Variation in practice: an analysis of Scottish Surgical Profiles ENT data.

PubMed

Yeo, J C L; Ah-See, K W; Mackenzie, K

2013-02-01

Variation in otolaryngology intervention rates is reported in the Scottish Surgical Profiles Project. Tonsillectomy is one of the selected key indicator procedures. The variation in practice was discussed nationally at the Scottish Otolaryngology Society summer meetings in 2009 and 2010. NHS Grampian had a significantly higher tonsillectomy rate compared with other Scottish NHS boards. To determine the accuracy of NHS Grampian data reported by the Information Service Division (ISD) and to record the appropriateness of listing of patients for tonsillectomy with reference to the Scottish Intercollegiate Guidelines Network (SIGN). Retrospective review of case notes and surgical records of patients who had undergone tonsillectomy between March 2007 and March 2008 in NHS Grampian. Between March 2007 and March 2008, 509 tonsillectomy cases were performed in NHS Grampian. This corresponded to the data received from ISD. 87% of tonsillectomies performed were compliant with SIGN guidelines. The Scottish otolaryngology clinicians have found the reporting of the intervention rates stimulating and challenging. Discussion of the surgical profile project regularly at national specialty meetings resulted in a preliminary detailed targeted audit of those who were persistent outliers for tonsillectomy. This refuted the presumed reasons for this variation, namely inaccurate figures from ISD and inappropriate listings by clinicians.

Tonsillectomy and the risk of inflammatory bowel disease: A systematic review and meta-analysis.

PubMed

Sun, Weili; Han, Xiao; Wu, Siyuan; Yang, Chuanhua

2016-06-01

Tonsillectomy remains a controversial environmental factor in the etiology of inflammatory bowel disease (IBD). This meta-analysis aims to elucidate a more defined role of tonsillectomy in the development of IBD. Four databases, including PubMed, EMBASE, the Cochrane Library, and Web of Science, were searched for studies exploring the association between tonsillectomy and the risk of IBD. The pooled estimates of odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using a random effects model. Heterogeneity was assessed using chi-squared and I(2) statistical analysis. A funnel plot was performed to assess publication bias. A total of 23 observational studies involving 19 569 patients were included in our meta-analysis. Of these, 17 studies investigated the association between tonsillectomy and Crohn's disease (CD), and 22 studies explored its relationship with ulcerative colitis (UC). Overall, a positive relationship between tonsillectomy and development of CD (OR 1.37, 95% CI: 1.16-1.62) was observed, while there was no association between tonsillectomy and UC (OR 0.94, 95% CI: 0.84-1.05). When ORs were adjusted for smoking, the pooled OR for CD increased to 1.66 (95% CI: 1.03-2.68) and, for UC, changed to 1.03 (95% CI: 0.74-1.44). This meta-analysis demonstrates that tonsillectomy is associated with an increased risk of developing CD. We found no evidence to suggest that tonsillectomy exerts a protective effect on the development of UC, as is the case with appendectomy. Further prospective studies are required to confirm the validity of these observations. © 2015 Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.

A Pilot Program: Using Text Messaging to Improve Timely Communication to Tonsillectomy Patients.

PubMed

Newton, Laurie; Sulman, Cecille

2016-01-01

Approximately 1,500 tonsillectomies are performed annually at a large pediatric academic medical center each year. Families need to be educated on how to care for their child after this surgery. Most tonsillectomy patients are discharged home either the same day as surgery or after one night of observation, resulting in post-operative tonsillectomy recovery and care falling upon the patient's family. Multiple quality improvement efforts to improve family education post tonsillectomy surgery have been performed over the last several years at a large pediatric academic medical center. None of these efforts, however, have focused on the use of technology to provide innovative patient education. The purpose of this project is to provide information to parents via text messages and videos to improve patient experience and outcomes following tonsillectomy. Families provided positive feedback, including that the texts were helpful, easy to understand, and reduced pre-operative and recovery anxiety. Also, none of these families needed to call the ENT clinic for any other questions or concerns. The recovery from tonsillectomy is not easy and this pediatric otolaryngology practice is always searching for new ways to improve care and education. Use of technology is an innovative approach and likely one that will be used more often in the future.

The effect of tonsillectomy on the immune system: A systematic review and meta-analysis.

PubMed

Bitar, Mohamad A; Dowli, Alexander; Mourad, Marc

2015-08-01

The immunological sequelae of tonsillectomy in children have been a source of debate among physicians and a continuous concern for parents. Contradictory pertinent results exist in the literature. To understand the real effect of tonsillectomy on the immune system. MEDLINE, EMBASE and COCHRANE. Articles addressing the effect of tonsillectomy on the immune system, up to Dec 2014. Related keywords and medical subject headings were used during the search. The abstracts were reviewed to determine suitability for inclusion based on a set of criteria. Manual crosscheck of references was performed. We checked the tests results and the conclusion of each study to classify it as supporting or refuting the hypothesis of a negative effect of tonsillectomy on the immune system. We reviewed 35 articles, published between 1971 and 2014, including 1997 patients. Only Four studies (11.4%), including 406 patients (20.3%) found that tonsillectomy negatively affects the immune system. We performed a separate meta-analysis on various reviewed humoral and cellular immunological parameters (e.g. total and specific serum Ig's, SecIgA, cellular immunity, and Ag specific Ig). There is more evidence to suggest that tonsillectomy has no negative clinical or immunological sequalae on the immune system. Study limitations included heterogeneity in the diagnostic tools, timing of testing, indication for tonsillectomy and patients' age. It is reasonable to say that there is enough evidence to conclude that tonsillectomy has no clinically significant negative effect on the immune system. It will be important for future studies to uniformly use both preoperative and control laboratory tests' levels to compare the postoperative levels with, to have short and long term follow-up levels, and to include both humoral and cellular immunity in their measurements. The results should reassure both surgeons and parents that tonsillectomy has no proven clinical sequalae. If more research is to be done in the future, it should be performed in a standardized way to avoid the heterogeneity seen in the literature. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.

The Effects of Tonsillectomy Education Using Smartphone Text Message for Mothers and Children Undergoing Tonsillectomy: A Randomized Controlled Trial.

PubMed

Yang, Ji Yeon; Lee, Hanna; Zhang, Yongai; Lee, Ji Uhn; Park, Jun Hee; Yun, Eun Kyoung

2016-11-01

Tonsillectomy is the most common type of surgical procedure performed in preschool children. Due to short period of hospitalization, mothers are expected to manage their children's care at home. However, they are rarely provided with sufficient information about postoperative management. This study aims to determine the effectiveness of providing caregivers with information on tonsillectomy care by smartphone text messaging in increasing their mothers' knowledge, reducing the anxiety, and improving the sick-role behavior of pediatric tonsillectomy patients. A sample of 61 pediatric patients and their mothers was recruited. Participants were randomly assigned into either the experimental group (n = 27) or the control group (n = 34). The control group was given information about the tonsillectomy by conventional textual and verbal means, whereas the experimental group received the same information in the form of 10 text messages during the period from hospitalization to their first follow-up visits. Results of mixed design, two-way analysis of variance indicated significant interaction effects between time points and groups for mothers' knowledge (F = 4.26, p = 0.043) and children's anxiety (F = 3.32; p = 0.037). Thus, the results do support the effectiveness of tonsillectomy education using smartphone text messaging in increasing mothers' knowledge and reducing children's anxiety. These results can be applied to preoperative and postoperative interventions for children not only for tonsillectomy but also for many other operations. The development of various educational programs using smartphone text messaging for postoperative patient management would also be valuable.

Post-tonsillectomy analgesia: the use of benzocaine lozenges.

PubMed

Dempster, J H

1988-09-01

Tonsillectomy frequently results in a significant degree of post-operative pain. Conventional management consists of the administration of intra-muscular opiates prior to the commencement of oral analgesia and is often inadequate, producing variable levels of pain relief. One of the recommended uses of benzocaine lozenges is the relief of throat discomfort following tonsillectomy, but there are no clinical trials to support this claim. Therefore, a prospective placebo controlled trial was undertaken to compare the efficacy of benzocaine lozenges (10 mg.) with standard oral analgesia in the management of post-operative pain following tonsillectomy in an adult population. Consecutive patients undergoing elective tonsillectomy were randomised to receive either benzocaine lozenges (10 mg.) or placebo. Intake of supplementary oral analgesia was recorded, and the level of post-operative pain was assessed by use of a visual linear analogue scale. There was no significant difference in analgesic intake or pain severity as measured by linear analogue between the two groups. These results suggest that there is no benefit in administering benzocaine lozenges for the relief of post-tonsillectomy pain, and its use in this situation cannot be recommended.

Tonsillectomy in children and in adults: changes in practice following the opening of a day-surgery unit with dedicated operating room.

PubMed

Bartier, S; Gharzouli, I; Kiblut, N; Bendimered, H; Cloutier, L; Salvan, D

2018-05-30

To study the impact of the opening of a day-surgery unit on the practice of tonsillectomy in adults and children in the light of the experience of our department, and to compare complications between day-surgery and conventional admission. A retrospective review was conducted of all tonsillectomies performed since the opening of a dedicated day-surgery room, using the ENT and emergency department data-bases. Between October 2013 and December 2014, 179 tonsillectomies were performed (51 in adults, 128 in children), including 108 day-surgeries. Between 2012 and 2014, the number of tonsillectomies increased by 12.7%, with an 18.27% increase in children and stable adult rate. Within 1 year, day-surgery became predominant for children (73.19%) and equaled conventional admission for adults (47.22%). For almost all patients without same-day discharge, the reasons were organizational or due to malorientation (comorbidity, or unsuitable home environment). Day-case tonsillectomy in children showed a 30-day complications rate comparable to those reported in the literature (8.3% postoperative hemorrhage), with a higher rate in adults (35.3%). Onset of complications was at a mean 6 days in adults and 9 days in children; only 2 patients developed complications between 6 and 24hours postoperatively. The present study showed that opening a day-surgery unit led to changes in practice, with most tonsillectomies now performed on an outpatient basis, without increased complications, and notably immediate complications. Outpatient tonsillectomy thus seems to be a solution of choice compared to conventional admission, in terms of cost saving and of patient comfort, without sacrificing safety. The dedicated operating room facilitates scheduling and thereby increasing turnover by reducing wait time. Copyright © 2018. Published by Elsevier Masson SAS.

Inpatient Pediatric Tonsillectomy: Does Hospital Type Affect Cost and Outcomes of Care?

PubMed

Raol, Nikhila; Zogg, Cheryl K; Boss, Emily F; Weissman, Joel S

2016-03-01

To ascertain whether hospital type is associated with differences in total cost and outcomes for inpatient tonsillectomy. Cross-sectional analysis of the 2006, 2009, and 2012 Kids' Inpatient Database (KID). Children ≤18 years of age undergoing tonsillectomy with/without adenoidectomy were included. Risk-adjusted generalized linear models assessed for differences in hospital cost and length of stay (LOS) among children managed by (1) non-children's teaching hospitals (NCTHs), (2) children's teaching hospitals (CTHs), and (3) nonteaching hospitals (NTHs). Risk-adjusted logistic regression compared the odds of major perioperative complications (hemorrhage, respiratory failure, death). Models accounted for clustering of patients within hospitals, were weighted to provide national estimates, and controlled for comorbidities. The 25,685 tonsillectomies recorded in the KID yielded a national estimate of 40,591 inpatient tonsillectomies performed in 2006, 2009, and 2012. The CTHs had significantly higher risk-adjusted total cost and LOS per tonsillectomy compared with NCTHs and NTHs ($9423.34/2.8 days, $6250.78/2.11 days, and $5905.10/2.08 days, respectively; P < .001). The CTHs had higher odds of complications compared with NCTHs (odds ratio [OR], 1.48; 95% CI, 1.15-1.91; P = .002) but not when compared with NTHs (OR, 1.19; 95% CI, 0.89-1.59; P = .23). The CTHs were significantly more likely to care for patients with comorbidities (P < .001). Significant differences in costs, outcomes, and patient factors exist for inpatient tonsillectomy based on hospital type. Although reasons for these differences are not discernable using isolated claims data, findings provide a foundation to further evaluate patient, institutional, and system-level factors that may reduce cost of care and improve value for inpatient tonsillectomy. © American Academy of Otolaryngology—Head and Neck Surgery Foundation 2015.

Variation in inpatient tonsillectomy costs within and between US hospitals attributable to postoperative complications.

PubMed

Sun, Gordon H; Auger, Katherine A; Aliu, Oluseyi; Patrick, Stephen W; DeMonner, Sonya; Davis, Matthew M

2013-12-01

Tonsillectomy is the second most common inpatient procedure in US children. However, the factors that influence tonsillectomy-related costs are unknown. The objective of the study was to describe variation in US inpatient tonsillectomy costs and examine whether postoperative complications contribute to these disparities in costs. This is a retrospective cohort study of the 2009 Nationwide Inpatient Sample. Hierarchical, mixed-effects linear regression modeling was used to analyze the association between postoperative complications and cost, controlling for clinically relevant characteristics such as age, number of chronic comorbidity indicators, and hospital mean complication rates. We also estimated the variance in cost attributable to the treating hospital using the intraclass correlation coefficient. The study cohort comprised 12,512 adult and pediatric patients undergoing tonsillectomy or adenotonsillectomy in the inpatient setting. Cost, posttonsillectomy hemorrhage, and mechanical ventilator use at the individual encounter and at hospital level were evaluated. The aggregate cost of tonsillectomies in the cohort was $94.2 million. The median cost per encounter across all hospitals was $4393 (interquartile range, $3279-$6981), whereas the mean cost was $7525 (95% confidence interval, $6453-$8597). Mechanical ventilation was associated with an adjusted increase of $30,081 per encounter (95% confidence interval, $18,199-$41,964). The intraclass correlation coefficient declined from 0.117 to 0.070 after adjusting for mean hospital mechanical ventilation rate, which accounted for 40.2% of the interhospital variation in cost. Use of mechanical ventilation significantly increases the cost of inpatient tonsillectomy care. Further research should examine risk factors contributing to higher rates of mechanical ventilation after tonsillectomy, which in turn can guide systemic quality improvement interventions to reduce costs.

The severity and duration of postoperative pain and analgesia requirements in children after tonsillectomy, orchidopexy, or inguinal hernia repair.

PubMed

Stewart, David W; Ragg, Philip G; Sheppard, Suzette; Chalkiadis, George A

2012-02-01

To provide parents of children with accurate information regarding postoperative pain, its management, and functioning following common surgical procedures. The increasing prevalence of pediatric day-case procedures demands a more thorough understanding of the recovery profiles associated with these operations. To document postdischarge pain profiles, analgesia requirements, and functional limitation in children following tonsillectomy, orchidopexy, or inguinal hernia repair (IHR). Following hospital discharge, parents were asked to record their children's pain levels, analgesia consumption, and degree of functional limitation each day until complete recovery. Pain and functional limitation were measured using the Parents' Postoperative Pain Measurement (PPPM) scale and Functional Activity Score, respectively. Significant pain was defined as PPPM ≥ 6. One hundred and five patients (50, tonsillectomy; 24, orchidopexy; and 31, IHR) were recruited. Median PPPM was always <6 after IHR, ≥6 only on day 1 after orchidopexy and persisted through to day 8 after tonsillectomy. Mild or severe functional limitation was observed after all surgeries and persisted for 4, 5, and 4 days after median PPPM < 6 after IHR, orchidopexy, and tonsillectomy, respectively. Combination analgesia was commonly administered after orchidopexy and tonsillectomy but less so after IHR. The general practitioner consultation rate following tonsillectomy was 54%. After tonsillectomy, children experience significant pain and severe functional limitation for 7 days after surgery. For many children, pain and functional limitation persists throughout the second postoperative week. In children undergoing orchidopexy, paracetamol and ibuprofen provide adequate analgesia. Pain begins to subside after the first postoperative day, and normal activity resumes after 7 days. After IHR, children experience mild pain that can be treated with paracetamol and return to normal functioning after 4 days. © 2011 Blackwell Publishing Ltd.

Efficacy of dexpanthenol for pediatric post-tonsillectomy pain and wound healing.

PubMed

Celebi, Saban; Tepe, Cigdem; Yelken, Kursat; Celik, Oner

2013-07-01

We evaluated the efficacy of dexpanthenol in managing pediatric post-tonsillectomy pain and wound healing and sought to discover which of two surgical tonsillectomy techniques provides better healing and less postoperative pain. One hundred twenty patients who underwent tonsillectomy were equally randomized to thermal welding and cold dissection groups. Dexpanthenol pastilles were given to half of each group. Postoperative throat pain was determined with a visual analog scale on the 1st, 3th, 7th, and 14th days, and mucosal healing patterns were assessed on the 7th and 14th days. Regardless of surgical technique, post-tonsillectomy throat pain was significantly less in the dexpanthenol groups than in the placebo groups (p < 0.05), and tonsillar wound healing was significantly better in the dexpanthenol groups than in the placebo groups (p < 0.05). When a comparison was made with regard to surgical technique, wound healing was significantly better in the cold dissection group (p < 0.05), whereas postoperative throat pain was less in the thermal welding group (p < 0.05). Postoperative administration of dexpanthenol significantly accelerates the wound healing process and decreases tonsillectomy-related pain complaints.

Pulsating Tonsil Due to Medial Displacement of the Internal Carotid Artery.

PubMed

Alsini, Albaraa Y; Ibrahim, Alsheikhi

2017-05-06

BACKGROUND The internal carotid artery (ICA) is about 2.5 cm away from the tonsils. It has no branches in the cervical portion. ICA anomalies of the neck zone may result in a massive arterial bleeding during pharynx and neck surgery. Due to these anomalies, the surgeon must be aware of this risk during tonsillectomy, adenoidectomy, and pharyngeal operations.  CASE REPORT A 23-year-old woman who was discovered to have an acute S curling-type anomaly of the ICA in contact with the lateral border of the right tonsil during a work-up for a tonsillectomy. This anomaly was incidentally discovered via computed tomography (CT) with contrast. In re-evaluating the course of treatment, we found a severe S-shape kink on the right side, bringing it close to the right tonsil by approximately 2 mm, and putting it at severe risk of injury during a simple tonsillectomy, possibly exposing the patient to serious bleeding. Partial tonsillectomy was performed for this patient with the aim to preserve and not expose the internal carotid artery. Pulsation of right tonsil was recorded. The patient made an uneventful postoperative recovery. CONCLUSIONS Undetected ICA anomaly variation can lead to fatal bleeding during a simple procedure, like tonsillectomy. We recommend vigilance during tonsillectomy if one is using a hot dissection method versus a cold dissection method, which may allow for detection of a perioperative ICA anomaly. Tonsillectomy performed by a junior resident should be under direct supervision, particularly if the hot dissection method is used.

Effectiveness of hyaluronic acid in post-tonsillectomy pain relief and wound healing: a prospective, double-blind, controlled clinical study.

PubMed

Hancı, Deniz; Altun, Huseyin

2015-09-01

To find the effectiveness of hyaluronic acid in post-tonsillectomy pain relief and wound healing. Fifty patients were included in this prospective, double-blind, controlled clinical study (20 males, 30 females mean age of 13.56 years). Hyaluronic acid was applied to one side and the other side was used as a control during tonsillectomy. Therefore, the same patient evaluated and scored the post-tonsillectomy pain, excluding individual bias. Results indicated that patients had significantly lower pain scores for hyaluronic acid treated side (p<0.001). At the end of two weeks follow-up period, the wound in the hyaluronic acid side was almost completely healed, indicating that the healing was faster with hyaluronic acid compared to control side (p<0.001). Hyaluronic acid could be recommended as an effective treatment for the management of post-tonsillectomy pain and wound healing. Copyright © 2015. Published by Elsevier Ireland Ltd.

Perioperative ketorolac increases post-tonsillectomy hemorrhage in adults but not children.

PubMed

Chan, Dylan K; Parikh, Sanjay R

2014-08-01

To evaluate the risk of post-tonsillectomy hemorrhage associated with perioperative ketorolac use. Systematic review and meta-analysis of primary articles reporting individual-level post-tonsillectomy hemorrhage rates in subjects receiving perioperative ketorolac and matched controls. Retrospective and prospective studies were both included. PubMed search was performed for "[ketorolac OR toradol] AND tonsillectomy." Articles fulfilling inclusion criteria were subjected to meta-analysis to determine summary relative risk (RR). Adults are at five times increased risk for post-tonsillectomy hemorrhage with ketorolac use (RR: 5.64; 95% confidence interval [CI]: 2.08-15.27; P < .001). In contrast, children under 18 are not at statistically significantly increased risk (RR: 1.39; 95% CI: 0.84-2.30; P = .20). Both retrospective and prospective studies yield consistent findings. There is no association of RR with pre- or postoperative administration of ketorolac. Ketorolac can be used safely in children, but is associated with a five-fold increased bleeding risk in adults. © 2014 The American Laryngological, Rhinological and Otological Society, Inc.

Post-operative pain following coblation or monopolar electrocautery tonsillectomy in children: a prospective, single-blinded, randomised comparison.

PubMed

Parker, N P; Walner, D L

2011-10-01

To compare post-operative pain following tonsillectomy by either coblation or monopolar electrocautery in children. A parallel-designed, prospective, single-blinded, randomised trial. Ambulatory surgical facility. Eighty otherwise healthy paediatric patients undergoing coblation or electrocautery tonsillectomy by a fellowship-trained paediatric otolaryngologist. (i) The number of post-operative days with severe pain based on subjective qualification by the caretaker, (ii) post-operative days with pain rated ≥ 5 on a scale of 1-10, (iii) post-operative days requiring oral paracetamol/acetaminophen with codeine solution and (iv) post-operative days until resumption of a regular diet were assessed and recorded daily using a post-operative pain survey as a form of daily diary that was returned at the 2-week follow-up visit. Patients were consecutively enrolled into two groups of 40 patients. Average ages were 5.2 years for coblation tonsillectomy and 6.0 years for electrocautery tonsillectomy. The average number of post-operative days with severe pain was 4.2 for coblation and 5.9 for electrocautery (P = 0.006), days rating pain ≥ 5 were 3.6 for coblation and 4.8 for electrocautery (P = 0.037), days of codeine use were 2.5 for coblation and 2.9 for electrocautery (P = 0.324), and days until resumption of a regular diet were 5.2 for coblation and 6.2 for electrocautery (0.329). Coblation tonsillectomy may reduce post-operative pain and the time until resumption of a regular diet compared to electrocautery tonsillectomy. © 2011 Blackwell Publishing Ltd.

Role of Laryngopharyngeal Reflux in Complications of Tonsillectomy in Pediatric Patients.

PubMed

Salturk, Ziya; Kumral, Tolgar Lutfi; Arslanoglu, Ahmet; Aydogdu, Imran; Yildirim, Guven; Berkiten, Guler; Uyar, Yavuz

2017-09-01

Tonsillectomy and tonsillectomy with adenoidectomy are among the most common surgical procedures in otolaryngology practice. Gastroesophageal reflux was identified as a risk factor for complications in tonsillectomy. This prospective study was designed to assess the role of reflux in the development of complications following tonsillectomy in pediatric patients. Children (n = 60) who underwent tonsillectomy with adenoidectomy were divided into two groups, i.e., the laryngopharyngeal reflux (LPR) group and control group. Patients with LPR were identified by reflux symptom index and reflux finding score. Pain, hemorrhage, fever, nausea, vomiting, fever, dehydration, infection, and pulmonary problems were evaluated post operatively. The mean lengths of hospital stay were 2.11 days in the reflux group and 1.05 days in the control group. The difference was statistically significant. Visual analogue scores of both groups were similar on day 1 but it was significantly higher on day 7 and 14 in LPR group. Nausea and vomiting rates were 11.1 and 9.5 % for the patients in the LPR group and the controls, respectively. The difference between the two groups was not significant. The mean fever was 37.6 °C in the reflux group and 37.3 °C in the controls, which were not significantly different. 19 % of the controls and 22 % of the LPR group patients were readmitted. This difference was not statistically significant. There were two cases of bleeding in the reflux group, while no bleeding occurred in the control group. This difference was significant statistically. LPR is a risk factor for complications following tonsillectomy.

