BY A RECENT URTI RISK OF PRIMARY (LESS THAN 24 HOURS) BLEED IS 1-2 % RISK OF SECONDARY BLEED (MORE THAN 24 HOURS OUT) IS 2-3 % FOR REPEAT HEMORRAGE GET HEMATOLOGY PROFILE (COAGS, BLEEDING TIME, PTT MIX, CBC WITH PLTS AND HEMATOLOGY CONSULT—-IF THAT IS NL GET ANGIOGRAM PRIMARY HEMATOLOGIC ABNL IS VWDz—MORE THAN 20 SUBTYPES —SOME RESPOND TO DDAVP (1 HOUR OCOR)—SOME DO NOT CXR AND EKG FOR SEVERE OSA EKG FOR R HEART STRAIN CXR FOR CARDIOMEGALY LOOK FOR NOTCHED HARD PALATE, BIFID UVULA, ZONA PELLUCIDA (MUSCULAR DIASTASIS), OR ABSENCE OF MUSCULUS UVULAE ON NASOPHARYNGOSCOPY SPECAIL ATTN TO DOWNS(C1-C2 LIG LAXITY), OSA–NEUROMUSCULAR Dz, DIABETICS, JEHOVAHS WITNESSES ADMIT 23 HOUR OBS IF < 3, OSA, ASSOC MEDICAL Hx, OTHER CONCERNS IF YOU SUSPECT LYMPHOMA—-NOTIFY PATH—MUST DO FRESH AND TOUCH PREPS INTRAOP STEROID SEEM TO BE OF BENEFIT—AMOUNT CONTROVERSIAL (1MG/KG UP TO 15-20MG)—PROBABLY INCREASE APPETITE AS MUCH AS THEY INHIBIT INFLAMMATION IBUPROFEN IS USEFUL (DOESN’T SEEM TO INCREASE BLEEDING)—-TORADOL POTENTIATES BLEEDING POST OP AMOX TREATS THE PARENTS AND SAVES PHONE CALLS POST OP LORTAB ELIXER—-AGE 2-3(12-15 KG)—3/4 TSP, AGE 4-6(16-22KG)—1 TSP, 32-45KG—2 TSP, >45 KG 3 TSP (1 TBSP) Q 4 HOURS—– OR TYLENOL WITH CODEINE IS A MUST DEMEROL ELIXER (50MG/5CC) 5-10 CC PO Q 2 HOURS MSO4 SOLUTION 5MG/5CC, 5-10 CC PO Q 4 HOURS PRN INTRAOP INJECTION OF EITHER LIDOCAINE OR BUPIVICAINE (BUPIVICAINE HAS BEEN SHOWN TO ELIMINATE ENTRANCE TO SOME PAIN CYCLES) CHAR DOESN’T BLEED (RIGHT AWAY) BUT IT DOESN’T TAKE P.O. WELL EITHER ANZAMET 0.35 MG/KG IV Q 6 HOURS PRN!!! LASER, BIPOLAR, ULTRASOUND, AND SHARP DISSECTION CURRENTLY ARE STUPID VERY CAREFUL PRECISE CONSERVATIVE MONOPOLAR ELECTRODISSECTION SEEMS TO BE THE BEST CURRENTLY—A MINIMALLY TRAUMATIC AND BLOODLESS DISSECTION CAN BE ACCOMPLISHED FOR THE RARE CASE OR POST OP PULM EDEMA-(POST OBSTRUCTIVE PULM EDEMA)—-FROTHY SPUTUM AND HYPOXIA—-GET CXR AND ABG’S—TREAT WITH POS. PRESSURE , DIURETICS, AND MSO4—-GET POST OP ECHO AS THER IS A HIGH INCIDENCE OF SIG VALVULAR Dz—TRICUSPID REGURGE) POST TONSILLECTOMY INSTRUCTIONS DIET: We make no restrictions on diet after surgery. You must at least keep the child well hydrated and may find that ice chips, ice cream, Jell-O, etc. is most appealing immediately following surgery. ACTIVITY: We discourage any strenuous activity following surgery to include heavy lifting for roughly two weeks. Normal play activity is OK. PAIN: It is normal to have throat pain after surgery for up to two weeks following the procedure. Ear pain is a common complaint following tonsillectomy and is related to the surgery. It usually is not an ear infection. Gum chewing occasionally helps relieve the ear pain. BLEEDING: Any bleeding following tonsillectomy or adenoidectomy is taken seriously and must be evaluated by us. Bleeding may occur following tonsillectomy up to two weeks after surgery. If your child is bleeding and swallowing the blood, it will cause the child to throw up either bloody stomach contents or black looking material. Blood streaked saliva is not concerning but persistent or profuse bleeding warrants calling either the ENT clinic or the ENT physician on call. MEDICATIONS: You may have been given prescriptions for pain medication and an antibiotic. The pain medication may be used on a more regular basis for the first few post-operative days to help decrease the pain. Any pre-operative medications taken by the patient should be continued unless you are told otherwise.