Tonsillectomy and infectious mononucleosis--a possible relationship.

PubMed

Goode, R L; Coursey, D L

1976-07-01

A review of 1,192 student medical records shows a prior history of tonsillectomy in 41 percent of a control group and 22 percent of an infectious mononucleosis group--a significant difference (p less than 0.01). Nine hundred eighty-nine Stanford University students (421 females, 568 males) who visited Cowell Student Health Center between April and September, 1973, comprise the control group. Two hundred three students with positive monospot tests and clinical mononucleosis diagnosed between June, 1968, and May, 1973, comprise the experimental group. The lower incidence of tonsillectomy in the infectious mononucleosis group implies that the tonsillar lymphoid tissue serves as a reservoir and possible replicating milieu for the Epstein-Barr virus. Prior tonsillectomy may reduce the possibility of contracting infectious mononucleosis.

The comparison of bleeding and pain after tonsillectomy in bipolar electrocautery vs cold dissection.

PubMed

Dadgarnia, Mohammad Hossein; Aghaei, Mohammad Ali; Atighechi, Saeid; Behniafard, Nasim; Vahidi, Mohammad Reza; Meybodian, Mojtaba; Zand, Vahid; Vajihinejad, Maryam; Ansari, Abdollah

2016-10-01

Although tonsillectomy is one of the most common surgeries performed in pediatric, it has potential major complications such as pain and bleeding. This study aimed to compare the bleeding and pain after tonsillectomy in bipolar electrocautery tonsillectomy versus cold dissection. This double blind clinical trial was conducted on 70 pediatric patients who were candidate of tonsillectomy. Patients were divided into two groups of including bipolar cautery (BC) and cold dissection (CD). operation time, intraoperative blood loss, and postoperative bleeding and pain were evaluated in the current study. In both of the CD and BC groups, no significant difference was found in terms of sex and age. The average amount of the intraoperative blood loss in BC group was 14.086 ± 5.013 ml and in CD group was 26.14 ± 4.46 ml (p. v = 0.0001). The mean time of operation in BC group was 19 ± 2.89 min and in CD group was 29.31 ± 5.29 min (p. v = 0.0001). patients were evaluated in terms of pain on the first, third, fifth, and seventh days after the operation. No statistically significant difference was found between two groups. Moreover, Compared pain scores in all times across two groups, no significant difference was found. In terms of postoperative bleeding, none of the patients in both groups had bleeding during follow-up. Our study showed that bipolar electrocautery tonsillectomy can significantly reduce the operation time and intraoperative blood loss; however, postoperative pain and blood loss were similar in both techniques. We recommend bipolar electrocautery as the most suitable alternative method for tonsillectomy, especially in children. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

Scoping review of pediatric tonsillectomy quality of life assessment instruments.

PubMed

Kao, Stephen Shih-Teng; Peters, Micah D J; Dharmawardana, Nuwan; Stew, Benjamin; Ooi, Eng Hooi

2017-10-01

Sleep-disordered breathing or recurrent tonsillitis have detrimental effects on the child's physical health and quality of life. Tonsillectomy is commonly performed to treat these common conditions and improve the child's quality of life. This scoping review aims to present a comprehensive and descriptive analysis of quality of life questionnaires as a resource for clinicians and researchers when deciding which tool to use when assessing the quality of life effects after tonsillectomy. A comprehensive search strategy was undertaken across MEDLINE (PubMed), CINAHL, Embase, and Cochrane CENTRAL. Quality of life questionnaires utilized in studies investigating pediatric patients undergoing tonsillectomy for chronic tonsillitis or sleep-disordered breathing were included. Methodological quality and data extraction were conducted as per Joanna Briggs Institute methodology. Ten questionnaires were identified, consisting of six generic and four disease-specific instruments. The Pediatric Quality of Life Inventory was the most commonly utilized generic questionnaire. The Obstructive Sleep Apnea-18 was the most commonly utilized disease-specific questionnaire. This review identified a range of generic and disease-specific quality of life questionnaires utilized in pediatric patients who have undergone tonsillectomy with or without adenoidectomy for sleep-disordered breathing or chronic tonsillitis. Important aspects of each questionnaire have been summarized to aid researchers and clinicians in choosing the appropriate questionnaire when evaluating the quality of life effects of tonsillectomy. NA Laryngoscope, 127:2399-2406, 2017. © 2017 The American Laryngological, Rhinological and Otological Society, Inc.

INCIDENCE OF POLIOMYELITIS—The Effect of Tonsillectomy and Other Operations on the Nose and Throat

PubMed Central

Miller, Alden H.

1952-01-01

A statistical survey was made of all the cases of poliomyelitis occurring in all of Los Angeles County during the three years of 1949, 1950 and 1951 in an attempt to determine the effect of operations on the nose and throat on the incidence of poliomyelitis. Tonsillectomy and adenoidectomy were the only operations noted with any degree of frequency. Yet, in the total of 3,601 cases of poliomyelitis that occurred in this three-year period there were only 20 (0.55 per cent) in which the patient had had recent tonsillectomy and adenoidectomy. The incidence of this disease in patients who had had tonsillectomy and adenoidectomy was compared with the “expected” incidence as determined from the incidence in other patients, in the same age group. There was no significant difference between actual and expected incidence even during the summer months when most cases of poliomyelitis occurred. The same was true with regard to recently tonsillectomized patients in the epidemic months of July through October. In a separate survey of 675 patients with poliomyelitis, it was noted that only 30 per cent ever had had tonsillectomy or adenoidectomy. Inasmuch as it is estimated that one of every three persons in the general young population nowadays has had tonsillectomy and adenoidectomy, this figure is no more or less than could be expected. PMID:12978882

Tonsillectomy and infectious mononucleosis.

PubMed

Sumaya, C V; Downey, K; Ullis, K C

1978-01-01

Tonsillar tissue may be the primary site of infection with Epstein-Barr virus (EBV), the etiologic agent of classical infectious mononucleosis (IM). Therefore, a retrospective study of the association between tonsillectomy and IM was performed in a college student population. In the first part of the study, tonsillectomy rates were compared between 164 IM-positive students and 164 student controls who attended UCLA in 1972-1975. Although it was determined that the development of IM during college years was statistically less commin in tonsillectomized students, the difference was not inordinately large and probably had no significant biologic meaning. The authors speculate that the difference was due to the greater likelihood, and greater yield, in considering the diagnosis of IM in young adults with enlarged, inflamed tonsils. In support of this is the fact that IM-positive students who had received a prior tonsillectomy usually had the surgical procedure performed at a younger age than the control group. Conceivably, tonsillar ablation in the very young is more liable to result in incomplete removal and eventual regrowth of this tissue. Indeed, six IM-positive students who had received a tonsillectomy at six years of age or less were found to have exudate in tonsillar fossae or pillars during their IM episode. In the second part of the study, clinical and laboratory measures were found to be similar between a larger group of IM-positive students with or without a history of prior tonsillectomy.

Beneficial effects of dexmedetomidine on early postoperative cognitive dysfunction in pediatric patients with tonsillectomy.

PubMed

Han, Chuanlai; Fu, Rong; Lei, Weifu

2018-07-01

According to clinical investigations, early postoperative cognitive dysfunction is the most common adverse event in pediatric patients after tonsillectomy. A previous study has indicated that dexmedetomidine (DEX) is an efficient drug for the treatment of postoperative cognitive dysfunction. However, the efficacy of DEX in alleviating early postoperative cognitive dysfunction in pediatric patients following tonsillectomy has remained elusive, which was therefore assessed in the present study. A total of 186 children presenting with cognitive dysfunction subsequent to tonsillectomy were recruited to analyze the efficacy of DEX. Patients were randomly divided into two groups and received intravenous treatment with DEX (n=112) or placebo (n=74). Duration of treatment, dose-limiting toxicities (DLT) and maximum tolerated dose (MTD) of DEX were evaluated in a preliminary experiment. The improvement of postoperative cognitive function in children with tonsillectomy was analyzed with a Mini-Mental State Examination (MMSE) following treatment with DEX. A 40-item quality of life (MONEX-40) questionnaire was used to assess the efficacy of DEX. The plasma levels of interleukin (IL)-6, IL-1, tumor necrosis factor (TNF)-α, superoxide dismutase (SOD), neuron-specific enolase (NSE), C-reactive protein (CRP), cortisol and melatonin were also analyzed. The preliminary experiment determined that the DLT was 10 mg/kg and the MTD was 15 mg/kg. In the major clinical trial, it was revealed that MMSE scores in the DEX treatment group were markedly improved, indicating that DEX had a beneficial effect in pediatric patients with early postoperative cognitive dysfunction after tonsillectomy. In addition, IL-1and TNF-α were downregulated, while IL-6 and SOD were upregulated in patients with cognitive dysfunction after treatment with DEX compared with those in the placebo group. Furthermore, DEX treatment markedly decreased the serum levels of CRP, NSE cortisol and melatonin, which are associated with the occurrence of postoperative cognitive dysfunction in pediatric patients following tonsillectomy. In conclusion, intravenous administration of DEX at a dose of 10 mg/kg improves postoperative cognitive function in pediatric patients with tonsillectomy by decreasing the serum levels of inflammatory factors and stress-associated signaling molecules. Trial registration no. QLSDHOS0200810102C (Qilu Hospital of Shandong University, Jinan, China).

Specified data for tonsil surgery in Germany

PubMed Central

Windfuhr, Jochen P.

2016-01-01

Background: Tonsillectomy rates vary considerably among different states, regions, and times. This study was conducted to identify the prevalence of “chronic” tonsillitis, peritonsillar abscess, hypertrophy of the tonsils with and without adenoids in absolute and relative numbers in an 80 million people nation. Moreover, the number and rates of different surgical procedures to resolve either “chronic” tonsillitis, peritonsillar abscess, or upper airway obstruction due to (adeno)tonsillar hypertrophy over several years was evaluated in this study (tonsillectomy, adenotonsillectomy, tonsillotomy, abscess tonsillectomy, transoral incision and drainage). Finally, the post-tonsillectomy hemorrhage rate was calculated and analyzed in relation to age and gender. Material and methods: Calculations were based on data as published by the Federal Institute of Statistics or on request, if needed. The latest data were provided for 2013. Results: The total number of the aforementioned diseases (stratified by ICD-10) decreased from 142,574 (in 2000) to 87,624 in 2013 (38.5%). Tonsillectomy, with or without adenoidectomy, was performed in a total of 833,896 patients between 2006 and 2013 in Germany. The yearly number decreased continually from 120,993 in 2006 to 84,332 procedures in 2013 (30.3%). The most significant decrease was registered in patients younger than 20 years of age for this time period: 70.92 per 10,000 in 2010 to 58.68 per 10,000 in 2013. If all age groups were included, the rate decreased from 13.34 per 10,000 to 10.90 per 10,000. In contrast, an increasing number of tonsillotomies was observed between 2007 (4,659 procedures) and 2013 (11,493). The cumulated number of procedures was 59,049. A constant number of 15,000 cases with peritonsillar abscess were diagnosed per year in Germany (19 patients per 100,000). The prevalence increased significantly at an age of 15 years and there was a preponderance of female patients below that age. Compared to the transoral incision and drainage, a 2.8-fold greater number of abscess tonsillectomies were performed annually. Post-tonsillectomy hemorrhage was experienced in 5.98% of all patients after 245,721 procedures in 2010 and 2013 (all indications, except tonsillotomy). Bleeding complications had occurred less frequently in female patients (5.06% vs. 7.02%). Finally, a considerable increase of post-tonsillectomy hemorrhage in patients older than 10 years of age was registered in male patients only. Conclusion: Chronic tonsillitis was less frequently diagnosed and surgically treated in terms of tonsillectomy (with or without adenoidectomy), particularly in female patients. In contrast, the number of tonsillotomies increased continually, particularly in male patients. Peritonsillar abscess was diagnosed and surgically treated in a constant number of patients in the yearly comparison. Most of these patients were scheduled for abscess tonsillectomy, and only a 2.8-fold smaller number for transoral incision and drainage. Independent from the indication for surgery, post-tonsillectomy hemorrhage was clearly associated with male gender and age (>10 years). The study reveals a dramatic change mandating further surveillance in insurance companies and authorities in the national health system of an 80 million people nation. (Tab. 1) PMID:28025608

Recurring Strep Throat: When Is Tonsillectomy Useful?

MedlinePlus

... throat: When is tonsillectomy useful? My 7-year-old daughter has been diagnosed with strep throat four ... of Privacy Practices Notice of Nondiscrimination Manage Cookies Advertising Mayo Clinic is a not-for-profit organization ...

Tonsils and Tonsillectomies (For Parents)

MedlinePlus

... may order a throat culture to check for strep throat. About Tonsillectomies Doctors might recommend surgical removal of ... Kids With No Tonsils More Susceptible to Infections? Strep Throat Preparing Your Child for Surgery Tonsillitis Enlarged Adenoids ...

Enlarged Adenoids (For Parents)

MedlinePlus

... topic for: Parents Kids Teens Tonsils and Tonsillectomies Strep Throat Obstructive Sleep Apnea Preparing Your Child for Surgery ... the Operating Room? Snoring Tonsillitis All About Adenoids Strep Throat Enlarged Adenoids Tonsils and Tonsillectomies What's It Like ...

Efficacy of honey in reduction of post tonsillectomy pain, randomized clinical trial.

PubMed

Mohebbi, Saleh; Nia, Fatemeh Hasan; Kelantari, Farbood; Nejad, Sheqhayeqh Ebrahim; Hamedi, Yaghoob; Abd, Reza

2014-11-01

Tonsillectomy is one of the most common operations performed in pediatric population. One of the most prevalent tonsillectomy complications is early or delayed post-operative hemorrhage. Other important morbidity is post-operative pain. Historically, honey has been used for wound control, reducing the inflammation, and healing acceleration. The aim of this study is to investigate the effect of honey on reducing pain after tonsillectomy in children 5-15 years old. After tonsillectomy, 80 patients were randomly divided in two equal groups. Patients in the first group were treated with antibiotic and acetaminophen, while those in the second group were treated with antibiotic, acetaminophen and honey. Data was gathered via a questionnaire and observation of tonsillar bed healing. Data was analyzed by SPSS17 software and related tests. Pain comparison between two groups showed that the average time required for pain relief in patients who received honey was less than the control. The pain intensity was higher during the first 9 days post-operatively in control group. Results also showed that acetaminophen consumption in patients who received honey is lower. In the case group, the average time to resume regular diet and the frequency of awakening at night is significantly less than the control group. Honey administration after tonsillectomy has valuable effect in pain relief and it can be used as an adjunctive regimen after surgery for better pain control. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.

‘A Wicked Operation’? Tonsillectomy in Twentieth-Century Britain

PubMed Central

Dwyer-Hemmings, Louis

2018-01-01

Histories of twentieth-century surgery have focused on surgical ‘firsts’ – dramatic tales of revolutionary procedures. The history of tonsillectomy is less glamorous, but more widespread, representing the experience and understanding of medicine for hundreds of children, parents and surgeons daily. At the start of the twentieth century, tonsillectomy was routine – performed on at least 80 000 schoolchildren each year in Britain. However, by the 1980s, public and professional discourse condemned the operation as a ‘dangerous fad’. This profound shift in the medical, political and social position of tonsillectomy rested upon several factors: changes in the organisation of medical institutions and national health care; changes in medical technologies and the criteria by which they are judged; the political, cultural and economic context of Britain; and the social role of the patient. Tonsillectomy was not a mere passive subject of external influences, but became a potent concept in medical, political, and social discourse. Therefore, it reciprocally influenced these discourses and subsequently the development of twentieth-century British medicine. These complex interactions between ‘medical’ and ‘non-medical’ spheres question the possibility of demarcating what is internal from what is external to medicine. PMID:29553012

Evaluation of the effect of aromatherapy with lavender essential oil on post-tonsillectomy pain in pediatric patients: a randomized controlled trial.

PubMed

Soltani, Rasool; Soheilipour, Saeed; Hajhashemi, Valiollah; Asghari, Gholamreza; Bagheri, Mahdi; Molavi, Mahdi

2013-09-01

To evaluate the effect of aromatherapy with Lavandula angustifolia essential oil on post-tonsillectomy pain in pediatric patients. This was a randomized controlled prospective clinical trial. In this study, 48 post-tonsillectomy patients aged 6-12 years were randomly assigned to two groups (24 patients in each group). After tonsillectomy surgery, all patients received acetaminophen (10-15 mg/kg/dose, PO) every 6h as necessary to relieve pain. The patients of the case group also inhaled lavender essential oil. The frequencies of daily use of acetaminophen and nocturnal awakening due to pain, and pain intensity (evaluated using visual analog scale [VAS]) were recorded for each patient for 3 days after surgery. Finally, the mean values of variables were compared between two groups separately for each post-operative day. The use of lavender essential oil caused statistically significant reduction in daily use of acetaminophen in all three post-operative days but had not significant effects on pain intensity and frequency of nocturnal awakening. Aromatherapy with lavender essential oil decreases the number of required analgesics following tonsillectomy in pediatric patients. Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.

Outcome measures to evaluate new technology for tonsillectomy: preliminary experience with Coblation

NASA Astrophysics Data System (ADS)

Shah, Udayan K.; Puchalski, Robert; Briggs, Marianne; Chiavacci, Rosetta; Galinkin, Jeffrey

2001-05-01

Evaluating the benefits of new surgical technologies does not end with the observation of successful instrument-to- tissue interaction. The impact of new technologies in medicine today is also gauged by improvements in patients' daily activities and performance. We present our outcomes assessment tool for judging the value of applying a novel tonsillectomy technique, plasma- mediated ablation using Coblation technology. Plasma- mediated ablation (PMA) achieves soft tissue resection in the oropharynx by energizing protons to break bonds. Less heat is released, allowing for less thermal injury, and possibly less pain, than with tonsillectomy performed using electrocautery alone. Children undergoing tonsillectomy by PMA, were evaluated using our outcomes-based scale, which asked families to report the degree of interruption of normal activities for the patient and their family during the post-tonsillectomy recovery period. A preliminary review of several outcomes assessments exemplify the benefits and limitations of this tool. The tracking of valuable data is weighed against the limitations of a short time course relative to the duration of disability, and a poor response rate. Future work aims to improve this data collection tool to allow application to other new technologies in otolaryngology.

Analysis of clinical negligence claims following tonsillectomy in England 1995 to 2010.

PubMed

Mathew, Rajeev; Asimacopoulos, Eleni; Walker, David; Gutierrez, Tatiana; Valentine, Peter; Pitkin, Lisa

2012-05-01

We determined the characteristics of medical negligence claims following tonsillectomy. Claims relating to tonsillectomy between 1995 and 2010 were obtained from the National Health Service Litigation Authority database. The number of open and closed claims was determined, and data were analyzed for primary injury claimed, outcome of claim, and associated costs. Over 15 years, there were 40 claims of clinical negligence related to tonsillectomy, representing 7.7% of all claims in otolaryngology. There were 34 closed claims, of which 32 (94%) resulted in payment of damages. Postoperative bleeding was the most common injury, with delayed recognition and treatment of bleeding alleged in most cases. Nasopharyngeal regurgitation as a result of soft palate fistulas or excessive tissue resection was the next-commonest cause of a claim. The other injuries claimed included dentoalveolar injury, bums, tonsillar remnants, and temporomandibular joint dysfunction. Inadequate informed consent was claimed in 5 cases. Clinical negligence claims following tonsillectomy have a high success rate. Although postoperative bleeding is the most common cause of negligence claims, a significant proportion of claims are due to rare complications of surgery. Informed consent should be tailored to the individual patient and should include a discussion of common and serious complications.

[Analysis of the causes of postoperative delayed hemorrhage of low temperature plasma tonsillectomy in children].

PubMed

Ye, Yuhua; Wang, Zhinan; Xu, Zhiqiang

2015-03-01

Probe into the causes of postoperative delayed hemorrhage of low temperature plasma tonsillectomy in children. The methods of retrospective analysis the difference of postoperative bleeding time and bleeding rate between tonsillectomy by the low temperature plasma and the traditional cold surgical devices in 2-14 years old children. Plasma group contained the tonsillectomy by low temperature plasma between the March in 2012 to the August in 2013. Traditional group contained the tonsillectomy by traditional cold surgical devices between the March in 2005 to the August in 2006. In the 1,000 cases of plasma group, 19 cases occurred postoperative hemorrhage, the hemorrhage rate was 1. 9%. Four cases occurred postoperative primary hemorrhage in 8 hours after operation, the postoperative primary hemorrhage rate was 0. 4%. Fifteen cases occurred postoperative delayed hemorrhage, the delayed hemorrhage rate was 1. 50%, the bleeding time was 2-13 days after operation, the average number was 7. 5 days. Nine cases had wound infection and 6 cases had eaten some food improperly in these 15 cases. And in these eaten improperly cases, 4 children had eaten fruit and hard food, 2 children had eaten a little food who lost their weight. In 860 cases of the traditional group, 29 cases occurred postoperative hemorrhage, the hemorrhage rate was 3. 37%. 26 cases occurred postoperative primary hemorrhage in 8 hours after operation, the postoperative primary hemorrhage rate was 3. 02%. Three cases occurred postoperative delayed hemorrhage, the delayed hemorrhage rate was 0. 35%, the bleeding time was 2-6 days, the average number was 4 days. It is preferable for chileren to having low temperature plasma tonsillectomy. The causes of postoperative delayed hemorrhage of low temperature plasma tonsillectomy in children are probably related to the postoperative infection, the differences of operation skills, the method of stop bleeding, eating the wrong foods, irritating cough, improper nursing and so on.

Dental arch dimensional changes after adenoidectomy or tonsillectomy in children with airway obstruction: A meta-analysis and systematic review under PRISMA guidelines.

PubMed

Zhu, Yanfei; Li, Jiaying; Tang, Yanmei; Wang, Xiaoling; Xue, Xiaochen; Sun, Huijun; Nie, Ping; Qu, Xinhua; Zhu, Min

2016-09-01

Children with severe airway obstruction tend to have a vertical direction of growth, class II malocclusion, and narrow arches. Adenoidectomy and tonsillectomy were recommended for the promotion of balanced dentition growth in these children.The aim of this study was to determine the effect of adenoidectomy and tonsillectomy on the growth of dental morphology in children with airway obstruction. A comprehensive search of the Medline, Embase, Web of science, and OVID databases for studies published through to January 17, 2016 was conducted. Prospective, comparative, clinical studies assessing the efficacy of adenoidectomy, or tonsillectomy in children with airway obstruction were included. The weighted mean difference (WMD) and 95% confidence interval (CI) were used for continuous variables. Forest plots were drawn to demonstrate effects in the meta-analyses. Eight papers were included in our study. We found that adenoidectomy and tonsillectomy led to a significant change in nasal-breathing in children with airway obstruction. Children with airway obstruction had a significantly narrower posterior maxillary dental arch than children without airway obstruction (WMD = -0.94, 95% CI [-1.13, -0.76]; P < 0.001). After surgery, these children still had a significantly narrower dental arch than the nasal-breathing children (WMD = -0.60, 95% CI [-0.79, -0.42]; P < 0.001). In terms of dental arch width, malocclusion, palatal height, overjet, overbite, dental arch perimeter, and arch length, a tendency toward normalization was evident following adenoidectomy or tonsillectomy, with no significant differences evident between the surgical group and the normal group. The small number of studies and lack of randomized controlled trials were the main limitations of this meta-analysis. Following adenoidectomy and tonsillectomy, the malocclusion and narrow arch width of children with airway obstruction could not be completely reversed. Therefore, other treatments such as functional training or orthodontic maxillary widening should be considered after removing the obstruction in the airway.

Demonstration of analgesic effect of intranasal ketamine and intranasal fentanyl for postoperative pain after pediatric tonsillectomy.

PubMed

Yenigun, Alper; Yilmaz, Sinan; Dogan, Remzi; Goktas, Seda Sezen; Calim, Muhittin; Ozturan, Orhan

2018-01-01

Tonsillectomy is one of the oldest and most commonly performed surgical procedure in otolaryngology. Postoperative pain management is still an unsolved problem. In this study, our aim is to demonstrate the efficacy of intranasal ketamine and intranasal fentanyl for postoperative pain relief after tonsillectomy in children. This randomized-controlled study was conducted to evaluate the effects of intranasal ketamine and intranasal fentanyl in children undergoing tonsillectomy. Tonsillectomy performed in 63 children were randomized into three groups. Group I received: Intravenous paracetamol (10 mg/kg), Group II received intranasal ketamine (1.5 mg/kg ketamine), Group III received intranasal fentanyl (1.5 mcg/kg). The Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) and Wilson sedation scale scores were recorded at 15, 30, 60 min, 2 h, 6hr, 12 h and 24 h postoperatively. Patients were interviewed on the day after surgery to assess the postoperative pain, nightmares, hallucinations, nausea, vomiting and bleeding. Intranasal ketamine and intranasal fentanyl provided significantly stronger analgesic affects compared to intravenous paracetamol administration at postoperative 15, 30, 60 min and at 2, 6, 12 and 24 h in CHEOPS (p < 0.05). Sedative effects were observed in three patients in the intranasal ketamine administration group. No such sedative effect was seen in the groups that received intranasal fentanyl and intravenous paracetamol in Wilson Sedation Scale (p < 0.05). Cognitive impairment, constipation, nausea, vomiting and bleeding were not observed in any of the groups. This study showed that either intranasal ketamine and intranasal fentanyl were more effective than paracetamol for postoperative analgesia after pediatric tonsillectomy. Sedative effects were observed in three patients with the group of intranasal ketamine. There was no significant difference in the efficacy of IN Ketamine and IN Fentanyl for post-tonsillectomy pain. Copyright © 2017 Elsevier B.V. All rights reserved.

Influence of radiofrequency surgery on architecture of the palatine tonsils.

PubMed

Plzak, Jan; Macokova, Pavla; Zabrodsky, Michal; Kastner, Jan; Lastuvka, Petr; Astl, Jaromir

2014-01-01

Radiofrequency surgery is a widely used modern technique for submucosal volume reduction of the tonsils. So far there is very limited information on morphologic changes in the human tonsils after radiofrequency surgery. We performed histopathological study of tonsillectomy specimens after previous bipolar radiofrequency induced thermotherapy (RFITT). A total of 83 patients underwent bipolar RFITT for hypertrophy of palatine tonsils. Tonsil volume reduction was measured by 3D ultrasonography. Five patients subsequently underwent tonsillectomy. Profound histopathological examination was performed to determine the effect of RFITT on tonsillar architecture. All tonsillectomy specimens showed the intact epithelium, intact germinal centers, normal vascularization, and no evidence of increased fibrosis. No microscopic morphological changes in tonsillectomy specimens after bipolar RFITT were observed. RFITT is an effective submucosal volume reduction procedure for treatment of hypertrophic palatine tonsils with no destructive effect on microscopic tonsillar architecture and hence most probably no functional adverse effect.

Pain experiences and non-pharmacological strategies for pain management after tonsillectomy: a qualitative interview study of children and parents.

PubMed

Idvall, Ewa; Holm, Charlotta; Runeson, Ingrid

2005-09-01

Tonsillectomy is one of the most common paediatric surgical procedures. This study aimed to investigate children's experience of pain and the nonpharmacological strategies that they used to manage pain after tonsillectomy. A further aim was to investigate parental views on these same phenomena. Six children (aged seven to 18 years) and their parents (four mothers and two fathers) were interviewed separately on the day after tonsillectomy. The data were analysed using a qualitative approach. Pain experiences were divided into the categories of physiological pain and psychological pain. Children rated their 'worst pain' during the past 24 hours between 6 and 10 (visual analogue scale, 0-10). The non-pharmacological strategies used most frequently to manage pain were thermal regulation (physical method) and distraction (cognitive-behavioural method) according to the framework used. Specific non-pharmacological strategies for pain management relative to different surgical procedures need to be considered.

Histologic assessment of thermal injury to tonsillectomy specimens: a comparison of electrocautery, coblation, harmonic scalpel, and tonsillotome.

PubMed

Modi, Vikash K; Monforte, Hector; Geller, Kenneth A; Koempel, Jeffrey A

2009-11-01

To determine the extent of thermal injury to the tonsillar tissue following the use of various types of instrumentation. To determine if tonsillectomy specimens routinely contain tissue other than lymphoid tissue. Retrospective histologic analysis. A histologic analysis performed on 228 tonsillectomy specimens removed by use of an electrocautery in 132 specimens, harmonic scalpel in 46, coblation device in 24, and a tonsillotome in 26. The specimens were evaluated for presence and percentage of skeletal muscle and depth of thermal tissue injury. The mean percentage of skeletal muscle present in the specimens was 0.79% for electrocautery, 1.74% for harmonic scalpel, 0.97% for coblation device, and 1.66% for the tonsillotome. Skeletal muscle was absent in only 8 of 228 specimens (3.5%). Electrocautery has a statistically significant (P < .05) lower percentage of muscle tissue compared to harmonic scalpel and the tonsillotome. There was no statistically significant difference in the mean depth of thermal injury among the harmonic scalpel (0.68 mm), electrocautery (0.58 mm), and coblation device (0.71 mm) specimens. The tonsillotome specimens had no thermal injury. Attempts to remove the entire tonsil results in a similar depth of thermal injury to tonsillectomy specimens when using the harmonic scalpel, electrocautery, and coblation device. Skeletal muscle is a nearly ubiquitous finding in routine tonsillectomy specimens. The use of an electrocautery with a needle point may allow for a more precise dissection as it results in tonsillectomy specimens with a smaller percentage of muscle present.

Indirect costs related to caregivers' absence from work after paediatric tonsil surgery.

PubMed

Gudnadottir, Gunnhildur; Tennvall, G Ragnarson; Stalfors, J; Hellgren, J

2017-06-01

Tonsillotomy has gradually replaced tonsillectomy as the surgical method of choice in children with upper airway obstruction during sleep, because of less postoperative pain and a shorter recovery time. The aim of this study was to examine the costs related to caregivers' absenteeism from work after tonsillectomy (TE) and tonsillotomy (TT). All tonsillectomies and tonsillotomies in Sweden due to upper airway obstruction during 1 year, reported to the National Tonsil Surgery Register in children aged 1-11 were included, n = 4534. The number of days the child needed analgesics after surgery was used as a proxy to estimate the number of work days lost for the caregiver. Data from the Social Insurance Agency (Försäkringskassan) regarding the days the parents received temporary parental benefits in the month following surgery were also analysed. The indirect costs due to the caregivers' absenteeism after tonsillectomy vs tonsillotomy were calculated, using the human capital method. The patient-reported use of postoperative analgesic use was 77% (n = 3510). Data from the Social Insurance Agency were gathered for all 4534 children. The mean duration of analgesic treatment was 4.6 days (indirect cost of EUR 747). The mean number of days with parental benefits was 2.9 (EUR 667). The indirect cost of tonsillectomy was 61% higher than that of tonsillotomy (EUR 1010 vs EUR 629). The results show that the choice of surgical method affects the indirect costs, favouring the use of tonsillotomy over tonsillectomy for the treatment of children with SDB, due to less postoperative pain.

Efficacy of Opioid-free Anesthesia in Reducing Postoperative Respiratory Depression in Children Undergoing Tonsillectomy

ClinicalTrials.gov

2018-05-04

Anesthesia; General Anesthesia; Analgesics, Opioid; Postoperative Complications; Pathologic Processes; Physiologic Effects of Drugs; Narcotics; Analgesics; Sleep Disordered Breathing; Obstructive Sleep Apnea of Child; Tonsillectomy; Respiratory Depression; Dexmedetomidine; Ketamine; Lidocaine; Gabapentin; Pulse Oximetry

The NAtional randomised controlled Trial of Tonsillectomy IN Adults (NATTINA): a clinical and cost-effectiveness study: study protocol for a randomised control trial.

PubMed

Rubie, Isabel; Haighton, Catherine; O'Hara, James; Rousseau, Nikki; Steen, Nick; Stocken, Deborah D; Sullivan, Frank; Vale, Luke; Wilkes, Scott; Wilson, Janet

2015-06-06

The role of tonsillectomy in the management of adult tonsillitis remains uncertain and UK regional variation in tonsillectomy rates persists. Patients, doctors and health policy makers wish to know the costs and benefits of tonsillectomy against conservative management and whether therapy can be better targeted to maximise benefits and minimise risks of surgery, hence maximising cost-effective use of resources. NATTINA incorporates the first attempt to map current NHS referral criteria against other metrics of tonsil disease severity. A UK multi-centre, randomised, controlled trial for adults with recurrent tonsillitis to compare the clinical and cost-effectiveness of tonsillectomy versus conservative management. An initial feasibility study comprises qualitative interviews to investigate the practicality of the protocol, including willingness to randomise and be randomised. Approximately 20 otolaryngology staff, 10 GPs and 15 ENT patients will be recruited over 5 months in all 9 proposed main trial participating sites. A 6-month internal pilot will then recruit 72 patients across 6 of the 9 sites. Participants will be adults with recurrent acute tonsillitis referred by a GP to secondary care. Randomisation between tonsillectomy and conservative management will be according to a blocked allocation method in a 1:1 ratio stratified by centre and baseline disease severity. If the pilot is successful, the main trial will recruit a further 528 patients over 18 months in all 9 participating sites. All participants will be followed up for a total of 24 months, throughout which both primary and secondary outcome data will be collected. The primary outcome is the number of sore throat days experienced over the 24-month follow-up. The pilot and main trials include an embedded qualitative process evaluation. NATTINA is designed to evaluate the relative effectiveness and efficiency of tonsillectomy versus conservative management in patients with recurrent sore throat who are eligible for surgery. Most adult tonsil disease and surgery has an impact on economically active age groups, with individual and societal costs through loss of earnings and productivity. Avoidance of unnecessary operations and prioritisation of those individuals likely to gain most from tonsillectomy would reduce costs to the NHS and society. ISRCTN55284102, Date of Registration: 4 August 2014.

Impact of the Korean Diagnosis-Related Groups payment system on the outcomes of adenotonsillectomy: A single center experience.

PubMed

Kwak, Sang Hyun; Kim, Ji Hoon; Kim, Da Hee; Kim, Jung Min; Byeon, Hyung Kwon; Kim, Won Shik; Koh, Yoon Woo; Kim, Se-Heon; Choi, Eun Chang

2018-06-01

To report outcomes with regard to clinical aspects and medical costs of adenotonsillectomy and tonsillectomy at a single institution before and after implementation of the Diagnosis-Related Groups (DRG) payment system in Korea. We retrospectively reviewed the records of patients treated with adenotonsillectomy or tonsillectomy between July 2012 and June 2014. The Korean DRG payment system was applied to seven groups of specific diseases and surgeries including adenotonsillectomy and tonsillectomy from July 2013 at all hospitals in Korea. We divided patients into four groups according whether the fee-for-service (FFS) or DRG payment system was implemented and operation type (FFS-adenotonsillectomy (AT), DRG-AT, FFS-tonsillectomy (T), and DRG-T). A total of 1402 patients were included (485 FFS-AT, 490 DRG-AT, 203 FFS-T, and 223 DRG-T). The total medical cost of the DRG-AT group was significantly lower than that of the FFS-AT group (1191±404 vs. 1110±279 USD, P<0.05). There were no significant differences in length of hospital stay or postoperative complications among groups. The Korean DRG system for adenotonsillectomy and tonsillectomy reduced medical costs and clinical outcomes were not significantly altered by the adoption of the DRG system. 4. Copyright © 2017 Elsevier B.V. All rights reserved.

Postoperative morbidity and histopathologic characteristics of tonsillar tissue following coblation tonsillectomy in children: a prospective randomized single-blind study.

PubMed

Roje, Zeljka; Racić, Goran; Dogas, Zoran; Pisac, Valdi Pesutić; Timms, Michael

2009-03-01

The aim of this prospective randomized single blind study was to determine the depth of thermal damage to tonsillar tissue due to coblation, and to compare it with thermal damage to tonsillar tissue following conventional tonsillectomy; to correlate the depth of thermal damage to tonsillar tissue with the parameters of postoperative morbidity, to compare intraoperative blood loss, postoperative pain severity, time to resuming normal physical activity, and incidence of postoperative bleeding between two groups of tonsillectomized children aged up to 16 years. 72 children aged 3-16 years scheduled for tonsillectomy randomly assigned into two groups submitted either to conventional tonsillectomy with bipolar diathermy coagulation or to coblation tonsillectomy, with a 14-day follow up. Statistically significant differences were observed in the depth of thermal damage to tonsillar tissue (p < 0.001), intraoperative blood loss (p < 0.004), in postoperative pain severity (p < 0.05) and in time to resuming normal physical activity between the two groups (p < 0.001). There was no case of reactionary or secondary bleeding in either group. In this paper for the first time we have correlated postoperative morbidity and thermal tissue damage: less thermal damage is associated with less postoperative morbidity.

Factors influencing the indication for tonsillectomy: a historical overview and current concepts.

PubMed

Hultcrantz, Elisabeth; Ericsson, Elisabeth

2013-01-01

Tonsil surgery has been performed for more than 3,000 years. During the 19th century when anesthesia became available, techniques were refined and the number of procedures performed increased. Repeated throat infections often causing big tonsils was the reason why parents asked for the procedure. During the preantibiotic era, scarlet fever was feared since potential heart or kidney complications were life-threatening. The technique used before 1900 was tonsillotomy since neither a fingernail, snare nor the later 'guillotine' were used extracapsularly. Bleeding was small and the surgery ambulatory. Extracapsular tonsillectomy developed around the turn of the 20th century with the purpose of avoiding remnants - the 'focal infection theory' was prevailing. The whole tonsil was now extirpated with good visibility of the tonsillar area in a deeply anesthetized patient. During the first half of the 20th century, the two methods competed, but by 1950, total tonsillectomy had become the only 'correct' tonsil surgery. The indication was still recurrent infections. The risk for serious bleeding increased; therefore large clinics arose where patients remained for at least a week after tonsillectomy. When oral penicillin for children became available during the 1960s, the threat of throat infection decreased and the number of tonsillectomies declined. The awareness of obstructive problems in children rose at the same time when obstructive sleep apnea syndrome became a disease for adults (1970s). Tonsillotomy was revived during the 1990s and is today used increasingly in many countries. The indication is mainly obstructive sleep apnea syndromeor sleep-disordered breathing, especially in small children. Total tonsillectomy is still preferred for recurrent infections, which include periodic fever/adenitis/pharyngitis/aphthous ulcer syndrome and recurrent peritonsillitis. Copyright © 2013 S. Karger AG, Basel.

Preferred parental method of post-operative tonsillectomy and adenoidectomy follow-up (phone call vs. clinic visit).

PubMed

Anderson, Martin E; Brancazio, Brianna; Mehta, Deepak K; Georg, Matthew; Choi, Sukgi S; Jabbour, Noel

2017-01-01

Tonsillectomy is the second most common procedure performed in the United States. Over 530,000 tonsillectomies are performed on children under 15 years of age in the United States, accounting for 16% of surgeries in this age group, resulting in missed school for patients of school-age and also resulting in missed work for caregivers. This study compared parent preferences for in-clinic follow-up (CFU) to telephone interview follow-up (TFU) after tonsillectomy. One hundred twenty-one parents of children who underwent a tonsillectomy and/or adenoidectomy were recruited to complete a survey about their child's post-operative visit. Statistical analyses were performed using t-test, Wilcoxon rank-sum, and Fischer's exact tests where appropriate. 60.3% of the surveys were completed as a TFU and the remainder were completed as a CFU. There were no statistical differences in the children's age, the time to follow-up, satisfaction with their follow-up, or the frequency of unresolved symptoms. Of parents receiving TFU, 91.8% disagreed they would have preferred a CFU, with 86.3% strongly disagreeing, and only 5.5% expressing that they would have preferred a CFU. Of the parents with CFU, 47.9% expressed a preference for a TFU. For CFU, 43.9% of parents missed work and 58.1% of their school-age children missed school. Our study results indicate that parents receiving phone follow-up strongly preferred this method to an in-clinic follow-up, and that nearly half of all parents receiving in-clinic follow-up would have preferred a telephone follow-up. In select patients, telephone follow-up after tonsillectomy may increase patient satisfaction and decrease days of missed work and school. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

Coblation versus unipolar electrocautery tonsillectomy: a prospective, randomized, single-blind study in adult patients.

PubMed

Noordzij, J Pieter; Affleck, Brian D

2006-08-01

To determine if the coblation tonsillectomy (subcapsular dissection) results in less postoperative pain, equivalent intraoperative blood loss, equivalent postoperative hemorrhage rates, and faster healing compared with tonsillectomy was performed using unipolar electrocautery in adult patients. The authors conducted a prospective clinical trial. Forty-eight patients underwent tonsillectomy and were randomly assigned to have one tonsil removed with coblation and the other with unipolar electrocautery. Outcome measures included time to remove each tonsil, intraoperative blood loss, patient-reported pain, postoperative hemorrhage, and amount of healing 2 weeks after surgery. Mean time to remove a single tonsil with coblation and electrocautery was 8.22 minutes and 6.33 minutes, respectively (P = .011). Mean intraoperative blood loss for each technique was less than 10 mL. Postoperative pain was significantly less with coblation as compared with electrocautery: 18.6% less painful during the first week of recovery. Seventy percent of blinded patients identified the coblation side as less painful during the overall 14-day convalescent period. Postoperative hemorrhage rates (2.1% for coblation and 6.2% for electrocautery) were not significantly different. No difference in tonsillar fossa healing was observed between the two techniques 2 weeks after surgery. During nine of the 48 surgeries, wires on the tip of the coblation handpiece experienced thinning to the point of discontinuity while removing a single tonsil. Coblation subcapsular tonsillectomy was less painful than electrocautery tonsillectomy in this 48-patient group. On average, intraoperative blood loss was less than 10 mL for both techniques. Postoperative hemorrhage rates and the degree of tonsillar fossa healing were similar between the two techniques. The coblation handpiece experienced degradation of vital wires in 18% of cases necessitating the use of a second, new handpiece.

Comparison of the Effect of Thiopental Sodium with Midazolam-ketamine on Post-tonsillectomy Agitation in Children.

PubMed

Toliyat, Maryam; Zangoee, Maliheh; Ahrari, Shahnaz; Zangoee, Reza

2015-10-01

The aim of this study was to determine the effect of thiopental sodium with that of midazolam-ketamine on relieving agitation after tonsillectomy in children. In a clinical trial, 50 children aged 5-10 years, candidates for tonsillectomy, were randomly divided into two 25-member groups. In the first group, thiopental sodium 5mg/kg/IV, and in the second group combination of midazolam 0.01 mg/kg/IV and ketamine 1 mg/kg/IV were used to induce anesthesia. The level of sedation was assessed after surgery with the Ramsay scale. There were no significant differences between the two groups in terms of heart rate, arterial oxygen pressure (PO2), and duration of anesthesia. The Ramsay sedation score was significantly higher in the thiopental sodium group than in the midazolam-ketamine group (P=0.01). Thiopental sodium can be more effective than the combination of midazolam-ketamine for controlling agitation after tonsillectomy in children.

Blood, sweat and tears: androgenic-anabolic steroid misuse and recurrent primary post-tonsillectomy haemorrhage

PubMed Central

Fox, Richard; Varadharajan, Kiran; Patel, Bhavesh; Beegun, Issa

2014-01-01

A 30-year-old male body builder and androgenic-anabolic steroid and insulin abuser was admitted for day case elective tonsillectomy (bipolar). He returned with primary post-tonsillectomy haemorrhage 18 h after the operation and required bipolar cautery to the multiple small bleeding points in the right and left tonsillar fossa. Thorough coagulation screen was normal. Recurrent primary haemorrhage occurred 3 h post-operatively requiring immediate surgical intervention, removal of the inferior poles, precautionary throat packs, intubation and observation on the intensive treatment unit (ITU). Re-examination in theatre revealed a bleeding left superior pole that was under-run to achieve haemostasis and the patient returned to ITU. Hypertensive episodes were noted in the emergency department and intraoperatively including one recording >200 mm Hg. Haemostasis was eventually achieved once the blood pressure was adequately controlled. A slow wean of steroids was also instigated and the patient was managed on a surgical ward for 2 weeks post-tonsillectomy. PMID:25398921

Blood, sweat and tears: androgenic-anabolic steroid misuse and recurrent primary post-tonsillectomy haemorrhage.

PubMed

Fox, Richard; Varadharajan, Kiran; Patel, Bhavesh; Beegun, Issa

2014-11-14

A 30-year-old male body builder and androgenic-anabolic steroid and insulin abuser was admitted for day case elective tonsillectomy (bipolar). He returned with primary post-tonsillectomy haemorrhage 18 h after the operation and required bipolar cautery to the multiple small bleeding points in the right and left tonsillar fossa. Thorough coagulation screen was normal. Recurrent primary haemorrhage occurred 3 h post-operatively requiring immediate surgical intervention, removal of the inferior poles, precautionary throat packs, intubation and observation on the intensive treatment unit (ITU). Re-examination in theatre revealed a bleeding left superior pole that was under-run to achieve haemostasis and the patient returned to ITU. Hypertensive episodes were noted in the emergency department and intraoperatively including one recording >200 mm Hg. Haemostasis was eventually achieved once the blood pressure was adequately controlled. A slow wean of steroids was also instigated and the patient was managed on a surgical ward for 2 weeks post-tonsillectomy. 2014 BMJ Publishing Group Ltd.

Robotic lateral oropharyngectomy following diagnostic tonsillectomy is oncologically safe in patients with high risk human papillomavirus related squamous cell cancer.

PubMed

Siddiq, Somiah; Cartlidge, David; Stephen, Sarah; Sathasivam, Hans P; Fox, Hannah; O'Hara, James; Meikle, David; Iqbal, Muhammad Shahid; Kelly, Charles G; Robinson, Max; Paleri, Vinidh

2018-05-12

Diagnostic tonsillectomy is rarely an oncologic operation owing to close or positive margins. The standard of care is for further treatment to the primary site, typically with adjuvant radiotherapy. 14 patients with close or positive margins following a diagnostic tonsillectomy underwent transoral robotic surgery (TORS) and lateral oropharyngectomy; five patients with the longest follow-up had their excision specimens examined with a step serial sectioning technique (SSS). Conventional histopathological examination of the TORS resection specimens did not demonstrate residual carcinoma in 13 patients, confirmed by examination using SSS in 5 patients. There were no post-operative complications or long-term functional deficit. Seven patients received surgery alone with 100% overall and disease specific survival, respectively (median follow-up 27.5 months; range 5.2-50.4). This prospective study suggests that TORS lateral oropharyngectomy alone is an oncologically safe treatment when close or positive margins are identified on diagnostic tonsillectomy in HPV-positive SCC.