MISCELLANEOUS: Bad breath is occasionally noticed following surgery. This is transient and will improve over the next several weeks as the diet returns to normal. Low grade temperature is not uncommon following this procedure and usually is best managed with continued oral fluids and Tylenol. Reasons to call following tonsillectomy: -Any persistent bleeding -Continued nausea and vomiting with dehydration. -Temperature greater than 101.5 degrees If you need to contact us we are available 24 hours daily. BLEEDING DISORDERS HISTORY IS KEY—ASK ABOUT BRUISING, PROBLEMS WITH CIRCUMCISION, BLEEDING INTO JOINT SPACES, Fhx, ECT… PROBABLY DO NOT NEED TO TEST IF HISTORY IS NL GET PTS OFF OF THEIR ASA FOR AT LEAST 10 DAYS PREOP—THIS REALLY DOES MATTER—-ALSO NSAIDS–MIGHT AS WELL KEEP THEM OFF OF THESE AS WELL PT (EXTRINSIC PATHWAY)—-THINK OF WARFARIN/LIVER PROBLEMS ECT… FOR REVERSAL VIT K CAN BE GIVEN (FAT SOLUBLE)—-FACTORS 2,7,9,10 ARE THE VIT K DEP FACTORS—FACTOR 7 IS THE LIMITING FACTOR—-T1/2 = 6 HOURS—-AFFFECTED BY ANYTHING THAT ALTERS HEPATIC METABOLISM PTT(INTRINSIC PATHWAY—-ACCELERATES THE ACTIVITY OF ANTITHROMBIN III (HEPARIN COFACTOR) IN BINDING TO THROMBIN PRIMARY REASON IT IS ELEVATED IS PROBABLY A CIRCULATING “LUPUS” ANTICOAGULANT FROM A RECENT URTI—–NO CONSEQUENCE—CAN DO A “MIX” TEST TO CONFIRM—MIX PTS BLOOD WITH NL DONOR BLOOD–CORRECTS FACTOR DEFICIENCY FOR REVERSAL PROTAMINE SULFATE CAN BE GIVEN—TOO MUCH PROTAMINE CAN BE COAGULOPATHIC BEWARE OF HEPARIN ANTIBODIES—-THROMBOCYTOPENIA-HYPERCOAGULABLE STATES BLEEDING TIME—REALLY WHERE THE RUBBER MEETS THE ROAD? NOT NECESSARILY WHAT YOU SEE IN THE OR PROLONGED IN VWDz AND OTHER PLT DISORDERS (ASA, UREMIA, THROMBOCYTOPENIA, ANTIPLATELET AB’S, TICLOPIDINE) THROMBIN TIME (FACTOR 1 FIBRINOGEN LEVELS) PLATELET COUNT—NL IS 100-400 (<40 = THROMBOCYTOPENIA)—START LOOKING FOR CAUSE—ANTI-PLT ANTIBODIES, DRUGS, BM SUPPRESSION ECT… ENTITIES: VWDz = MOST COMMON INHERETED BLEEDING DISORDER (PREVELENCE = 0.8%) VWF CIRCULATES IN THE PLASMA AS A COMPLEX WITH FACTOR VIII—-GENERALLY FACALITATES THE EXISTENCE AND FUNCTION OF FACTOR VIII THREE TYPES OF VWDz TYPE I -75%—AUTO D —-PARTIAL QUANTITATIVE DEFECT—-RESPONDS TO DDAVP TYPE II-AUTO D OR R—QUALITATIVE DEFECT—-PARTIAL RESPONSE TO DDAVP TYPE III–AUTO R—ABSENCE OF THE VWF—NO RESPONSE TO DDAVP WILL HAVE ABNL PTT IF LOW FACTOR VIII BLEEDING TIME IS OFTEN ELEVATED VWF ANTIGEN MEASUREMENT—-GIVES YOU A CLUE RISTOCETIN COFACTOR ACTIVITY—THE MOST SENSITIVE TEST—EXPLORES THE ABILITY OF VWF TO BIND PLATELETS Rx: DDAVP-–ENHANCES THE RELEASE OF VWF FROM ENDOTHELIAL CELLS CAN LEAD TO H2O RETENTION—HYPONATREMIA FACTOR VIII/VWF CONCENTRATE–LASTS ABOUT A WEEK FACTOR VIII DEFICIENCY = HEMOPHILIA A X- LINKED RECESSIVE (1/10,000) LONG PTT AND LOW FACTOR VIII WITH NL VWF Rx: TRY DDAVP—-MOST HAVE TO USE CONCENTRATES FACTOR IX DEFICIENCY (HEMOPHILIA B, CHRISTMAS Dz) 1/100,000 SAME DX AND RX TO HEMOPHILIA A HIGH DOSES (>400 IU) VIT E AND FISH OILS CAN ALSO INCREASE YOUR BLEEDING TIME