Pediatric Tonsillectomy and Ketorolac.

PubMed

Phillips-Reed, Lesley D; Austin, Paul N; Rodriguez, Ricardo E

2016-12-01

The use of ketorolac in children undergoing tonsillectomy remains limited because of the concern about postoperative bleeding. A search was performed addressing the question: For patients undergoing a surgical tonsillectomy, does a weight-appropriate single dose of intravenous ketorolac affect the incidence of postoperative hemorrhage? Five systematic reviews met the inclusion criteria. A Cochrane Review included 15 studies with 1,101 pediatric subjects and focused on perioperative bleeding requiring intervention. Many of the systematic reviews appraised the same studies. Subgroup analysis often allowed assessment of the effects of ketorolac administration. There was no consensus on the increased risk of bleeding when nonsteriodal anti-inflammatory drugs such as ketorolac are given to pediatric patients undergoing tonsillectomy. The conclusions varied from ketorolac should not be used to it is safe to use with these patients. The perianesthesia team must carefully weigh the risks and benefits before deciding to use ketorolac with this subset of patients. Copyright © 2016 American Society of PeriAnesthesia Nurses. Published by Elsevier Inc. All rights reserved.

Postoperative complications of powered intracapsular tonsillectomy and monopolar electrocautery tonsillectomy in teens versus adults.

PubMed

Johnston, Douglas R; Gaslin, Michael; Boon, Maurits; Pribitkin, Edmund; Rosen, David

2010-07-01

This study was performed to determine whether teens have different rates of posttonsillectomy hemorrhage, admission for dehydration, or recurrent tonsillitis compared to adults. Specifically, these parameters were compared within two groups: patients who underwent powered intracapsular tonsillectomy (PIT) and those who underwent monopolar electrocautery tonsillectomy (MET). In a retrospective review of 579 patients at least 12 years of age from January 2000 to July 2006 in a tertiary referral center, outcome measures of reoperation for hemorrhage, readmission or emergency room visit for dehydration, and postoperative tonsillitis were compared for 200 patients 12 to 19 years of age and 379 patients more than 19 years of age. These outcome measures in teens were compared to those in adults who had tonsillectomy by the same technique (101 teens who underwent PIT compared to 117 adults who underwent PIT, and 99 teens who underwent MET compared to 262 adults who underwent MET). Outcome measures were also compared within the PIT and MET groups based on the indication for surgery (chronic tonsillitis, tonsillar hypertrophy, or both). In comparing teens to adults who underwent the same technique (PIT versus PIT, or MET versus MET), no statistically significant differences existed in the incidence of hemorrhage, dehydration, or postoperative tonsillitis. Greater hemorrhage rates for adults who underwent MET compared to teens, however, almost met statistical significance (p = 0.053). Analyzing complication rates by indication within the PIT and MET groups exclusively revealed higher rates of hemorrhage in adults who underwent the MET technique for the indication of chronic tonsillitis. Within the PIT comparison, no significant differences were found on the basis of indication for surgery. Teenage patients who undergo tonsillectomy should be considered unique as far as complication rates are concerned. Comparison of technique-specific complication rates between adults and teens showed no significant differences in either the PIT or MET groups, although adults who underwent MET had greater hemorrhage rates that almost met significance (p = 0.053). Adults who were undergoing tonsillectomy for chronic tonsillitis were more likely than teens to encounter postoperative hemorrhage if they underwent the MET technique.

Hypertrophied tonsils impair velopharyngeal function after palatoplasty.

PubMed

Abdel-Aziz, Mosaad

2012-03-01

When tonsillar hypertrophy obstructing the airway is encountered in a child with a repaired cleft palate and velopharyngeal insufficiency, the surgeon may opt for tonsillectomy to relieve the airway obstruction, with possible effects on velopharyngeal closure. The aim of this study was to assess the impact of hypertrophied tonsils on velopharyngeal function in children with repaired cleft palate and to measure the effect of tonsillectomy on velopharyngeal closure and speech resonance. Case series. Twelve children with repaired cleft palate and tonsillar hypertrophy underwent tonsillectomy to relieve airway obstruction. Preoperative and postoperative evaluation of velopharyngeal function was performed. Auditory perceptual assessment of speech and nasalance scores were measured, and velopharyngeal closure was evaluated by flexible nasopharyngoscopy. Preoperative impairment of velopharyngeal function was detected. However, significant postoperative improvement of speech parameters (hypernasality, nasal emission of air, and weak pressure consonants measured with auditory perceptual assessment) was achieved, and the overall postoperative nasalance score was improved significantly for nasal and oral sentences. Reduction of velopharyngeal gap size was detected after removal of hypertrophied tonsils. Although the improvement of velopharyngeal closure was not significant, three cases demonstrated complete postoperative closure with no gap. Hypertrophied tonsils may impair velopharyngeal function in children with repaired cleft palate, and tonsillectomy is beneficial for such patients as it can improve the velopharyngeal closure and speech resonance. Secondary corrective surgery may be avoided in some cases after tonsillectomy. Copyright © 2012 The American Laryngological, Rhinological, and Otological Society, Inc.

Need for better analgesic treatment after tonsillectomy in ear, nose and throat practices.

PubMed

Kamarauskas, Audrius; Dahl, Mads Ronald; Hlidarsdottir, Tinna; Mainz, Jan; Ovesen, Therese

2013-05-01

The objective of this study was to investigate patient-reported outcomes on quality (PRO) of outpatient tonsillectomy in Danish ear, nose and throat practices in terms of indicators, standards and prognostic factors. Patients filled in a post-operative questionnaire three weeks after tonsillectomy. The questions were focused on the preoperative information about the procedure. Unscheduled contacts to Danish health care after the tonsillectomy and number of days absent from work/school were reported. A pain score was indicated daily during the first 14 post-operative days. A total of 89% of the 614 enrolled patients returned the questionnaire. 30% were dissatisfied with the information they had been afforded about post-operative complications and risks and 23% had unscheduled contacts to Danish health care. The daily pain score and absence from work/school were significantly higher among adults (> 15 years) than among children. The pain score correlated significantly with absence from work/school, unscheduled contacts and short observation time. PRO was significantly influenced by the length of the observation time before discharge, and a higher pain score was associated with a lower satisfaction with preoperative information about complications/risks. Most patients/parents are satisfied with outpatient tonsillectomy. However, the post-operative pain control needs revision, the preoperative information should be intensified and the observation of the patients before discharge should be extended. not relevant. not relevant.

Cognitive, Temperamental, and Family Characteristics as Predictors of Children's Adjustment to Surgery.

ERIC Educational Resources Information Center

Carson, David K.; And Others

Findings from a study of 47 children between 3.5 and 12 years of age who received tonsillectomies at a children's hospital are presented. During a home visit before hospitalization, the child's adjustment, cognition, temperament, and family characteristics were assessed. Tonsillectomies were followed by an overnight stay at the hospital, and…

Presence of keratin-specific antibody-forming cells in palatine tonsils of patients with pustulosis palmaris et plantaris (PPP) and its correlation with prognosis after tonsillectomy.

PubMed

Tanimoto, Yoichiro; Fukuyama, Satoshi; Tanaka, Norimitsu; Ohori, Jun-Ichiro; Tanimoto, Yukari; Kurono, Yuichi

2014-01-01

Keratin-specific immune responses in tonsils may be associated with the pathogenesis of pustulosis palmaris et plantaris (PPP). Evaluation of keratin-specific immune responses in tonsils might be useful to predict the effectiveness of tonsillectomy for patients with PPP. The aim of the present study was to clarify the role of keratin-specific immune responses in the pathogenesis of PPP in tonsils. It has been reported that anti-keratin antibodies in serum were higher in patients with PPP and decreased after tonsillectomy, indicating that anti-keratin antibodies might be generated in tonsils. In order to demonstrate the presence of keratin-specific immune responses in tonsils, the numbers of keratin-specific antibody-forming cells (AFCs) in tonsillar and peripheral blood lymphocytes were examined by enzyme-linked immunospot assay. The prognosis of PPP was compared after tonsillectomy. The numbers of keratin-specific IgM and IgG AFCs in tonsils and of IgG AFCs in peripheral blood were significantly increased in patients with PPP. The numbers of keratin-specific IgG AFCs in peripheral blood correlated positively with tonsil and serum IgG antibodies specific to keratin. Our data show that a good prognosis in patients with PPP depended on the numbers of keratin-specific IgG and IgM AFCs in peripheral blood and the levels of keratin-specific IgG antibodies in serum being significantly decreased 6 months after tonsillectomy.

The efficiacy of anterior and posterior archs suturation at inferior tonsillar pole for posttonsillectomy pain control.

PubMed

Sakallioğlu, Oner; Düzer, Sertaç; Kapusuz, Zeliha

2014-01-01

The aim of our study was to investigate the efficiacy of the suturation technique after completing the tonsillectomy procedure for posttonsillectomy pain control in adult patients. August 2010-February 2011, 44 adult patients, ages ranged from 16 to 41 years old who underwent tonsillectomy at Elaziğ Training and Research Hospital Otorhinolaryngology Clinic were included to the study. After tonsillectomy procedure, anterior and posterior tonsillar archs were sutured each other and so, the area of tonsillectomy lodges which covered with mucosa were increased. Twenty two patients who applied posttonsillectomy suturation were used as study group and remnant 22 patients who did not applied posttonsillectomy suturation were used as control group. The visual analogue score (VAS) was used to evaluate the postoperative pain degree (0 no pain, 10 worst pain). ANOVA test (two ways classification with repeated measures) was used for statistical analysis of VAS values. P < 0.05 was accepted as statistically significant. The effect of time (each post-operative day) on VAS values was significant. The mean VAS values between study and control group on post-operative day 1st, 3rd, 7th, and 10th were statistically significant (P < 0.05). The severity of posttonsillectomy pain was less in study group patients than control group patients. The suturation of anterior and posterior tonsillar archs after tonsillectomy procedure was found effective to alleviate the posttonsillectomy pain in adult patients.

A study on the efficacy and safety of combining dental surgery with tonsillectomy in pediatrics

PubMed Central

Syed, Faizaan; Uffman, Joshua C; Tumin, Dmitry; Flaitz, Catherine M; Tobias, Joseph D; Raman, Vidya T

2018-01-01

Purpose Few data exist on combining pediatric surgical procedures under a single general anesthetic encounter (general anesthesia). We compared perioperative outcomes of combining dental surgical procedures with tonsillectomy during one anesthetic vs separate encounters. Methods We classified elective tonsillectomy ± adenoidectomy and restorative dentistry as combined (group C) or separate (group S). Outcomes included anesthesia time, recovery duration, the need for overnight hospital stay, and postoperative complications. Results Patients aged 4±1 years underwent tonsillectomy and dental surgery in combination (n=7) or separately (n=27). No differences were noted in total anesthesia time (C: median: 150, interquartile range [IQR]: 99, 165 vs S: median: 109, IQR: 92, 132; 95% CI of difference in median: −58, +10 minutes; P=0.115) and total recovery time (C: median: 54, IQR: 40, 108 vs S: median: 72, IQR: 58, 109; 95% CI of difference in median: −16, +48 minutes; P=0.307). The need for overnight stay (C: 4 of 7, S: 20 of 27; P=0.394) did not differ between the groups. No postoperative complications were noted in either group. Conclusion These preliminary data support the potential feasibility of combining dental procedures with tonsillectomy during a single anesthetic encounter. Such care may not only reduce costs but also limit parental work absences and increase convenience for patient families. When compared with procedures performed separately, combined procedures did not result in increased morbidity or significant changes in postoperative outcomes. PMID:29628777

A study on the efficacy and safety of combining dental surgery with tonsillectomy in pediatrics.

PubMed

Syed, Faizaan; Uffman, Joshua C; Tumin, Dmitry; Flaitz, Catherine M; Tobias, Joseph D; Raman, Vidya T

2018-01-01

Few data exist on combining pediatric surgical procedures under a single general anesthetic encounter (general anesthesia). We compared perioperative outcomes of combining dental surgical procedures with tonsillectomy during one anesthetic vs separate encounters. We classified elective tonsillectomy ± adenoidectomy and restorative dentistry as combined (group C) or separate (group S). Outcomes included anesthesia time, recovery duration, the need for overnight hospital stay, and postoperative complications. Patients aged 4±1 years underwent tonsillectomy and dental surgery in combination (n=7) or separately (n=27). No differences were noted in total anesthesia time (C: median: 150, interquartile range [IQR]: 99, 165 vs S: median: 109, IQR: 92, 132; 95% CI of difference in median: -58, +10 minutes; P =0.115) and total recovery time (C: median: 54, IQR: 40, 108 vs S: median: 72, IQR: 58, 109; 95% CI of difference in median: -16, +48 minutes; P =0.307). The need for overnight stay (C: 4 of 7, S: 20 of 27; P =0.394) did not differ between the groups. No postoperative complications were noted in either group. These preliminary data support the potential feasibility of combining dental procedures with tonsillectomy during a single anesthetic encounter. Such care may not only reduce costs but also limit parental work absences and increase convenience for patient families. When compared with procedures performed separately, combined procedures did not result in increased morbidity or significant changes in postoperative outcomes.

HLA-Cw6 homozygosity in plaque psoriasis is associated with streptococcal throat infections and pronounced improvement after tonsillectomy: A prospective case series.

PubMed

Thorleifsdottir, Ragna H; Sigurdardottir, Sigrun L; Sigurgeirsson, Bardur; Olafsson, Jon H; Petersen, Hannes; Sigurdsson, Martin I; Gudjonsson, Johann E; Johnston, Andrew; Valdimarsson, Helgi

2016-11-01

Carriage of the HLA-Cw*0602 allele is associated with a particular set of clinical features and treatment responses in psoriasis. Tonsillectomy can improve psoriasis. We sought to evaluate whether HLA-Cw*0602 predicts a favorable outcome after tonsillectomy of patients with psoriasis. This prospective case series followed up 28 tonsillectomized patients with plaque psoriasis for 24 months. The Psoriasis Area and Severity Index, Psoriasis Disability Index, and Psoriasis Life Stress Inventory were used for assessment. Tonsils were swabbed for bacteria and patients genotyped for HLA-Cw*0602. After tonsillectomy, HLA-Cw*0602 homozygotes showed significantly more improvement, compared with heterozygous and HLA-Cw*0602-negative patients. Thus, Psoriasis Area and Severity Index score was reduced by 82% in the homozygous patients compared with 42% and 31%, respectively (P < .001), Psoriasis Disability Index score improved by 87% compared with 38% and 41%, respectively (P < .001), and Psoriasis Life Stress Inventory score was 82% reduced compared with 60% and 54%, respectively (P < .001). The homozygotes more often had psoriasis onset associated with a throat infection (P = .007) and an increased frequency of streptococcal throat infections per lifetime (P = .038). Few patients were included and some data were retrospective. Homozygous HLA-Cw*0602 carriage in plaque psoriasis may predict a favorable outcome after tonsillectomy. Copyright © 2016 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.

[N. glossopharyngeus and tonsillectomy (author's transl)].

PubMed

Beck, C

1979-05-01

Due to its course in the pharyngeal space, the trunk of the glossopharyngeal nerve can be damaged during tonsillectomy which results in paralysis of the soft palate and impairment of the sense of taste. These symptoms may recede within two years but permanent damages can be seen as well. They can be treated by logopedia and relaxation therapy.

[Ischemic stroke in childhood. A complication of tonsillectomy].

PubMed

Matilla Álvarez, A; García Serrano, E; González de la Huebra Labrador, T; Morales Martín, A C; Yusta Martín, G; Vaquero Roncero, L M

2016-02-01

Tonsillectomy is one of the most frequently performed otorhinolaryngological procedures on children. The postoperative complications are classified into primary or intermediate, which generally appear within 24h, and as secondary or delayed, after 48 h. We present the case of an ischemic stroke after performing a tonsillectomy on a 3 year-old boy, which was diagnosed in the immediate postoperative period. Using brain echo-doppler and angio-CT, an intraluminal clot was observed in the left internal carotid artery, probably as a result of direct vessel injury during arterial ligature for hemostasis. Copyright © 2015 Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor. Publicado por Elsevier España, S.L.U. All rights reserved.

Management of pediatric second branchial fistulae: is tonsillectomy necessary?

PubMed

Cheng, Jeffrey; Elden, Lisa

2012-11-01

To describe the surgical management of second branchial fistulae that extend to the pharynx, specifically to determine whether tonsillectomy, along with surgical excision of the tract affects the rate of recurrence. Retrospective chart review of pediatric patients (age<18) who underwent surgical excision of second branchial anomalies at a tertiary-care children's hospital between January 1, 2006 and September 1, 2011. Sinus tracts that extended to the pharynx were considered to be fistulae. Seventy-four patients were identified who underwent surgical excision of 85 total second branchial anomalies - 20 cysts (23.5%), 29 sinuses (34.1%), and 36 fistulae (42.4%). The 36 fistulae were removed from 32 patients, 23 males and 9 females, with an average age of 43.3 months. There were 16 right, 11 left, and 5 bilateral lesions. In 14 (43.8%) of the fistulae cases, a tonsillectomy was performed. There was only one recurrence (2.8%), which occurred 41 months postoperatively. No statistically significant difference for recurrence (p=1.0) was found between the group of patients that underwent tonsillectomy and those that did not. Pediatric branchial anomalies can present as a cyst, sinus, or fistula. They are developmental failures in the involution of the branchial apparatus during the embryologic period. Management of second branchial anomalies is with surgical excision of the tract and ligation of the terminal attachment to the pharynx. Our results suggest that the recurrence rates are not affected by whether or not an ipsilateral tonsillectomy is performed. Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.

Safety of preoperative ibuprofen in pediatric tonsillectomy.

PubMed

Michael, Alexander; Buchinsky, Farrel J; Isaacson, Glenn

2018-05-14

Oral ibuprofen is believed to be safe and effective after pediatric adenotonsillectomy. There has been little study of its use as a preoperative analgesic. We attempt to document its safety in this setting. Individual case control study. Children who underwent tonsillectomy or adenotonsillectomy from January 2013 to December 2015 did not receive preoperative ibuprofen. Those who underwent tonsillectomy or adenotonsillectomy from January 2016 to December 2017 received oral ibuprofen 7 mg/kg preoperatively. Pre- and postoperative records were reviewed. Intraoperative bleeding > 50 mL or early postoperative bleeding requiring surgical control were outcome measures. Delayed bleeding events were also recorded. A total of 217 children met inclusion criteria. Of those, 112 patients did not receive preoperative ibuprofen, and 105 patients did receive preoperative ibuprofen. Mean age was 8.7 years (range: 1-18) in the control/non-ibuprofen cohort and 8.3 years (range: 1-18) in the ibuprofen cohort. No child experienced significant intraoperative or early postoperative bleeding in the non-ibuprofen (95% confidence interval [CI] 0-0.027) or in the ibuprofen cohort (95% CI 0- 0.029). Delayed bleeding rates were similar in both groups. In this series, children treated with preoperative ibuprofen did not experience increased bleeding during or soon after tonsillectomy compared to controls. Pain control was not studied in these patients. These favorable safety data argue for a future prospective randomized study of preoperative ibuprofen's effectiveness in reducing pain and opioid requirement after pediatric tonsillectomy. 3B. Laryngoscope, 2018. © 2018 The American Laryngological, Rhinological and Otological Society, Inc.

Can Red Blood Cell Distribution Width be a Potential Marker in the Decision to Perform Tonsillectomy?

PubMed

Sakat, Muhammed Sedat; Kilic, Korhan; Kars, Ayhan; Kara, Mustafa; Gozeler, Mustafa Sitki

2018-02-01

Tonsillectomy is one of the most common surgical procedures performed at ear, nose, and throat clinics. Chronic recurrent tonsillitis, obstructive tonsillitis, and halitosis are among the most common indications for surgery. Determining whether the infection is chronic and the patient's annual number of infections are important in estimating the necessity for surgery to be performed due to infectious causes. Red blood cell distribution width (RDW) is a numerical value present in normal complete blood count that provides information about erythrocytes and their dimensions. Studies in recent years have shown that RDW increases in chronic infections, hypoxia, and oxidative stress. This study investigated the changes in RDW in patients with chronic tonsillitis and the effect tonsillectomy has on this value by comparing RDW between patients scheduled for tonsillectomy and normal population and examining preoperative and postoperative changes in RDW. Sixty-three patients scheduled for tonsillectomy due to recurrent tonsillitis aged 4-14 years were included in the study. The control group consisted of 60 subjects comparable in terms of age and sex. Hemoglobin level and RDW were recorded by collecting 2 mlof blood before surgery and at 4 months postoperatively from all patients. Preoperative RDW was significantly higher in the patient group than in the control group. Comparison of patients' preoperative and postoperative RDW revealed a significant decrease in RDW after surgery. As a biomarker showing chronic infection in patients with tonsillitis, RDW can provide support to the clinician in deciding on surgery. However, this has to be confirmed in further studies with greater participation.

The Role of Tonsillectomy in Adults with Tonsillar Hypertrophy and Obstructive Sleep Apnea.

PubMed

Smith, Matthew M; Peterson, Ed; Yaremchuk, Kathleen L

2017-08-01

Objective To determine if tonsillectomy alone is an effective treatment in improving obstructive sleep apnea in adult subjects with tonsillar hypertrophy and to evaluate the effect of tonsillectomy on patient-reported quality-of-life indices. Study Design Case series with planned data collection. Setting Academic hospital. Subjects and Methods Thirty-four subjects completed enrollment and intervention from January 2011 to January 2016. Subjects completed pre- and postoperative quality-of-life questionnaires, including the Insomnia Severity Index, Epworth Sleepiness Scale, and the Functional Outcomes of Sleep Questionnaire-10. Surgical response to treatment was defined by a >50% decrease in the Apnea-Hypopnea Index and a decrease in the overall Apnea-Hypopnea Index to <20. Wilcoxon matched-pairs signed-rank tests were used to test each variable to assess for a change from pre- to postintervention. Subjects were then split into 3 BMI subgroups, with results also evaluated by Wilcoxon matched-pairs signed-rank tests. Results There was a significant difference discovered between the mean preoperative Apnea-Hypopnea Index of 31.57 and the mean postoperative value of 8.12 ( P < .001). All patient-reported outcomes improved significantly following tonsillectomy. After stratifying all outcome variables (Apnea-Hypopnea Index, Epworth Sleepiness Scale, Insomnia Severity Index, and Functional Outcomes of Sleep Questionnaire-10) by sex, race, and tonsil size, no statistically significant difference was noted among any of these subgroups. There was a 78% surgical response to treatment. Conclusion Tonsillectomy appears to be an effective treatment for obstructive sleep apnea in a select population of adults with tonsillar hypertrophy.

Detection of group A Streptococcus in tonsils from pediatric patients reveals high rate of asymptomatic streptococcal carriage.

PubMed

Roberts, Amity L; Connolly, Kristie L; Kirse, Daniel J; Evans, Adele K; Poehling, Katherine A; Peters, Timothy R; Reid, Sean D

2012-01-09

Group A Streptococcus (GAS) causes acute tonsillopharyngitis in children, and approximately 20% of this population are chronic carriers of GAS. Antibacterial therapy has previously been shown to be insufficient at clearing GAS carriage. Bacterial biofilms are a surface-attached bacterial community that is encased in a matrix of extracellular polymeric substances. Biofilms have been shown to provide a protective niche against the immune response and antibiotic treatments, and are often associated with recurrent or chronic bacterial infections. The objective of this study was to test the hypothesis that GAS is present within tonsil tissue at the time of tonsillectomy. Blinded immunofluorescent and histological methods were employed to evaluate palatine tonsils from children undergoing routine tonsillectomy for adenotonsillar hypertrophy or recurrent GAS tonsillopharyngitis. Immunofluorescence analysis using anti-GAS antibody was positive in 11/30 (37%) children who had tonsillectomy for adenotonsillar hypertrophy and in 10/30 (33%) children who had tonsillectomy for recurrent GAS pharyngitis. Fluorescent microscopy with anti-GAS and anti-cytokeratin 8 & 18 antibodies revealed GAS was localized to the tonsillar reticulated crypts. Scanning electron microscopy identified 3-dimensional communities of cocci similar in size and morphology to GAS. The characteristics of these communities are similar to GAS biofilms from in vivo animal models. Our study revealed the presence of GAS within the tonsillar reticulated crypts of approximately one-third of children who underwent tonsillectomy for either adenotonsillar hypertrophy or recurrent GAS tonsillopharyngitis at the Wake Forest School of Medicine. The tissue collected was normally discarded tissue and no patient identifiers were collected. Thus, no subjects were formally enrolled.

A devastating outcome after adenoidectomy and tonsillectomy: ideas for improved prevention and management.

PubMed

Windfuhr, Jochen P; Schloendorff, Georg; Sesterhenn, Andreas M; Prescher, Andreas; Kremer, Bernd

2009-02-01

To develop strategies that may assist the surgeon to prevent and manage severe bleeding complications after adenoidectomy and tonsillectomy. Retrospective. Expert reports for malpractice lawsuits or professional boards were reviewed. The review was restricted to "deaths" and "permanent generalized neurological deficiencies." Forty-three cases matched our search criteria, including 32 deaths. Adenoidectomy cases (2) were associated with immediate bleeding because of direct vascular injury resulting in one death. Tonsillectomy cases were associated with delayed and repeated episodes of bleeding resulting in 31 deaths, including 19 children. Autopsy verified predominantly aspiration and vascular injuries. An apallic syndrome prevailed in surviving patients. Careful inspection of the nasopharynx immediately before adenoidectomy and curettage in a piecemeal fashion under visual control is helpful to prevent direct injury to aberrant arteries. Tonsillectomy cases are associated with delayed and episodic bleeding with spontaneous cessation and young age. Inpatient observation should be strongly considered in cases with repeated bleeding episodes to provide immediate treatment. The follow-up should be focused on disturbed wound healing. Outcome appears to be dependent on adequate airway management. Rigid instruments and tracheotomy in case of intubation failure are highly recommended to facilitate airway protection and ventilation.

Contact Nd:YAG tonsillectomy: effects on weight loss and recovery.

PubMed

Maloney, R W

1991-01-01

Contact Nd:YAG tonsillectomy using synthetic sapphire blades appears to meet or exceed standards established by spot monopolar cautery. Subjects' percentage of weight loss and return to work/social activities was measured and the laser group displayed less percentage of weight loss, faster return to pre-operative weight, and less recovery time than the comparative cautery group. Because of the unique nature of Nd:YAG laser light combined with sapphire blades, special consideration should be given to these accessories by physicians before attempting tissue cutting and vessel coagulation. The author believes that the extent of physician training and proficiency may be key to the success of soft tissue head and neck applications, such as tonsillectomy, which will have an effect on the outcome of clinical data.

Hematology Expert System (HES) For Tonsillectomy/Adenoidectomy Patients

NASA Astrophysics Data System (ADS)

Pizzi, Nicolino J.; Kapoor, Sandhya; Gerrard, Jon M.

1989-03-01

The purpose of this expert system is to assess a predisposition to bleeding in a patient undergoing a tonsillectomy and/or adenoidectomy as may occur with patients who have certain blood conditions such as hemophilia and von Willebrand's disease. This goal is achieved by establishing a correlation between the patients' responses to a medical questionnaire and the relative quantities of blood lost during the operation.

Epstein-Barr virus is related with 5-aminosalicylic acid, tonsillectomy, and CD19(+) cells in Crohn's disease.

PubMed

Andreu-Ballester, Juan C; Gil-Borrás, Rafael; García-Ballesteros, Carlos; Catalán-Serra, Ignacio; Amigo, Victoria; Fernández-Fígares, Virgina; Cuéllar, Carmen

2015-04-21

To study anti-Epstein-Barr virus (EBV) IgG antibodies in Crohn's disease in relation to treatment, immune cells, and prior tonsillectomy/appendectomy. This study included 36 CD patients and 36 healthy individuals (controls), and evaluated different clinical scenarios (new patient, remission and active disease), previous mucosa-associated lymphoid tissue removal (tonsillectomy and appendectomy) and therapeutic regimens (5-aminosalicylic acid, azathioprine, anti-tumor necrosis factor, antibiotics, and corticosteroids). T and B cells subsets in peripheral blood were analyzed by flow cytometry (markers included: CD45, CD4, CD8, CD3, CD19, CD56, CD2, CD3, TCRαβ and TCRγδ) to relate with the levels of anti-EBV IgG antibodies, determined by enzyme-linked immunosorbent assay. The lowest anti-EBV IgG levels were observed in the group of patients that were not in a specific treatment (95.4 ± 53.9 U/mL vs 131.5 ± 46.2 U/mL, P = 0.038). The patients that were treated with 5-aminosalicylic acid showed the highest anti-EBV IgG values (144.3 U/mL vs 102.6 U/mL, P = 0.045). CD19(+) cells had the largest decrease in the group of CD patients that received treatment (138.6 vs 223.9, P = 0.022). The analysis of anti-EBV IgG with respect to the presence or absence of tonsillectomy showed the highest values in the tonsillectomy group of CD patients (169.2 ± 20.7 U/mL vs 106.1 ± 50.3 U/mL, P = 0.002). However, in the group of healthy controls, no differences were seen between those who had been tonsillectomized and subjects who had not been operated on (134.0 ± 52.5 U/mL vs 127.7 ± 48.1 U/mL, P = 0.523). High anti-EBV IgG levels in CD are associated with 5-aminosalicylic acid treatment, tonsillectomy, and decrease of CD19(+) cells.

Addressing the Challenges in Tonsillectomy Research to Inform Health Care Policy: A Review.

PubMed

Mandavia, Rishi; Schilder, Anne G M; Dimitriadis, Panagiotis A; Mossialos, Elias

2017-09-01

Eighty-five percent of investment in medical research has been wasted, with lack of effect on clinical practice and policy. There is increasing effort to improve the likelihood of research being used to influence clinical practice and policy. Tonsillectomy is one of the most common otorhinolaryngologic surgical procedures, and its frequency, cost, and morbidity create a clear need for evidence-based guidelines and policy. The first systematic review on tonsillectomy was conducted 40 years ago and highlighted the lack of definitive evidence for the procedure. Since that study, the body of evidence has still not been able to sufficiently inform policy. This review provides an overview of the key challenges in research to inform tonsillectomy policy and recommendations to help bridge the evidence-policy gap. The challenges in using research to inform policy can be summarized as 4 main themes: (1) non-policy-focused evidence and lack of available evidence, (2) quality of evidence, (3) communication of research findings, and (4) coordinating time frames. Researchers and decision makers should be aware of the limitations of research designs and conflicts of interest that can undermine policy decisions. Researchers must work with decision makers and patients throughout the research process to identify areas of unmet need and political priority, align research and policy time frames, and disseminate research findings. Incentives for researchers should be reorganized to promote dissemination of findings. It is important to consider why evidence gaps in tonsillectomy research have not been addressed during the past 40 years despite considerable investment in time and resources. These findings and recommendations will help produce research that is more responsive to policy gaps and more likely to result in policy changes.

Quality and readability of websites for patient information on tonsillectomy and sleep apnea.

PubMed

Chi, Ethan; Jabbour, Noel; Aaronson, Nicole Leigh

2017-07-01

Tonsillectomy is a common treatment for obstructive sleep apnea (OSA). The Internet allows patients direct access to medical information. Since information on the Internet is largely unregulated, quality and readability are variable. This study evaluates the quality and readability of the most likely visited websites presenting information on sleep apnea and tonsillectomy. The three most popular search engines (Google, Bing, Yahoo) were queried with the phrase "sleep apnea AND tonsillectomy." The DISCERN instrument was used to assess quality of information. Readability was evaluated using the Flesch-Kincaid Reading Grade Level (FKGL) and Flesch Reading Ease Score (FRES). Out of the maximum of 80, the average DISCERN quality score for the websites was 55.1 (SD- 12.3, Median- 60.5). The mean score for FRES was 42.3 (SD- 15.9, Median- 45.5), which falls in the range defined as difficult. No website was above the optimal score of 65. The mean score for the FKGL was US grade-level of 10.7 (SD- 1.6, Median- 11.6). Only 4(27%) websites were in the optimal range of 6-8. There was very weak correlation between FRES and DISCERN (r = 0.07) and FKGL and DISCERN (r = 0.21). Tonsillectomy is one of the most common surgeries in the US. However, the internet information readily available to patients varies in quality. Additionally, much of the information is above the recommended grade level for comprehension by the public. By being aware of what information patients are reading online, physicians can better explain treatments and address misunderstandings. Physicians may consider using similar methods to test the readability for their own resources for patient education. Copyright © 2017 Elsevier B.V. All rights reserved.

Post-tonsillectomy pulmonary complication in a patient with tonsillar myeloid sarcoma.

PubMed

Cheng, Chia-Chi; Ueng, Shir-Hwa; Li, Hseuh-Yu; Chen, Huan-Wu; Chen, Tsung-Ming; Lee, Li-Ang; Kang, Chung-Jan; Kuo, Ying-Ling; Huang, Hao-Chun; Hsiao, Han-Ren; Fang, Tuan-Jen

2011-02-01

Myeloid sarcoma in a patient with myelodysplastic syndrome (MDS) manifesting as a non-healing tonsillar ulcer is an extremely rare occurrence. We report the case of a 57-year-old male smoker with a non-healing tonsillar ulcer who underwent tonsillectomy to rule out tonsillar carcinoma after failed antibiotic therapy. On postoperative day 2, he presented with a temperature of 40°C and white blood cell count of 34700/μL. Antibiotic therapy was begun; however, he died 1 day later due to pulmonary infection and septic shock. Though extremely rare, tonsillar involvement of MDS should be considered in the differential diagnosis of a non-healing tonsillar lesion. When definitive diagnosis requires a tissue sample, punch biopsy may be preferable to tonsillectomy in a patient who may be immunocompromised, and appropriate prophylactic antibiotics should be administered.

Preoperative use of granisetron plus dexamethasone and granisetron alone in prevention of post operative nausea and vomiting in tonsillectomy.

PubMed

Islam, M R; Haq, M F; Islam, M A; Meftahuzzaman, S M; Sarkar, S C; Rashid, H; Rashid, H U

2011-07-01

This prospective study was done for to see the efficacy of preoperative use of granisetron plus dexamethasone (Group A) & granisetron (Group B) alone for the postoperative prevention of nausea & vomiting after tonsillectomy operation. One hundred patients undergoing tonsillectomy & adenoidectomy operation under general anaesthesia who were admitted in the Mymensingh Medical College Hospital during the period from July 2008 to June 2009 with American Society of Anaesthesiologists (ASA) grade I & II with age 3-40 years, body weight 10-60 kgs, were studied. Observation of this study was analyzed in the light of comparison between the two groups. All results were expressed as mean±SEM. Age in Group A 15.98±1.028 & Group B 17.18±0.961 years; Weight in Group A 38.40±1.492 & Group B 39.76±1.561 kgs and operational duration in Group A 52.60±0.786 & Group B 52.70±0.823 minutes. The studied groups were statistically matched for age, weight, duration of surgery. We observed that the effects of combination of granisetron & dexamthasone are more than granisetron alone in prevention of nausea & vomiting after tonsillectomy operation. The frequency of vomiting was 4% in combination & 16% in single therapy which is statically significant (p<0.05).

Comparison of post-tonsillectomy pain with two different types of bipolar forceps: low temperature quantum molecular resonance device versus high temperature conventional electrocautery.

PubMed

Chang, Hyun; Hah, J Hun

2012-06-01

The low temperature device did not show any advantages over the conventional high temperature electrocautery in terms of the postoperative pain, operation time, and complications in pediatric tonsillectomy. To compare post-tonsillectomy pain following the use of two different instruments with the same bipolar forceps techniques: low temperature quantum molecular resonance (QMR) device versus conventional high temperature electrocautery. Pediatric patients admitted from July 2008 through January 2009 were included. The participants underwent bilateral tonsillectomy; one side by the QMR device and the other by the bipolar electrocautery. The sides for each instrument were counterbalanced by the order of presentation. The postoperative pain was measured using the faces pain rating scale. In all, 33 patients with a mean age of 7.6 years were enrolled. The postoperative pain, operation time, and complications in 33 sides dissected by the electrocautery and 33 sides by the QMR device were compared. The average operation times with each device were not statistically different. The mean ratings of the perception of pain related to each instrument were not different on operation day and postoperative day 1, day 4, and day 7 (p = 0.133, 0.057, 0.625, and 1.0, respectively). There was no postoperative complication in any of the patients.

Clinical effects of the use of a bipolar vessel sealing device for soft palate resection and tonsillectomy in dogs, with histological assessment of resected tonsillar tissue.

PubMed

Cook, D A; Moses, P A; Mackie, J T

2015-12-01

To investigate whether soft palate resection and tonsillectomy with a bipolar vessel sealing device (BVSD) improves clinical respiratory score. To document histopathological changes to tonsillar tissue following removal with a BVSD. Case series of 22 dogs with clinical signs of upper respiratory obstruction related to brachycephalic airway syndrome. Soft palate and tonsils were removed using a BVSD. Alarplasty and saccullectomy were also performed if indicated. A clinical respiratory score was assigned preoperatively, 24-h postoperatively and 5 weeks postoperatively. Excised tonsillar samples were measured and then assessed histologically for depth of tissue damage deemed to be caused by the device. Depth of tissue damage was compared between two power settings of the device. Soft palate resection and tonsillectomy with a BVSD lead to a significant improvement in respiratory scores following surgery. Depth of tissue damage was significantly less for power setting 1 compared with power setting 2. Using power setting 1, median calculated depth of tonsillar tissue damage was 3.4 mm (range 1.2-8.0). One dog experienced major complications. Soft palate resection and tonsillectomy with a BVSD led to significant improvement in clinical respiratory score. © 2015 Australian Veterinary Association.

Intraoperative Cryoanalgesia for Reducing Post-Tonsillectomy Pain: A Systemic Review.

PubMed

Raggio, Blake S; Barton, Blair M; Grant, Maria C; McCoul, Edward D

2018-06-01

Summarize the effectiveness of intraoperative cryoanalgesia in the management of postoperative pain among patients undergoing palatine tonsillectomy. A systematic review of PubMED, MEDLINE, EMBASE, Google Scholar, and Cochrane trial registries was performed through January 2017 using the PRISMA standards. We included English-language randomized controlled trials evaluating patients of all age groups with benign pathology who underwent tonsillectomy with cryoanalgesia versus without. Three limited quality randomized controlled trials involving 153 participants (age range, 1-60 years) were included. Cryoanalgesia was performed with a cryotherapy probe (-56°C) in 1 trial and ice-water cooling (4°C to 10°C) in 2. In the 3 trials reviewed, patients who received cryoanalgesia reported 21.38%, 28.33%, and 31.53% less average relative postoperative pain than controls on the visual analog scale. Review of secondary outcomes suggested no significant difference in time to resume normal diet (2 studies) or postoperative bleeding (2 studies) between the 2 groups. Cryoanalgesia allowed patients to return to work 4 days earlier than controls in 1 study. Two studies reported a trend toward less postoperative analgesia use among the treatment group; however, no statistical conclusions could be drawn. The available evidence suggests that patients undergoing tonsillectomy with cryoanalgesia experience less average postoperative pain without additional complications.

Stakeholders' views of recurrent sore throat, tonsillitis and their management: a qualitative interview study for the NAtional Trial of Tonsillectomy IN Adults (NATTINA Part 1).

PubMed

McSweeney, L A; Rousseau, N S; Wilson, J A; Wilkes, S; Haighton, C A

2017-04-01

To determine the impact of recurrent sore throats and tonsillitis in adults and stakeholder views of treatment pathways. Qualitative semistructured interview design reporting novel data from a feasibility study for a UK national trial of tonsillectomy in adults. Nine study sites linked to ear, nose and throat departments in National Health Service hospitals located across the United Kingdom. Fifteen patients, 11 general practitioners and 22 ear, nose and throat staff consented to in-depth interviews, which were analysed using a framework analysis approach. Views of stakeholder groups. Recurrent sore throats were reported to severely impact patients' family, work and social life. Ear, nose and throat staff stated that patients faced increasing barriers to secondary care service access. General practitioners were under pressure to reduce 'limited clinical value' surgical procedures. The findings from this study suggest that there is a disconnect between the attitudes of the stakeholders and the reality of recurrent sore throat, tonsillectomy procedures and service provision. More evidence for the role of tonsillectomy is needed from randomised controlled trials to determine whether it should continue to be ranked as a procedure of limited clinical effectiveness. © 2016 John Wiley & Sons Ltd.

Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS): an indication for tonsillectomy.

PubMed

Alexander, Alan A Z; Patel, Nitin J; Southammakosane, Cathy A; Mortensen, Melissa M

2011-06-01

Children with obsessive compulsive disorder or tic disorders that are associated with streptococcal infections (Group A beta-hemolytic) in the oro-pharyngeal region are given the diagnosis of pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS). Tonsillectomy has been reported to resolve the neuro-psychiatric symptoms in these children. We have a case of a 9-year-old boy who was seen in our clinic with multiple recurrent streptococcal infections of the oro-pharyngeal cavity. He also exhibited neuro-psychiatric symptoms including agitation, hyperactivity, and tics. These symptoms followed his recurrent infections. Tonsillectomy was performed and in one year follow-up the patient did not have any recurrent streptococcal infections, and his neuro-psychiatric symptoms resolved completely. Guidelines for medical and surgical management of recurrent strep infections in the face of PANDAS are reviewed. Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.

Coblation: improving outcomes for children following adenotonsillectomy.

PubMed

Benninger, Michael; Walner, David

2007-01-01

Tonsillectomy and adenoidectomy, 2 of the most common childhood surgeries, are performed for a number of indications, the most common being airway obstruction caused by adenotonsillar hypertrophy. Other indications for tonsillectomy include recurrent pharyngotonsillitis, streptococcal carriage, recurrent peritonsillar abscess, halitosis, and presumed neoplasia. Although adenotonsillar surgery is a safe and effective technique for treating disease and obstruction, parents remain concerned about postoperative morbidity, for which the potential is much greater after tonsillectomy than adenoidectomy. Postoperative pain and hemorrhage are 2 unpleasant side effects that can prolong postoperative recovery. Surgeons use a variety of surgical techniques to remove the tonsils and adenoids. When compared with older techniques, such as cold steel dissection and monopolar electrocautery, a new technique named Coblation that uses lower temperatures than electrocautery to remove tonsil tissue and achieve hemostasis, has been shown to reduce pain and decrease postoperative narcotic use, leading to shorter recovery times and a quicker return to normal in children.

Homeopathic Arnica montana for post-tonsillectomy analgesia: a randomised placebo control trial.

PubMed

Robertson, A; Suryanarayanan, R; Banerjee, A

2007-01-01

To evaluate the efficacy of Homeopathic Arnica in reducing the morbidity following tonsillectomy. Randomised double blind, placebo controlled trial at a tertiary referral centre. 190 patients over the age of 18 undergoing tonsillectomy were randomised into intervention and control groups receiving either Arnica 30c or identical placebo, 2 tablets 6 times in the first post-operative day and then 2 tablets twice a day for the next 7 days. The primary outcome measure was the change in pain scores (visual analogue scale) recorded by the patient on a questionnaire over 14 days post-operatively; Secondary outcome measures were: analgesia consumption, visits to the GP or hospital, antibiotic usage, the day on which their swallowing returned to normal and the day on which they returned to work. 111 (58.4%) completed questionnaires were available for analysis. The Arnica group had a significantly larger drop in pain score from day 1 to day 14 (28.3) compared to the placebo group (23.8) with p < 0.05. The two groups did not differ significantly on analgesic consumption or any of the other secondary outcome measures (number of post-operative visits to GP, use of antibiotics and secondary haemorrhage readmissions). The results of this trial suggest that Arnica montana given after tonsillectomy provides a small, but statistically significant, decrease in pain scores compared to placebo.

[Tonsillectomy for PANDAS?].

PubMed

Windfuhr, J P

2016-04-01

Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) is a disease attributed to children with obsessive compulsive or tic disorders associated with streptococcal infections. Because otolaryngologists evaluate a large number of pediatric patients with recurrent streptococcal infections, tonsillectomy (TE) is a common option of therapy. This study was undertaken to evaluate the efficacy of tonsillectomy in patients presenting with a verified PANDAS. A PubMed research was performed using search terms "tonsillectomy" and "PANDAS", "OCD", "compulsive", "pediatric autoimmune", "Chorea" and "Tic" limited by publication date January 1, 1995 to July 31, 2015. Reviews without patients were not included in the review. Nine papers matched our search terms, including 6 case reports with 8 patients and 3 case series. Most case reports were in favor for TE, but this was by far not supported by the findings in the case series. The follow-up ranged form 2-36 months (case reports) and 24-36 months (case series). establishing the diagnosis of PANDAS is complicated by underlying co-morbidities in the field of neurology-psychiatry and the lack of a reliable biomarker. The positive outcome after TE as reported in case studies may be influenced by the postoperative medication and is not supported by the results of large-scale studies. In the light of the considerable postoperative morbidity and unavoidable mortality rate it appears wise to indicate TE only in clinical studies with standardized inclusion criteria. © Georg Thieme Verlag KG Stuttgart · New York.

Comparison of topical ropivacaine with and without ketamine on post-surgical pain in children undergoing tonsillectomy: a randomized controlled double-blind study.

PubMed

Hong, Boohwi; Lim, Chae Seong; Kim, Yoon-Hee; Lee, Jung Un; Kim, Yong Min; Jung, Choonho; Jo, Yumin

2017-08-01

Tonsillectomy in pediatric patients may cause severe postoperative pain. Topical local anesthetics are an easy and safe way to control post-tonsillectomy pain, but there is no benefit during the early postoperative stage. Topical ketamine shows a good effect on early stage postoperative pain. We compared the effect of topical ropivacaine with and without ketamine on post-tonsillectomy pain. Patients aged 3-7 years undergoing tonsillectomy were selected to participate in the study. Our study was performed in a randomized, placebo-controlled, double-blind manner. Patients were randomly assigned to one of two groups using computer-generated random numbers. The researchers who assessed the pain score, the caregivers, and the patient were blinded to group assignment. One group received topical ropivacaine with saline (RS group) and the other group received topical ropivacaine with 20 mg ketamine (RK group) on the tonsillar bed. Pain scores using the modified Children's Hospital of Eastern Ontario Pain Scale (mCHEOPS) at 15 min and 30 min, and at 1, 2, 4, 8, 16 and 24 h were recorded. Rescue analgesic requirement and complications were also recorded. A total of 66 patients were randomly assigned to the RS group (n = 33) and the RK group (n = 33). The mCHEOPS scores were significantly lower in the RK group at 15 min (P = 0.046). The mCHEOPS scores of the two groups decreased with time, but there was no intergroup interaction. The RS group received more analgesics until 1 h after surgery and the RK group received more analgesics during 1-24 h after surgery. There were no differences in adverse outcomes. Topical ropivacaine with ketamine can reduce immediate postoperative pain and analgesic requirement better than ropivacaine alone.

Acoustic changes in voice after tonsillectomy.

PubMed

Saida, H; Hirose, H

1996-01-01

The vocal tract from the glottis to the lips is considered to he a resonator and the voice is changeable depending upon the shape of the vocal tract. In this report, we examined the change in pharyngeal size and acoustic feature of voice after tonsillectomy. Subjects were 20 patients. The distance between both anterior pillars (glossopalatine arches), and between both posterior pillars (pharyngopalatine arches) was measured weekly. For acoustic measurements, the five Japanese vowels and Japanese conversational sentences were recorded and analyzed. The distance between both anterior pillars became wider 2 weeks postoperatively, and tended to become narrower thereafter. The distance between both posterior pillars became wider even after 4 weeks postoperatively. No consistent changes in F0, F1 and F2 were found after surgery. Although there was a tendency for a decrease in F3, tonsillectomy did not appear to change the acoustical features of the Japanese vowels remarkably. It was assumed that the subject may adjust the shape of the vocal tract to produce consistent speech sounds after the surgery using auditory feedback.

A beta-blocker as anxiolytic and haemostatic in tonsillectomy.

PubMed

Basjrah, R; Lubis, H R; Tann, G

1983-01-01

Administration of a beta-blocker, pindolol, was utilized in the premedication of patients selected for tonsillectomies (dissection), to study anxiolytic effects. A curious result observed was that bleeding during and after operation in patients on pindolol was remarkably reduced compared to those not on beta-blocker treatment. This effect was further explored in a small controlled study. Nineteen patients were given pindolol, 5 mg the evening before and on the morning, an hour prior to surgery. Seventeen controls were on placebos. The amount of bleeding was measured in both groups. Patients on pindolol show significantly reduced bleeding when compared to controls (1.77 +/- 1.15 ml versus 7.30 +/- 6.05 ml; p less than 0.005). Coagulation and fibrinolytic profiles were studied in a number of patients in both groups attempting to clarify the cause of the reduced bleeding. The results will be reported. This preliminary study shows that pindolol is a useful drug for controlling bleeding in tonsillectomies. To our knowledge the haemostatic properties of pindolol have been reported before.

Throat infections are associated with exacerbation in a substantial proportion of patients with chronic plaque psoriasis

PubMed Central

Thorleifsdottir, Ragna H.; Eysteinsdottir, Jenna H.; Olafsson, Jon H.; Sigurdsson, Martin I.; Johnston, Andrew; Valdimarsson, Helgi; Sigurgeirsson, Bardur

2016-01-01

Streptococcal throat infections are known to trigger or exacerbate psoriasis, and several studies support the benefit of tonsillectomy. To evaluate the potential of tonsillectomy as a treatment, we used a retrospective study-specific questionnaire to assess the proportion of psoriasis patients with sore throat-associated psoriasis exacerbations. Our survey sampled 275 psoriasis patients. 42% of patients with plaque psoriasis reported sore throat-associated psoriasis exacerbations, and 72% of patients with confirmed streptococcal infections reported aggravation. Notably, women and early onset psoriasis patients were more likely to report psoriasis exacerbation after a sore throat (p<0.001, p=0.046 respectively). Other psoriasis aggravation factors were more common in patients with sore throat-associated exacerbations (p<0.01). 49% of tonsillectomized patients reported subsequent improvement and had more frequent sore throat-associated aggravation of psoriasis than patients who did not improve after tonsillectomy (p=0.015). These findings suggest a closer association between sore throats, streptococcal throat infections and plaque psoriasis than previously reported. PMID:26984718

Throat Infections are Associated with Exacerbation in a Substantial Proportion of Patients with Chronic Plaque Psoriasis.

PubMed

Thorleifsdottir, Ragna H; Eysteinsdóttir, Jenna H; Olafsson, Jón H; Sigurdsson, Martin I; Johnston, Andrew; Valdimarsson, Helgi; Sigurgeirsson, Bardur

2016-08-23

Streptococcal throat infections are known to trigger or exacerbate psoriasis, and several studies support the benefit of tonsillectomy. To evaluate the potential of tonsillectomy as a treatment, we used a retrospective study-specific questionnaire to assess the proportion of psoriasis patients with sore throat-associated psoriasis exacerbations. Our survey sampled 275 psoriasis patients. Of patients with plaque psoriasis, 42% reported sore throat-associated psoriasis exacerbations, and of patients with confirmed streptococcal infections, 72% reported aggravation. Notably, women and patients with early onset psoriasis were more likely to report psoriasis exacerbation after a sore throat (p < 0.001, p = 0.046, respectively). Other psoriasis aggravation factors were more common in patients with sore throat-associated exacerbations (p < 0.01). Of tonsillectomized patients, 49% reported subsequent improvement and had more frequent sore throat-associated aggravation of psoriasis than patients who did not improve after tonsillectomy (p = 0.015). These findings suggest a closer association between sore throats, streptococcal throat infections and plaque psoriasis than reported previously.

A descriptive feasibility study to evaluate scheduled oral analgesic dosing at home for the management of postoperative pain in preschool children following tonsillectomy.

PubMed

Sutters, Kimberly A; Holdridge-Zeuner, Danielle; Waite, Steven; Paul, Steven M; Savedra, Marilyn C; Lanier, Brent; Mahoney, Karla; Miaskowski, Christine

2012-03-01

The purpose of this study, in a sample of preschool children (ages 3-5 years; N = 47), was to evaluate the feasibility of scheduled analgesic dosing following outpatient tonsillectomy in order to optimize pain management. Parents were instructed to give their child acetaminophen with hydrocodone (167 mg/5 mL) every 4 hours around the clock for the first 3 days following surgery. Parents recorded ratings of their child's pain with/without swallowing using the Faces, Legs, Activity, Cry, and Consolability (FLACC) behavioral pain scale, pain relief ratings, and severity of analgesic side effects in a home diary. Audiotaped interviews were conducted with parents to document descriptions of their experiences in managing their child's pain at home. Mean FLACC scores with/without swallowing were less than two at each measurement time and pain relief scores increased over time. Total analgesic dose decreased, and the number of missed doses increased over the first 3 days after surgery. Moderate-to-severe daytime sedation, nausea, vomiting, and constipation were reported by parents. Study results suggest that acetaminophen with hydrocodone is effective in relieving preschool children's pain following tonsillectomy and that parental adherence to a scheduled analgesic regimen decreases over time. Time-contingent dosing was associated with moderate to severe side effects and should be addressed in discharge teaching with parents. Findings provide insight into parents' perspective of pain management at home following tonsillectomy and methods for relieving their child's pain. Wiley Periodicals, Inc.

Pain progression, intensity and outcomes following tonsillectomy.

PubMed

Warnock, F F; Lander, J

1998-03-01

The objective of this study was to assess outcomes of pediatric day surgery tonsillectomy. A total of 129 children, aged 5-16 years, and their parents were recruited from three urban hospitals which provided pediatric day surgery. Children reported pain on a visual analogue scale (VAS) in day surgery and then daily at home for 7 days. Parents reported outcomes of surgery, including fluid intake, nausea, vomiting and sleep disturbances. They also recorded analgesic administration. Three main results related to extent and duration of pain, quality of management of pain, and effect of pain on utilization of health services. Tonsillectomy caused considerable pain which lasted more than 7 days. Pain followed a trajectory of intense or moderately intense pain for the first 3 days followed by a gradual decline over the next 4 days. In general, post-tonsillectomy pain was poorly managed by health professionals and parents. An unexpected observation was that children who had a bupivacaine infiltration of the tonsil fossa during surgery had significantly more pain in the evening of surgery than children who did not have an infiltration. The increase in postoperative pain experienced by those who had the infiltration was attributed to quality of pain management. Children with persistent pain (those who did not follow the typical trajectory) were likely to be taken to a medical practitioner. One-third of the sample made unscheduled visits to practitioners with most occurring from Day 4 to Day 7 of the follow-up.

Oral Flurbiprofen Spray for Posttonsillectomy Pain.

PubMed

Muderris, Togay; Gul, Fatih; Yalciner, Gokhan; Babademez, Mehmet Ali; Bercin, Sami; Kiris, Muzaffer

2016-07-01

Tonsillectomy is still one of the most common surgical procedures, but there exists no standard guideline for pain management after tonsillectomy. Our aim is to determine whether oral spray of flurbiprofen reduces pain and has an influence on other morbid outcomes following tonsillectomy. Prospective, double-blind, randomized, placebo controlled. Patients at Ataturk Training and Research Hospital, Ankara, Turkey. This study was performed on 84 patients (45 in flurbiprofen group, 39 in placebo group) who underwent tonsillectomy. The patients were randomly chosen, and each used oral spray of flurbiprofen 3 times daily or placebo solution at the same regimen. Efficacy was assessed by changes in Numeric Pain Rating Scale. Data were collected at postoperative days 1, 3, 5, and 7 for pain, bleeding, and healing. Data for Mallampati scores were also collected. There were no significant difference between groups with respect to the demographic data. The flurbiprofen group had statistically significant lower pain scores at days 1, 3, 5, and 7 (P = .000, P = .002, P = .001, P = .000, respectively). On days 3 and 7, pain scores were significantly different between different Mallampati groups (P = .049, P = .015, respectively). The flurbiprofen group required less analgesic than the placebo group during the study period on days 1, 3, 5, and 7 (P = .001, P = .001, P = .03, P = .001, respectively). Healing and side effects were not significantly different between the groups. In this study, topical use of flurbiprofen may reduce posttonsillectomy pain without any evidence of additional complications. © American Academy of Otolaryngology—Head and Neck Surgery Foundation 2016.

Parecoxib sodium reduces the need for opioids after tonsillectomy in children: a double-blind placebo-controlled randomized clinical trial.

PubMed

Li, Xiuze; Zhou, Mengjun; Xia, Qing; Li, Juan

2016-03-01

Postoperative pain is a common phenomenon after pediatric tonsillectomy. This prospective randomized double-blind placebo-controlled clinical trial was performed to evaluate the analgesic efficacy of intravenous parecoxib sodium in children undergoing tonsillectomy. Sixty children (American Society of Anesthesiologists physical status I-III, aged three to seven years, and scheduled to undergo elective tonsillectomy under general anesthesia) were randomly allocated into one of two groups to receive intravenous parecoxib sodium 1 mg·kg(-1) (Group P, n = 30) or the same volume of saline (Group S, n = 30) just after induction of general anesthesia. Between-group comparisons were made for the number of patients requiring rescue morphine, total number of doses of postoperative rescue morphine, time to first rescue analgesic, postoperative pain and sedation scores, and adverse effects. Rescue morphine was given to more children in Group S (25/30, 83%) than in Group P (17/30, 57%) [relative risk (RR), 1.5; 95% confidence interval (CI), 1.0 to 2.1; P = 0.024]. The mean (SD) time to first rescue analgesic was shorter in Group S than in Group P [132 (54) min vs 193 (78) min, respectively; mean difference, 61; 95% CI, 26.6 to 96.1; P = 0.001]. The median (interquartile range [IQR]) Children's Hospital of Eastern Ontario Pain Scale scores in the postanesthesia care unit were lower in Group P than in Group S (7 [5-8] vs 9 [8-11], respectively; P = 0.001). The incidence of postoperative nausea and vomiting (PONV) was higher in Group S than in Group P [11/30 (37%) vs 4/30 (13%), respectively; RR, 2.8; 95% CI, 1.0 to 7.7; P = 0.037]. A single intravenous injection of parecoxib sodium 1 mg·kg(-1) after anesthesia induction is an effective method for the control of postoperative pain. It provides a morphine-sparing effect, prolongs the time to first rescue analgesic, and reduces PONV in children undergoing tonsillectomy.

A DESCRIPTIVE FEASIBILITY STUDY TO EVALUATE SCHEDULED ORAL ANALGESIC DOSING AT HOME FOR THE MANAGEMENT OF POSTOPERATIVE PAIN IN PRESCHOOL CHILDREN FOLLOWING TONSILLECTOMY

PubMed Central

Sutters, Kimberly A.; Holdridge-Zeuner, Danielle; Waite, Steven; Paul, Steven M.; Savedra, Marilyn C.; Lanier, Brent; Mahoney, Karla; Miaskowski, Christine

2012-01-01

Objectives The purpose of this study, in a sample of preschool children (ages 3 to 5 years; N=47), was to evaluate the feasibility of scheduled analgesic dosing following outpatient tonsillectomy in order to optimize pain management. Methods Parents were instructed to give their child acetaminophen with hydrocodone (167mg/5ml) every 4 hours around-the-clock for the first 3 days following surgery. Parents recorded ratings of their child’s pain with/without swallowing using the Faces, Legs, Activity, Cry, and Consolability (FLACC) behavioral pain scale, pain relief ratings, and severity of analgesic side effects in a home diary. Audiotaped interviews were conducted with parents to document descriptions of their experiences in managing their child’s pain at home. Results Mean FLACC scores with/without swallowing were less than 2 at each measurement time and pain relief scores increased over time. Total analgesic dose decreased and the number of missed doses increased over the first 3 days after surgery. Moderate-to-severe daytime sedation, nausea, vomiting, and constipation were reported by parents. Discussion Study results suggest that acetaminophen with hydrocodone is effective in relieving preschool children’s pain following tonsillectomy, and that parental adherence to a scheduled analgesic regimen decreases over time. Time-contingent dosing was associated with moderate to severe side effects, and should be addressed in discharge teaching with parents. Findings provide insight into parents’ perspective of pain management at home following tonsillectomy and methods for relieving their child’s pain. PMID:22313591

Ibuprofen with acetaminophen for postoperative pain control following tonsillectomy does not increase emergency department utilization.

PubMed

Bedwell, Joshua R; Pierce, Matthew; Levy, Michelle; Shah, Rahul K

2014-12-01

To compare the performance of ibuprofen vs codeine for postoperative pain management after tonsillectomy as measured by need for emergency department (ED) treatment for pain and/or dehydration. Retrospective case series with chart review. Tertiary children's hospital. Consecutive series of patients who underwent tonsillectomy with or without adenoidectomy at a tertiary children's hospital. Patients were categorized based on the type of postoperative pain management (acetaminophen with codeine vs acetaminophen and ibuprofen). The main outcome measure was the proportion of patients requiring ED visits or inpatient admissions for inadequate pain control or dehydration. Secondary measures included antibiotic use, postoperative hemorrhage, need for return to the operating room, vomiting, and oral diet tolerance. Patients in the ibuprofen/acetaminophen group were younger than those in the codeine/acetaminophen group (6.2 vs 8.1 years, P < .05). Patients in the codeine/acetaminophen group were more likely to use antibiotics in the postoperative period (50.3% vs 5.9%, P < .05). The proportion of patients requiring ED visits or inpatient admission for dehydration was not significantly different between the groups (5.1% for codeine, 2.7% for ibuprofen, P = .12). Multivariable analysis controlling for age and antibiotic use showed no difference in ED visits or admission for dehydration (P = .09). There was no difference between the groups for any of the secondary measures. Ibuprofen with acetaminophen represents a safe and acceptable analgesic alternative to codeine and acetaminophen in patients undergoing pediatric tonsillectomy. © American Academy of Otolaryngology—Head and Neck Surgery Foundation 2014.

The effectiveness of tonsillectomy and partial adenoidectomy on obstructive sleep apnea in cleft palate patients.

PubMed

Abdel-Aziz, Mosaad

2012-11-01

The most common cause of pediatric obstructive sleep apnea (OSA) is adenotonsillar hypertrophy (ATH). In cleft palate patients, however, the obstructive effects of ATH are more severe due to narrow airways. The aim of this study was to assess the effectiveness of tonsillectomy and/or partial adenoidectomy on OSA in cleft palate patients. Case series. Tonsillectomy and/or partial adenoidectomy was performed in 17 repaired cleft palate patients with tonsillar and/or adenoid hypertrophy and OSA. Apnea/hypopnea (A/H) index and minimum O(2) saturation were measured before and after surgery. In addition, because these patients are vulnerable to speech impairment after pharyngeal surgery, auditory perceptual assessment (APA) and nasometric assessment of speech were performed. The mean preoperative A/H index was 17.6 ± 3.9, and the mean preoperative minimum O(2) saturation was 88.7 ± 1.5%. Both parameters improved postoperatively, to 1.9 ± 2.3 and 93.7 ± 1.5% respectively, and the changes were significant (P < 0.001). In 12 cases (70.6%), A/H indexes were normalized following surgery. Associated comorbidities such as retrognathia and narrow pharyngeal airways may underlie incomplete recovery in some cases. There were no significant postoperative changes in APA and nasalance scores. In most cases, tonsillectomy and/or partial adenoidectomy is an effective method for treatment of OSA in repaired cleft palate patients presenting with tonsillar and/or adenoid hypertrophy. However, some cases may need further procedures to relieve airway obstruction due to associated comorbidities. Copyright © 2012 The American Laryngological, Rhinological, and Otological Society, Inc.

Design and validation of key text messages (Tonsil-Text-To-Me) to improve parent and child perioperative tonsillectomy experience: A modified Delphi study.

PubMed

Song, Jin Soo A; Wozney, Lori; Chorney, Jill; Ishman, Stacey L; Hong, Paul

2017-11-01

Parents can struggle while providing perioperative tonsillectomy care for their children at home. Short message service (SMS) technology is an accessible and direct modality to communicate timely, evidence-based recommendations to parents across the perioperative period. This study focused on validating a SMS protocol, Tonsil-Text-To-Me (TTTM), for parents of children undergoing tonsillectomy. This study used a modified Delphi expert consensus method. Participants were an international sample of 27 clinicians/researchers. Participants rated level of agreement with recommendations across seven perioperative domains, derived systematically from scientific and lay literature. A priori consensus analysis was conducted using threshold criterion. A multidisciplinary team of local clinicians were also individually interviewed to consolidate text messages and implement recurrent suggestions. In the modified Delphi panel, 30 statements reached threshold agreement (>3.0 of 4.0); recommendations surrounding diet (3.87) and hygiene (3.83) had the highest level of consensus, while recommendations regarding activity (3.42) and non-pharmacologic pain management (3.55) had the lowest consensus. The 30 statements reconfigured into 12 concise text messages. After further interviews with local clinicians, 14 final text messages were included in the SMS protocol to be sent two weeks preoperatively to one week postoperatively. This study illustrates the development of TTTM which is designed to deliver key sequential text messages at the optimal time during the perioperative setting to parents caring for their children who are undergoing tonsillectomy. Copyright © 2017 Elsevier B.V. All rights reserved.

Comparison of peritonsillar infiltration effects of ketamine and tramadol on post tonsillectomy pain: a double-blinded randomized placebo-controlled clinical trial

PubMed Central

Ayatollahi, Vida; Behdad, Shekoufeh; Hatami, Maryam; Moshtaghiun, Hossein; Baghianimoghadam, Behnam

2012-01-01

Aim To assess the effect of peritonsillar infiltration of ketamine and tramadol on post tonsillectomy pain and compare the side effects. Methods The double-blind randomized clinical trial was performed on 126 patients aged 5-12 years who had been scheduled for elective tonsillectomy. The patients were randomly divided into 3 groups to receive either ketamine, tramadol, or placebo. They had American Society of Anesthesiologists physical status class I and II. All patients underwent the same method of anesthesia and surgical procedure. The three groups did not differ according to their age, sex, and duration of anesthesia and surgery. Post operative pain was evaluated using CHEOPS score. Other parameters such as the time to the first request for analgesic, hemodynamic elements, sedation score, nausea, vomiting, and hallucination were also assessed during 12 hours after surgery. Results Tramadol group had significantly lower pain scores (P = 0.005), significantly longer time to the first request for analgesic (P = 0.001), significantly shorter time to the beginning of liquid regimen (P = 0.001), and lower hemodynamic parameters such as blood pressure (P = 0.001) and heart rate (P = 0.001) than other two groups. Ketamine group had significantly greater presence of hallucinations and negative behavior than tramadol and placebo groups. The groups did not differ significantly in the presence of nausea and vomiting. Conclusion Preoperative peritonsillar infiltration of tramadol can decrease post-tonsillectomy pain, analgesic consumption, and the time to recovery without significant side effects. Registration No: IRCT201103255764N2 PMID:22522994

Tonsillectomy in adults with obstructive sleep apnea.

PubMed

Holmlund, Thorbjörn; Franklin, Karl A; Levring Jäghagen, Eva; Lindkvist, Marie; Larsson, Torbjörn; Sahlin, Carin; Berggren, Diana

2016-12-01

To study whether tonsillectomy is effective on obstructive sleep apnea (OSA) in adults with large tonsils. A multicenter prospective interventional study. The study comprised 28 patients with OSA, an apnea-hypopnea index of > 10, large tonsils (Friedman tonsil size 3 and 4), and age 18 to 59 years. They were derived from 41 consecutive males and females with large tonsils referred for a suspicion of sleep apnea to the ear, nose, and throat departments in Umeå, Skellefteå, and Sunderbyn in northern Sweden. The primary outcome was the apnea-hypopnea index, measured with polygraphic sleep apnea recordings 6 months after surgery. Secondary outcomes included daytime sleepiness, as measured with the Epworth Sleepiness Scale, and swallowing function, using video-fluoroscopy. The apnea-hypopnea index was reduced from a mean of 40 units per hour (95% confidence interval [CI] 28-51) to seven units per hour (95% CI 3-11), P < 0.001, at the 6-month follow-up after surgery. The apnea-hypopnea index was reduced in all patients and 18 (64%) were cured. The Epworth Sleepiness Scale was reduced from a mean of 11 (95% CI 8-13) to 6.0 (95% CI 4-7), P < 0.001. A swallowing dysfunction was found in seven of eight investigated patients before surgery. Of those, swallowing function improved in five patients after surgery, whereas no one deteriorated. Tonsillectomy may be effective treatment for adult patients with OSA and large tonsils. Tonsillectomy may be suggested for adults with OSA and large tonsils. 4. Laryngoscope, 126:2859-2862, 2016. © 2016 The American Laryngological, Rhinological and Otological Society, Inc.

Tonsillectomy Versus Watchful Waiting for Recurrent Throat Infection: A Systematic Review.

PubMed

Morad, Anna; Sathe, Nila A; Francis, David O; McPheeters, Melissa L; Chinnadurai, Sivakumar

2017-02-01

The effectiveness of tonsillectomy or adenotonsillectomy ("tonsillectomy") for recurrent throat infection compared with watchful waiting is uncertain. To compare sleep, cognitive, behavioral, and health outcomes of tonsillectomy versus watchful waiting in children with recurrent throat infections. MEDLINE, Embase, and the Cochrane Library. Two investigators independently screened studies against predetermined criteria. One investigator extracted data with review by a second. Investigators independently assessed risk of bias and strength of evidence (SOE) and confidence in the estimate of effects. Seven studies including children with ≥3 infections in the previous 1 to 3 years addressed this question. In studies reporting baseline data, number of infections/sore throats decreased from baseline in both groups, with greater decreases in sore throat days, clinician contacts, diagnosed group A streptococcal infections, and school absences in tonsillectomized children in the short term (<12 months). Quality of life was not markedly different between groups at any time point. Few studies fully categorized infection/sore throat severity; attrition was high. Throat infections, utilization, and school absences improved in the first postsurgical year in tonsillectomized children versus children not receiving surgery. Benefits did not persist over time; longer-term outcomes are limited. SOE is moderate for reduction in short-term throat infections and insufficient for longer-term reduction. SOE is low for no difference in longer-term streptococcal infection reduction. SOE is low for utilization and missed school reduction in the short term, low for no difference in longer-term missed school, and low for no differences in quality of life. Copyright © 2017 by the American Academy of Pediatrics.

Applications of Evolving Robotic Technology for Head and Neck Surgery.

PubMed

Sharma, Arun; Albergotti, W Greer; Duvvuri, Umamaheswar

2016-03-01

Assess the use and potential benefits of a new robotic system for transoral radical tonsillectomy, transoral supraglottic laryngectomy, and retroauricular thyroidectomy in a cadaver dissection. Three previously described robotic procedures (transoral radical tonsillectomy, transoral supraglottic laryngectomy, and retroauricular thyroidectomy) were performed in a cadaver using the da Vinci Xi Surgical System. Surgical exposure and access, operative time, and number of collisions were examined objectively. The new robotic system was used to perform transoral radical tonsillectomy with dissection and preservation of glossopharyngeal nerve branches, transoral supraglottic laryngectomy, and retroauricular thyroidectomy. There was excellent exposure without any difficulties in access. Robotic operative times (excluding set-up and docking times) for the 3 procedures in the cadaver were 12.7, 14.3, and 21.2 minutes (excluding retroauricular incision and subplatysmal elevation), respectively. No robotic arm collisions were noted during these 3 procedures. The retroauricular thyroidectomy was performed using 4 robotic ports, each with 8 mm instruments. The use of updated and evolving robotic technology improves the ease of previously described robotic head and neck procedures and may allow surgeons to perform increasingly complex surgeries. © The Author(s) 2015.

COMPARISON OF THE EFFECTS OF ORAL VS. PERITONSILLAR INFILTRATION OF KETAMINE IN PAIN REDUCTION AFTER TONSILLECTOMY: A RANDOMIZED CLINICAL TRIAL.

PubMed

Norouzi, Afsaneh; Jafari, Abolfazl; Vishteh, Hamid Reza Khoddami; Fateh, Shahin

2015-02-01

Although oral ketamine has been used in some cases to reduce pain in children, the use of this drug to reduce pain after tonsillectomy has not been studied yet. This double-blind clinical trial was conducted in 2009 in 92 children who were aged three to nine years old, met ASA I or II criteria, and were candidate for tonsillectomy. Patients were divided randomly into two groups. Half an hour before general anesthesia, 5 mg/kg ketamine mixed in 2 cc/kg apple juice was given to the children in oral ketamine group and 2 cc/kg of apple juice alone was given to the children in the peritonsillar group. After general anesthesia and three minutes before surgery 1 cc of 0.9% normal saline in the oral group and 1cc of ketamine (0.5 mg/kg) in the peritonsillar group was injected to the tonsil bed of patients. There was no difference between the two groups in terms of sex, age, and weight. Duration of surgery was significantly shorter in the peritonsillar group (P < 0.001) and the severity of postoperative bleeding was significantly higher in peritonsillar group (P = 0.022). However, postoperative bleeding recurred in 25 patients (27%) and there was no statistically significant difference between the two groups. The level of pain in children six hours after surgery according to CHEOPS criteria was significantly lower in the peritonsillar group (0.9 ± 0.8) than in the oral group (2.6 ± 1) (P < 0.001). The finding of this study showed that, compared with the peritonsillar infiltration of ketamine, the use of oral ketamine before general anesthesia was less effective in reducing postoperative pain of tonsillectomy in children.

[Evaluation of swallowing function with surface electromyography before and after tonsillectomy].

PubMed

Gürkan, Emre; Veyseller, Bayram; Açıkalın, Reşit Murat; Elbistanlı, Suphi; Yurtsever, Serveren; Acar, Hürtan

2011-01-01

In this study, we evaluated the swallowing function with surface electromyography before and after tonsillectomy. Twenty patients (12 males, 8 females; mean age 23.8 years; range 17 to 30 years) who had tonsillectomy indication as study group, and 10 healthy individuals (8 males, 2 females; mean age 26 years; range 18 to 35 years) as control group were included in this prospective study between October 2008 and February 2009. Due to their significant role on oral and faringeal phases of swallowing; the surface electromyography prosedure is performed on the masseter muscle, the submental-submandibular muscle group and the infrahyoid muscles to measure their electrical activity and duration of contraction. For this purpose, single swallow and continuous drinking of 100 cc water tests were applied to each patient preoperatively and; in the postoperative 1st week and the 1st month. The preoperative duration of drinking periods were significanly longer in the study group compared to the control group (p<0.05). At the end of the first postoperative week the duration of drinking 100 cc water test was significantly longer than the preoperative mean of the study group (p<0.05). After one month single- swallow durations of study group were significantly shorter then the preoperative mean (p<0.05). The electrical activity of the masseter and infrahyoid muscles were significantly higher in study group compared with control group (p<0.05). The close proximity of the surgical area to the muscles affects swallowing after tonsillectomy. The surface electromyography is a simple, non-invasive and reliable method for postoperative evaluation of the swallowing functions of the throat muscles and thereby allows monitoring of the recovery and functional improvement of these muscles.

Internal Carotid Artery Pseudoaneurysm after Tonsillectomy Treated by Endovascular Approach

PubMed Central

Raffin, C.N.; Montovani, J.C.; Neto, J.M.P.; Campos, C.M.S.; Piske, R.L.

2002-01-01

Summary Surgery on the head and neck region may be complicated by vascular trauma, caused by direct injury on the vascular wall. Lesions of the arteries are more dangerous than the venous one. The traumatic lesion may cause laceration of the artery wall, spasm, dissection, arteriovenous fistula, occlusion or pseudoaneurysm. We present a case of a child with a giant ICA pseudoaneurysm after tonsillectomy, manifested by pulsing mass and respiratory distress, which was treated by endovascular approach, occluding the lesion and the proximal artery with Histoacryl. We reinforce that the endovascular approach is the better way to treat most of the traumatic vascular lesions. PMID:20594516

Treatment of extensive post tonsillectomy oropharyngeal stenosis secondary to fibromatosis.

PubMed

Chang, Brian; Ha, Jennifer F; Zopf, David

2018-04-01

Aggressive fibromatosis is an uncommon, benign tumor of fibroblastic origin with high potential for local invasion. Less than a quarter of these lesions are located in the head and neck, and although extremely rare, associations have been demonstrated with physical trauma. We describe a unique case of oropharyngeal fibromatosis with traumaticetiology, managed successfully with surgical excision of the lesion with negative surgical margins. A 5-year old patient was found to have an aggressive fibromatosis causing oropharyngeal stenosis following tonsillectomy. We demonstrate that surgical resection with a clear margin allowed for alleviation of stenosis without recurrences reported since the procedure. Copyright © 2018 Elsevier B.V. All rights reserved.

Comparing the Efficacy of Peritonsillar Injection of Tramadol With Honey in Controlling Post-Tonsillectomy Pain in Adults.

PubMed

Hatami, Maryam; Mirjalili, Mahdieh; Ayatollahi, Vida; Vaziribozorg, Sedighe; Zand, Vahid

2018-06-01

The authors investigated the effect of honey on post-tonsillectomy pain and compare its efficacy with tramadol. This clinical trial was performed on 60 patients with American Society of Anesthesia I and II aged between 18 and 55 years and underwent tonsillectomy. Induction of anesthesia was carried out using 2 mg/kg propofol and 0.5 atracurium following 1.5 μg/kg fentanyl administration. Group B was given tramadol at dose of 2 mg/kg and with volume of 4 mL and Group A was given normal saline with the same volume 2 mL of medications were injected using needle (25) into tonsil bed and anterior old of each tonsil by an anesthesiologist. Three minutes after injection, the surgery was performed by the same ENT residents for all patients. In the recovery room Group B received antibiotics and oral acetaminophen. Group A was given antibiotics, oral acetaminophen, and honey dissolved in 40 mL warm water every 6 hours from when the patient was fully awake. Patients in Group A were told to eat honey 3 times a day 7 days postoperatively. Pain was scored using Numeric Rating Scale at the time points of 2, 6, 12, and 24 hours as well as 3 and 7 days postoperatively. Moreover, the healing status and epithelialization degree of tonsillar bed were considered on 1 and 7 days after the surgery by ENT specialist. The mean of pain score was significantly higher in Group A within 24 hours postoperatively as compared with Group B (P < 0.01). The mean of pain score was lower in Group B after 3 and 7 days but this difference was not statistically significant (P > 0.05). Considering restoration status and epithelialization degree of tonsillar bed on the 1st and 7th days, there was no statistically significant difference between 2 groups; however, tonsillar bed healing process was better in Group B on the 7th day. The current investigation confirmed the positive impact of tramadol on post-tonsillectomy pain relief in adults. The authors also found that honey can be used as a complementary treatment along with acetaminophen and other analgesics for reducing post-tonsillectomy pain. Considering honey impact on wound healing and its anti-inflammatory effect, it is suggested for relieving complications after surgery.

Tonsillectomy for periodic fever, aphthous stomatitis, pharyngitis and cervical adenitis syndrome (PFAPA).

PubMed

Burton, Martin J; Pollard, Andrew J; Ramsden, James D; Chong, Lee Yee; Venekamp, Roderick P

2014-09-11

Periodic fever, aphthous stomatitis, pharyngitis and cervical adenitis (PFAPA) syndrome is a rare clinical syndrome of unknown cause usually identified in children. Tonsillectomy is considered a potential treatment option for this syndrome. This is an update of a Cochrane review first published in 2010. To assess the effectiveness and safety of tonsillectomy (with or without adenoidectomy) in children with PFAPA. We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the search was 30 October 2013. Randomised controlled trials comparing tonsillectomy (with or without adenoidectomy) with non-surgical treatment in children with PFAPA. Two authors independently assessed trial quality and extracted data. We used the standard methodological procedures expected by The Cochrane Collaboration. Two trials were included with a total of 67 children randomised (65 analysed); we judged both to be at low risk of bias.One trial of 39 participants recruited children with PFAPA syndrome diagnosed according to rigid, standard criteria. The trial compared adenotonsillectomy to watchful waiting and followed up patients for 18 months. A smaller trial of 28 children applied less stringent criteria for diagnosing PFAPA and probably also included participants with alternative types of recurrent pharyngitis. This trial compared tonsillectomy alone to no treatment and followed up patients for six months.Combining the trial results suggests that patients with PFAPA experience less fever and less severe episodes after surgery compared to those receiving no surgery. The risk ratio (RR) for immediate resolution of symptoms after surgery that persisted until the end of follow-up was 4.38 (95% confidence interval (CI) 0.64 to 30.11); number needed to treat to benefit (NNTB) = 2, calculated based on an estimate that 156 in 1000 untreated children have a resolution).There was a large overall reduction in the average number of episodes over the total length of follow-up in these studies (rate ratio 0.08, 95% CI 0.05 to 0.13), reducing the average frequency of PFAPA episodes from one every two months to slightly less than one every two years. The severity, as indicated by the length of PFAPA symptoms during these episodes, was also reduced. One study reported that the average number of days per PFAPA episode was 1.7 days after receiving surgery, compared to 3.5 days in the control group. The proportion of patients requiring corticosteroids was also lower in the surgery group compared to those receiving no surgery (RR 0.58, 95% CI 0.37 to 0.92).Both trials reported that there were no complications of surgery. However, the numbers of patients randomly allocated to surgery (19 and 14 patients respectively) were too small to detect potentially important complications such as haemorrhage. Other outcomes such as quality of life, number of days with pain after surgery and absence from school were not measured or reported. The evidence for the effectiveness of tonsillectomy in children with PFAPA syndrome is derived from two small randomised controlled trials. These trials reported significant beneficial effects of surgery compared to no surgery on immediate and complete symptom resolution (NNTB = 2) and a substantial reduction in the frequency and severity (length of episode) of any further symptoms experienced. However, the evidence is of moderate quality (further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate) due to the relatively small sample sizes of the studies and some concerns about the applicability of the results. Therefore, the parents and carers of children with PFAPA syndrome must weigh the risks and consequences of surgery against the alternative of using medications. It is well established that children with PFAPA syndrome recover spontaneously and medication can be administered to try and reduce the severity of individual episodes. It is uncertain whether adenoidectomy combined with tonsillectomy adds any additional benefit to tonsillectomy alone.

Tonsillectomy and Adenoids PostOp

MedlinePlus

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Post-operative pain control after tonsillectomy: dexametasone vs tramadol.

PubMed

Topal, Kubra; Aktan, Bulent; Sakat, Muhammed Sedat; Kilic, Korhan; Gozeler, Mustafa Sitki

2017-06-01

Tramadol was found to be more effective than dexamethasone in post-operative pain control, with long-lasting relief of pain. This study aimed to compare the effects of pre-operative local injections of tramadol and dexamethasone on post-operative pain, nausea and vomiting in patients who underwent tonsillectomy. Sixty patients between 3-13 years of age who were planned for tonsillectomy were included in the study. Patients were divided into three groups. Group 1 was the control group. Patients in Group 2 received 0.3 mg/kg Dexamethasone and Group 3 received 0.1 mg/kg Tramadol injection to the peritonsillary space just before the operation. Patients were evaluated for nausea, vomiting, and pain. When the control and the dexamethasone groups were compared; there were statistically significant differences in pain scores at post-operative 15 and 30 min, whereas there was no statistically significant difference in pain scores at other hours. When the control and tramadol groups were compared, there was a statistically significant difference in pain scores at all intervals. When tramadol and dexamethasone groups were compared, there was no statistically significant difference in pain scores at post-operative 15 and 30 min, 1 and 2 h, whereas there was a statistically significant difference in pain scores at post-operative 6 and 24 h.

The "Swiss-cheese Doppler-guided laser tonsillectomy": a new safe cribriform approach to intracapsular tonsillectomy.

PubMed

Palmieri, B; Iannitti, T; Fistetto, G; Rottigni, V

2013-05-01

Outpatient laser ablation of palatine tonsils is a very interesting procedure that has been recently introduced as a routine in head and neck surgery departments. The aim of this study was to describe a new strategy using a Doppler-guided fibre optic neodymium-yttrium-aluminium-garnet (YAG) laser to remove up to 80 % of tonsillar tissue, as assessed in the long-term postoperative clinical evaluation of the volume of the tonsils at the follow-up, and leaving the capsule in place, thus avoiding any haemorrhagic complication and minimize pain. A total of 20 patients (men, n=13; women, n=7), aged between 6 and 63, were recruited for the procedure. They were affected by chronic hypertrophic tonsillitis with a recurrent fever and other symptoms that were related to oral inflammation. Among the 20 patients, no serious adverse events, including haemorrhage-related complications, were observed. Treatment was well tolerated, even in patients displaying an overall low pain threshold. No dropout or uncompleted procedure occurred in the present study. Minor complications included sore throat, moderate oedema, mild acute pharynx inflammation, slight peritonsillar exudate and local burning. The postoperative pain, measured by Scott-Huskisson visual analogue scale, was between 5 and 40 mm and was easily counteracted by means of external ice packages and nonsteroidal anti-inflammatory drugs, according to the individual patient's need. During the 12-36-month follow-up patients showed improved symptoms (n=7) and complete recovery (n=13). A relapse episode was observed in two patients. This study supports fibre optic laser neodymium-YAG tonsil surgery, named "cribriform intracapsular tonsillectomy" or "Swiss-cheese laser tonsillectomy", as an effective alternative to the traditional cold knife approach or electrosurgery. This approach could become the gold standard for tonsil surgery in the third millennium for safety reasons, acceptable cost-benefit ratio, the precise targeting of the beam across the affected tissues and the short- and long-term recovery.

Correlation of MDR1 gene polymorphisms with anesthetic effect of sevoflurane–remifentanil following pediatric tonsillectomy

PubMed Central

Shi, Nian-Jun; Zhang, Wei-Xia; Zhang, Ning; Zhong, Li-Na; Wang, Ling-Ping

2017-01-01

Abstract Background: The motive of this study was to investigate the collaboration between MDR1 gene polymorphisms and anesthetic effects following pediatric tonsillectomy. Methods: All together 178 children undergoing tonsillectomy with preoperative sevoflurane–remifentanil anesthesia were selected. In order to determine MDR1 gene polymorphisms of 3435C > T, 1236C > T, and 2677G > T/A, polymerase chain reaction–restriction fragment length polymorphism was used. Mean arterial pressure (MAP), diastolic blood pressure (DBP), systolic blood pressure (SBP), and heart rate (HR) at T0 (5 mins after the repose), T1 (0 min after tracheal intubation), T2 (5 mins after the tracheal intubation), T3 (0 min after the tonsillectomy), T4 (0 min after removal of the mouth-gag) and T5 (5 min after the extubation) were observed. The visual analog scale (VAS), the face, legs, activity, cry, and consolability (FLACC) pain assessment, and Ramsay sedation score were recorded after the patients gained consciousness. The adverse reactions were also observed. Results: As compared to the CT + TT genotype of MDR1 1236C > T, the time of induction, respiration recovery, eye-opening, and extubation of children with the CC genotype was found to be shorter (all P <.05); the MAP, SBP, DBP, and HR were significantly reduced at T5 in children that possessed the CC genotype (all P <.05), the VAS at postoperative 1, 2, 4, and 8 hours and Ramsay sedation score were decreased, while the FLACC score increased (all P <.05). It was found that the adverse reaction rate was lower in children bearing the CC genotype (P <.05). Conclusion: It could be concluded that anesthetic effect in patients with the MDR1 1236C > T CC genotype was found to be superior to those carrying the CT + TT genotype. PMID:28614221

Tonsillitis and sore throat in children

PubMed Central

Stelter, Klaus

2014-01-01

Surgery of the tonsils is still one of the most frequent procedures during childhood. Due to a series of fatal outcomes after hemorrhage in children in Austria in 2006, the standards and indications for tonsillectomy have slowly changed in Germany. However, no national guidelines exist and the frequency of tonsil surgery varies across the country. In some districts eight times more children were tonsillectomized than in others. A tonsillectomy in children under six years should only be done if the child suffers from recurrent acute bacterially tonsillitis. In all other cases (i.e. hyperplasia of the tonsils) the low risk partial tonsillectomy should be the first line therapy. Postoperative pain and the risk of hemorrhage are much lower in partial tonsillectomy (=tonsillotomy). No matter whether the tonsillotomy is done by laser, radiofrequency, shaver, coblation, bipolar scissor or Colorado needle, as long as the crypts are kept open and some tonsil tissue is left behind. Total extracapsular tonsillectomy is still indicated in severely affected children with recurrent infections of the tonsils, allergy to antibiotics, PFAPA syndrome (periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis) and peritonsillar abscess. With regard to the frequency and seriousness of the recurrent tonsillitis the indication for tonsillectomy in children is justified if 7 or more well-documented, clinically important, adequately treated episodes of throat infection occur in the preceding year, or 5 or more of such episodes occur in each of the 2 preceding years (according to the paradise criteria). Diagnosis of acute tonsillitis is clinical, but sometimes it is hard to distinguish viral from bacterial infections. Rapid antigen testing has a very low sensitivity in the diagnosis of bacterial tonsillitis and swabs are highly sensitive but take a long time. In all microbiological tests the treating physician has to keep in mind, that most of the bacterials, viruses and fungi belong to the healthy flora and do no harm. Ten percent of healthy children even bear strepptococcus pyogenes all the time in the tonsils with no clinical signs. In these children decolonization is not necessary. Therefore, microbiological screening tests in children without symptoms are senseless and do not justify an antibiotic treatment (which is sometimes postulated by the kindergartens). The acute tonsillitis should be treated with steroids (e.g. dexamethasone), NSAIDs (e.g. ibuprofene) and betalactam antibiotics (e.g. penicillin or cefuroxime). With respect to the symptom reduction and primary healing the short-term late-generation antibiotic therapy (azithromycin, clarithromycin or cephalosporine for three to five days) is comparable to the long-term penicilline therapy. There is no difference in the course of healing, recurrence or microbiological resistance between the short-term penicilline therapy and the standard ten days therapy. On the other hand, only the ten days antibiotic therapy has proven to be effective in the prevention of rheumatic fever and glomerulonephritic diseases. The incidence of rheumatic heart disease is currently 0.5 per 100,000 children of school age. The main morbidity after tonsillectomy is pain and the late haemorrhage. Posttonsillectomy bleeding can occur till the whole wound is completely healed, which is normally after three weeks. Life-threatening haemorrhages occur often after smaller bleedings, which can spontaneously cease. That is why every haemorrhage, even the smallest, has to be treated properly and in ward. Patients and parents have to be informed about the correct behaviour in case of haemorrhage with a written consent before the surgery. The handout should contain important addresses, phone numbers and contact persons. Almost all cases of fatal outcome after tonsillectomy were due to false management of haemorrhage. Haemorrhage in small children can be especially life-threatening because of the lower blood volume and the danger of aspiration with asphyxia. A massive haemorrhage is an extreme challenge for every paramedic or emergency doctor because of the difficult airway management. Intubation is only possible with appropriate inflexible suction tubes. All different surgical techniques have the risk of haemorrhage and even the best surgeon will experience a postoperative haemorrhage. The lowest risk of haemorrhage is after cold dissection with ligature or suturing. All “hot” techniques with laser, radiofrequency, coblation, mono- or bipolar forceps have a higher risk of late haemorrhage. Children with a hereditary coagulopathy have a higher risk of haemorrhage. It is possible, that these children were not identified before surgery. Therefore it is recommended by the Society of paediatrics, anaesthesia and ENT, that a standardised questionnaire should be answered by the parents before tonsillectomy and adenoidectomy. This 17-point-checklist questionnaire is more sensitive and easier to perform than a screening with blood tests (e.g. INR and PTT). Unfortunately, a lot of surgeons still screen the children preoperatively by coagulative blood tests, although these tests are inappropriate and incapable of detecting the von Willebrand disease, which is the most frequent coagulopathy in Europe. The preoperative information about the surgery should be done with the child and the parents in a calm and objective atmosphere with a written consent. A copy of the consent with the signature of the surgeon and both custodial parents has to be handed out to the parents. PMID:25587367

Tonsillectomy and Adenoids PostOp

MedlinePlus

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Arrhenius parameters for primary thermal injury in human tonsillar tissue

NASA Astrophysics Data System (ADS)

McMillan, Kathleen; Radabaugh, Rebecca; Coad, James E.

2011-03-01

Clinical implementation of a thermal therapy requires the ability to predict tissue injury following exposures to specific thermal histories. As part of an effort to develop a nonexcisional alternative to tonsillectomy, the degree of primary hyperthermic tissue injury in human tonsil was characterized. Fifteen fresh pediatric hypertrophic tonsillectomy specimens were sectioned and treated in a NIST-calibrated saline bath at temperatures of 40 to 70°C with hold times of one to seven minutes. The treated tissues were subsequently nitroblue tetrazolium (NBT) stained to assess for thermal respiratory enzyme inactivation as a marker of cellular injury/death. The NBT stains were quantitatively image analyzed and used to calculate Arrhenius parameters for primary thermal injury in human tonsils.

Improving postoperative tonsillectomy pain management in children--a double blinded randomised control trial of a patient analgesia information sheet.

PubMed

Bailey, Lucas; Sun, Jing; Courtney, Mark; Murphy, Paul

2015-05-01

To evaluate paediatric post-tonsillectomy pain management using oxycodone when a specific analgesia information sheet is included with standard postoperative information. Oxycodone information sheets were randomly allocated to half the study children's post-tonsillectomy information pack. The trial was double-blinded to the surgeon, anaesthetist, nursing and administrative staff. Parents and children completed the pain assessment on day 3, 5 and 7. On day 10 the parents completed a questionnaire. A postoperative analgesia information sheet provides for higher satisfaction and knowledge for parents using oxycodone (p<0.001) and children have improved postoperative pain control, most significantly at day 5 (p<0.05). Parent assessment of the child's analgesia was superior with the oxycodone information sheet, most significantly at day 3 and 7 post operatively (p<0.05). There is also a positive correlation between the parents' observed pain score and children's self reported pain score, with a low correlation efficient level observed (p<0.001). Information sheets are useful in education and use of postoperative analgesia. The primary objective to explore the efficacy of the information sheet has proved to be successful in this setting. Given risks of opioid analgesia, it is recommended that postoperative information sheets be given to all parents, to provide for improved analgesia control and safe management of children in the postoperative period. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.

Tonsillitis: MedlinePlus Health Topic

MedlinePlus

... Library of Medicine) Article: The debate continues: a prospective, randomised, single-blind study comparing Coblation... Article: Overnight in-hospital observation following tonsillectomy: retrospective study of post-operative intervention. Article: Immune thrombocytopenia ...

Tonsillectomy

MedlinePlus

... surgeon may cut out the tonsils using a blade (scalpel) or a specialized surgical tool that uses ... days after surgery, and strenuous activities — such as running and bike riding — should be avoided for two ...

Post-tonsillectomy hemorrhage--some facts will never change.

PubMed

Windfuhr, Jochen P; Verspohl, Berit C; Chen, Yue-Shih; Dahm, Julia D; Werner, Jochen A

2015-05-01

Bleeding remains the most significant complication following tonsillectomy (TE), sometimes requiring revision surgery under general anesthesia. This study was undertaken to verify whether or not bleeding rates changed after bipolar coagulation was replaced by suture ligation to achieve hemostasis at a single institution. The charts of all patients who had undergone tonsillectomy between April 1, 2007, and April 30, 2013, at our institution were reviewed. The tonsils were bluntly dissected with scissors and a rasp. While hemostasis was achieved with bipolar coagulation during the first 36 months (group A), this method was replaced after a transition period of 1 month by intraoperative suture ligation (group B) during the last 36 months. Group A encompassed 2,137 patients including 963 children scheduled for adenotonsillectomy (ATE), and group B consisted of 1,521 patients and included 435 ATE cases. Bleeding from the tonsillar wounds occurred in 111/2,137 group A (5.2 %) and 68/1,521 group B patients (4.5 %). The difference was not found to be significant (p = 0.317). The incidence of primary bleeding (PB) and secondary bleeding (SB) was significantly (p = 0,000) associated with the method to achieve hemostasis: PB prevailed in group B and SB prevailed in group A. The overall incidence of post-tonsillectomy hemorrhage (PTH) varied at different ages, but the difference was not significant in group A (p = 0.401) and group B (p = 0.661). Repeated episodes of PTH occurred in 11/111 group A (9.9 %) and 8/68 group B (11.7 %) patients. The statistical difference was not found to be significant (p = 0.725). However, there were significantly more male patients with bleeding complications in both groups. Despite the strongest efforts to avoid it, the potential risk of PTH remains a fact to be accepted by surgeons and patients. An increased surgical precision achieved by introduction of a surgical microscope as well as replacing bipolar cautery by suture ligation to achieve hemostasis could only reduce the overall rate of PTH. Another fact remains unchanged: PB occurs predominantly when electrosurgical means are avoided and SB prevails, whenever surgeons use them. We will continue our research on refined methods of cold steel microsurgical TE including suture techniques.

Development and validation of an objective instrument to measure surgical performance at tonsillectomy.

PubMed

Roberson, David W; Kentala, Erna; Forbes, Peter

2005-12-01

The goals of this project were 1) to develop and validate an objective instrument to measure surgical performance at tonsillectomy, 2) to assess its interobserver and interobservation reliability and construct validity, and 3) to select those items with best reliability and most independent information to design a simplified form suitable for routine use in otolaryngology surgical evaluation. Prospective, observational data collection for an educational quality improvement project. The evaluation instrument was based on previous instruments developed in general surgery with input from attending otolaryngologic surgeons and experts in medical education. It was pilot tested and subjected to iterative improvements. After the instrument was finalized, a total of 55 tonsillectomies were observed and scored during academic year 2002 to 2003: 45 cases by residents at different points during their rotation, 5 by fellows, and 5 by faculty. Results were assessed for interobserver reliability, interobservation reliability, and construct validity. Factor analysis was used to identify items with independent information. Interobserver and interobservation reliability was high. On technical items, faculty substantially outperformed fellows, who in turn outperformed residents (P < .0001 for both comparisons). On the "global" scale (overall assessment), residents improved an average of 1 full point (on a 5 point scale) during a 3 month rotation (P = .01). In the subscale of "patient care," results were less clear cut: fellows outperformed residents, who in turn outperformed faculty, but only the fellows to faculty comparison was statistically significant (P = .04), and residents did not clearly improve over time (P = .36). Factor analysis demonstrated that technical items and patient care items factor separately and thus represent separate skill domains in surgery. It is possible to objectively measure surgical skill at tonsillectomy with high reliability and good construct validity. Factor analysis demonstrated that patient care is a distinct domain in surgical skill. Although the interobserver reliability for some patient care items reached statistical significance, it was not high enough for "high stakes testing" purposes. Using reliability and factor analysis results, we propose a simplified instrument for use in evaluating trainees in otolaryngologic surgery.

Effects of intraoperative dexmedetomidine with intravenous anesthesia on postoperative emergence agitation/delirium in pediatric patients undergoing tonsillectomy with or without adenoidectomy: A CONSORT-prospective, randomized, controlled clinical trial.

PubMed

Cao, Jun-Li; Pei, Yu-Ping; Wei, Jing-Qiu; Zhang, Yue-Ying

2016-12-01

Postoperative emergence agitation/delirium (POED) is a common complication in pediatric surgery patients, which increases the risk of developing postoperative airway obstruction and respiratory depression. This study aims to investigate the safety and efficacy of intraoperative infusion of dexmedetomidine (DEX) and its effects on POED in pediatric patients undergoing tonsillectomy with or without adenoidectomy.Sixty patients scheduled for tonsillectomy with or without adenoidectomy, aged 2 to 8 years, were randomly allocated into 2 groups (n = 30). Pediatric patients in the group DEX received intravenous (IV) DEX 1 μg/kg over 10 minutes, followed by 0.5 μg/kg/h continuous infusion, and the same volume of 0.9% saline was administrated in the group control. Anesthesia was maintained with target-controlled infusion (TCI) of propofol and remifentanyl. Intraoperative heart rate (HR), noninvasive blood pressure (NIBP), blood oxygen saturation (SPO2), recovery time, and extubation time were recorded. Pain level was evaluated using the objective pain score (OPS), pediatric anesthesia emergence delirium (PAED) scale and Cole 5-point scale (CPS) was used to evaluate POED when patients at 0, 5, 15 minutes, and then at intervals of 15 minutes for 60 minutes after parents arrival at postanesthesia care unit (PACU).The results showed that intraoperative HR was significantly lower in group DEX (P <0.05), mean diastolic and systolic NIBP was not statistically different between groups. Time to wake and time to extubation were lengthened in group DEX as compared with group control (P <0.05). OPS and CPS were lower in group DEX at 15, 30, and 45 minutes time points (P <0.05); however, there were no significantly differences in the PAED score at different time points in the PACU.The present data suggested that intraoperative infusion of dexmedetomidine combined with intravenous anesthetics can provide satisfactory intraoperative conditions for pediatric patients undergoing tonsillectomy with or without adenoidectomy, without adverse hemodynamic effects, though the lower incidence of POED was not observed.

Tonsillitis (For Parents)

MedlinePlus

... streptococci bacteria are causing the infection. If it's strep throat , your child will need treatment with an antibiotic ... Tonsils and Tonsillectomies Peritonsillar Abscess Strep Test: Rapid Strep Throat Strep Test: Throat Culture Enlarged Adenoids Having Your ...

Second branchial cleft fistulae: patient characteristics and surgical outcome.

PubMed

Kajosaari, Lauri; Mäkitie, Antti; Salminen, Päivi; Klockars, Tuomas

2014-09-01

Second branchial cleft anomalies predispose to recurrent infections, and surgical resection is recommended as the treatment of choice. There is no clear consensus regarding the timing or surgical technique in the operative treatment of these anomalies. Our aim was to compare the effect of age and operative techniques to patient characteristics and treatment outcome. A retrospective study of pediatric patients treated for second branchial sinuses or fistulae during 1998-2012 at two departments in our academic tertiary care referral center. Comparison of patient characteristics, preoperative investigations, surgical techniques and postoperative sequelae. Our data is based on 68 patients, the largest series in the literature. One-fourth (24%) of patients had any infectious symptoms prior to operative treatment. Patient demographics, preoperative investigations, use of methylene blue, or tonsillectomy had no effect on the surgical outcome. There were no re-operations due to residual disease. Three complications were observed postoperatively. Our patient series of second branchial cleft sinuses/fistulae is the largest so far and enables analyses of patient characteristics and surgical outcomes more reliably than previously. Preoperative symptoms are infrequent and mild. There was no difference in clinical outcome between the observed departments. Performing ipsilateral tonsillectomy gave no outcome benefits. The operation may be delayed to an age of approximately three years when anesthesiological risks are and possible harms are best avoided. Considering postoperative pain and risk of postoperative hemorrhage a routine tonsillectomy should not be included to the operative treatment of second branchial cleft fistulae. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.

Efficacy of ketamine in improving pain after tonsillectomy in children: meta-analysis.

PubMed

Cho, Hye Kyung; Kim, Kyu Won; Jeong, Yeon Min; Lee, Ho Seok; Lee, Yeon Ji; Hwang, Se Hwan

2014-01-01

The goal of this meta-analysis study was to perform a systematic review of the literature on the effects of ketamine on postoperative pain following tonsillectomy and adverse effects in children. Two authors independently searched three databases (MEDLINE, SCOPUS, Cochrane) from their inception of article collection to February 2014. Studies that compared preoperative ketamine administration (ketamine groups) with no treatment (control group) or opioid administration (opioid group) where the outcomes of interest were postoperative pain intensity, rescue analgesic consumption, or adverse effects (sedation, nausea and vomiting, bad dream, worsening sleep pattern, and hallucination) 0-24 hours after leaving the operation room were included in the analysis. The pain score reported by the physician during first 4 hours and need for analgesics during 24 hours postoperatively was significantly decreased in the ketamine group versus control group and was similar with the opioid group. In addition, there was no significant difference between ketamine and control groups for adverse effects during 24 hours postoperatively. In the subgroup analyses (systemic and local administration) regarding pain related measurements, peritonsillar infiltration of ketamine was more effective in reducing the postoperative pain severity and need for analgesics. Preoperative administration of ketamine systemically or locally could provide pain relief without side-effects in children undergoing tonsillectomy. However, considering the insufficient evaluation of efficacy of ketamine according to the administration methods and high heterogeneity in some parameters, further clinical trials with robust research methodology should be conducted to confirm the results of this study.

Tonsillectomy remains a questionable option for pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS).

PubMed

Windfuhr, Jochen P

2016-01-01

Background: Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) is a disease attributed to children with obsessive compulsive disorders (OCD) or tic disorders associated with streptococcal infections. Because otolaryngologists examine a large number of pediatric patients with recurrent streptococcal infections, tonsillectomy (TE) is a common option of therapy. This study was conducted to evaluate the efficacy of TE in patients presenting with verified PANDAS. Material and methods: A PubMed review was performed using search terms "tonsillectomy" and "PANDAS", "OCD", "compulsive" "pediatric autoimmune", "chorea" and "tic" limited by publication date of January 1, 1995, to July 31, 2015. Reviews without patients were not included in the review. Results: Nine papers matched our search criteria, including 6 case reports with 8 patients and 3 case series. Most case reports were in favor of TE, but this was by far not supported by the findings in the case series. The follow-up ranged from 2 to 36 months in case reports and from 24 to 36 in case series. Conclusion: Establishing the diagnosis of PANDAS is complicated because of underlying comorbidities in the field of neurology-psychiatry and the lack of a reliable biomarker. The positive outcome after TE as reported in case studies may be influenced by the postoperative medication and is not supported by the results of large-scale studies. In the light of the considerable postoperative morbidity rate, it appears wise to indicate TE for PANDAS only in supervised clinical studies.

PANDAS: A systematic review of treatment options.

PubMed

Farhood, Zachary; Ong, Adrian A; Discolo, Christopher M

2016-10-01

Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcus (PANDAS) is a rare but important condition for pediatric otolaryngologists to recognize. Several treatment options exist including tonsillectomy, antibiotic treatment/prophylaxis, intravenous immunoglobulin (IVIG), and psychiatric medications/therapy. A systematic review of the PubMed, EMBASE, and Scopus databases was performed searching for articles that focused exclusively on the aforementioned treatment modalities in the PANDAS population. Review articles, single patient case reports, and studies examining the natural history or diagnostic strategies were excluded. Five articles regarding tonsillectomy treatments with level of evidence (LOE) 4 were found but no clear benefit could be determined. Three articles were selected involving the use of antibiotic therapy. One prospective study and one double-blind randomized control trial (DB RCT) supported the use of antibiotics but a separate DB RCT showed no benefit. Two selected articles described the use of IVIG: one unblinded RCT and one retrospective study. One prospective study on cognitive-behavioral therapy (CBT) showed benefit in PANDAS. There is a paucity of high-level studies regarding this rare disorder and no hard treatment recommendations can be made. Tonsillectomy should only be performed in those who are surgical candidates based on current published guidelines. Antibiotics are an option but provide uncertain benefit. CBT remains a low-risk option. Studies support the use of IVIG, however more investigation is needed prior to widespread adoption of this treatment given its potential risks. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

Carboxyhaemoglobin formation and ECG changes during hysteroscopic surgery, transurethral prostatectomy and tonsillectomy using bipolar diathermy.

PubMed

Overdijk, L E; van Kesteren, P J M; de Haan, P; Schellekens, N C J; Dijksman, L M; Hovius, M C; van den Berg, R G; Bakkum, E A; Rademaker, B M P

2015-03-01

Diathermy is known to produce a mixture of waste products including carbon monoxide. During transcervical hysteroscopic surgery, carbon monoxide might enter the circulation leading to the formation of carboxyhaemoglobin. In 20 patients scheduled for transcervical hysteroscopic resection of myoma or endometrium, carboxyhaemoglobin was measured before and at the end of the surgical procedure, and compared with levels measured in 20 patients during transurethral prostatectomy, and in 20 patients during tonsillectomy. Haemodynamic data, including ST-segment changes, were recorded. Levels of carboxyhaemoglobin increased significantly during hysteroscopic surgery from median (IQR [range]) 1.0% (0.7-1.4 [0.5-4.9])% to 3.5% (2.0-6.1 [1.3-10.3]%, p < 0.001), compared with levels during prostatectomy or tonsillectomy. Significant ST-segment changes were observed in 50% of the patients during hysteroscopic surgery. Significant correlations were observed between the increase in carboxyhaemoglobin and the maximum ST-segment change (ρ = -0.707, p < 0.01), between the increase in carboxyhaemoglobin and intravasation (ρ = 0.625; p < 0.01), and between intravasation and the maximum ST-segment change (ρ = -0.761; p < 0.01). The increased carboxyhaemoglobin levels during hysteroscopic surgery appear to be related to the amount of intravasation and this could potentially be a contributing factor to the observed ST-segment changes. © 2014 The Association of Anaesthetists of Great Britain and Ireland.

The functional role of the tonsils in speech.

PubMed

Finkelstein, Y; Nachmani, A; Ophir, D

1994-08-01

To present illustrative cases showing various tonsillar influences on speech and to present a clinical method for patient evaluation establishing concepts of management and a rational therapeutic approach. The cases were selected from a group of approximately 1000 patients referred to the clinic because of suspected palatal diseases. Complete velopharyngeal assessment was made, including otolaryngologic, speech, and hearing examinations, polysomnography, nasendoscopy, multiview videofluoroscopy, and cephalometry. New observations further elucidate the intimate relation between the tonsils and the velopharyngeal valve. The potential influence of the tonsils on the velopharyngeal valve mechanism, in hindering or assisting speech, is described. In selected cases, the decision to perform tonsillectomy depends on its potential effect on speech. The combination of nasendoscopic and multiview videofluoroscopic studies of the mechanical properties of the tonsils during speech is required for patients who present with velopharyngeal insufficiency in whom tonsillar hypertrophy is found. These studies are also required in patients with palatal anomalies who are candidates for tonsillectomy.

Tonsillar Surface Micro Flora: Does it Truly Represent Pathological Tonsillar Flora?

PubMed

Haq, Syed Nadeem Ul; Ayub, Zeeshan; Ahmed, Azeema

2017-01-01

To determine the best method of identifying core tonsillar flora. Quasi-experimental study. ENT Department, Combined Military Hospital, Lahore, from September 2013 to October 2015. Eighty-seven patients of recurrent tonsillitis undergoing tonsillectomy were included. All the patients, after being anaesthetised, had surface swabs taken from the tonsillar surface followed by tonsillar aspiration with a 5cc syringe. Following tonsillectomy, the tonsils were sent for culture of core flora. All three specimens from each patient were cultured according to established criteria. The patient population had 33 (37%) female and 54 (62%) male patients. Flora of 12 (13.8%) surface swabs and 68 (78.2%) tonsillar aspirates matched the flora cultured from core of the tonsils. Chi-square test showed this difference to be significant (p-value <0.001). Tonsillar aspiration gave a much more realistic picture of the tonsillar core flora as compared to surface swabs.

Postoperative bradycardia following adenotonsillectomy in children: Does intraoperative administration of dexmedetomidine play a role?

PubMed

Bush, Benjamin; Tobias, Joseph D; Lin, Chen; Ruda, James; Jatana, Kris R; Essig, Garth; Cooper, Jennifer; Tumin, Dmitry; Elmaraghy, Charles A

2018-01-01

Dexmedetomidine is a novel pharmacologic agent that has become a frequently used adjunct during care of pediatric patients with obstructive sleep apnea (OSA) undergoing tonsillectomy. While generally safe and effective, dexmedetomidine is associated with adverse effects of hypotension and bradycardia from its central sympatholytic effects. Due to safety concerns, our institution routinely admits patients with OSA for overnight cardiorespiratory monitoring following tonsillectomy. With such monitoring, we have anecdotally noted bradycardia in our patients and sought to investigate whether this was related to the increased use of intra-operative dexmedetomidine. We retrospectively reviewed records over an 11-month period to compare the incidence of postoperative bradycardia following hospital admission for tonsillectomy in patients who received dexmedetomidine versus those who did not. The study cohort included 921 patients (371 received dexmedetomidine and 550 did not). Bradycardia was asymptomatically noted in 66 patients (7.2%). No patient required medical intervention for the bradycardia or developed clinical symptoms. There was no association of bradycardia with the intra-operative administration of dexmedetomidine (8.9% of patients who received dexmetomidine vs. 9.4% who did not). In multivariable analysis, bradycardia was more common among older patients, with the administration of topical or injected lidocaine, and with specific associated procedures (inferior turbinate coblation with out-fracture or direct laryngoscopy and bronchoscopy). The increased incidence of asymptomatic bradycardia in our post-adenotonsillectomy patients seemed to relate more to increased utilization of postoperative cardiac telemetry, and did not appear associated with the use of dexmedetomidine use intra-operatively. Copyright © 2017 Elsevier B.V. All rights reserved.

Novel Associations between FAAH Genetic Variants and Postoperative Central Opioid related Adverse Effects

PubMed Central

Sadhasivam, Senthilkumar; Zhang, Xue; Chidambaran, Vidya; Mavi, Jagroop; Pilipenko, Valentina; Mersha, Tesfaye B.; Meller, Jaroslaw; Kaufman, Kenneth M.; Martin, Lisa J.; McAuliffe, John

2014-01-01

Opioid effects are potentiated by cannabinoid agonists including anandamide, an endocannabinoid. Inter-individual variability in responses to opioids is a major clinical problem. Multiple deaths and anoxic brain injuries occur every year in due to opioid induced respiratory depression in surgical patients and drug abusers of opioids and cannabinoids. This study aimed to determine specific associations between genetic variants of fatty acid amide hydrolase (FAAH) and postoperative central opioid adverse effects in children undergoing tonsillectomy. This is a prospective genotype blinded observational study 259 healthy children between 6 and 15 years that received standard perioperative care with a standard anesthetic and an intraoperative dose of morphine were enrolled. Associations between frequent polymorphisms of FAAH and central postoperative opioid adverse effects including, respiratory depression (RD), postoperative nausea and vomiting (PONV) and prolonged stay in Post Anesthesia Recovery Room (PACU) due to RD and PONV were analyzed. Five specific FAAH SNPs had significant associations with more than 2 fold increased risk for refractory PONV (adjusted p<0.0018), and nominal associations (p<0.05) with RD and prolonged PACU stay in white children undergoing tonsillectomy. FAAH SNP, rs324420 is a missense mutation with altered FAAH function and it is linked with other FAAH SNPs associated with PONV and RD in our cohort; association between PONV and rs324420 was confirmed in our extended cohort with additional 66 white children. Specific FAAH polymorphisms are associated with refractory PONV, opioid-related respiratory depression, and prolonged PACU stay due to opioid adverse effects in white children undergoing tonsillectomy. PMID:25558980

Salivary cotinine levels in children with otolaryngological disorders.

PubMed

Clark, Christine M; Printz, Jillian N; Stahl, Lauren E; Phillips, Brett E; Carr, Michele M

2017-11-01

To determine if salivary cotinine, a biomarker for tobacco smoke exposure, is elevated more often or to a higher degree in children meeting criteria for tonsillectomy or tympanostomy tube insertion. Saliva samples were obtained from 3 groups of children for salivary cotinine measurement. Group 1 served as healthy controls. Group 2 consisted of subjects meeting tympanostomy tube criteria. Group 3 consisted of patients meeting tonsillectomy criteria. Environmental tobacco smoke (ETS) exposure was defined as a salivary cotinine concentration ≥1.0 ng/mL. Demographic data, smoke exposure history, and co-morbidities were also determined. 331 patients were included, with 112 in Group 1, 111 in Group 2, and 108 in Group 3. No differences were encountered for smoke exposure by history or smoker's identity, salivary cotinine level, or frequency of positive cotinine results. 42.6% of Group 1 had positive salivary cotinine compared to 51.8% of Group 2 and 47.7% of Group 3. Group 1 had a mean salivary cotinine level of 2.42 ng/mL compared to 2.54 ng/mL in Group 2 and 2.60 ng/mL in Group 3. The frequency of positive cotinine levels was higher than expected based on parental history. Among subjects with positive cotinine levels, 93 had no ETS exposure, and 64 had ETS exposure by history. Approximately 50% of children who undergo tonsillectomy and tympanostomy tube insertion have objective evidence of ETS exposure. Parental history underestimates passive smoke exposure, which can impact perioperative care. Copyright © 2017 Elsevier B.V. All rights reserved.

Efficacy of Ketamine in Improving Pain after Tonsillectomy in Children: Meta-Analysis

PubMed Central

Cho, Hye Kyung; Kim, Kyu Won; Jeong, Yeon Min; Lee, Ho Seok; Lee, Yeon Ji; Hwang, Se Hwan

2014-01-01

Background and objectives The goal of this meta-analysis study was to perform a systematic review of the literature on the effects of ketamine on postoperative pain following tonsillectomy and adverse effects in children. Subjects and Methods Two authors independently searched three databases (MEDLINE, SCOPUS, Cochrane) from their inception of article collection to February 2014. Studies that compared preoperative ketamine administration (ketamine groups) with no treatment (control group) or opioid administration (opioid group) where the outcomes of interest were postoperative pain intensity, rescue analgesic consumption, or adverse effects (sedation, nausea and vomiting, bad dream, worsening sleep pattern, and hallucination) 0–24 hours after leaving the operation room were included in the analysis. Results The pain score reported by the physician during first 4 hours and need for analgesics during 24 hours postoperatively was significantly decreased in the ketamine group versus control group and was similar with the opioid group. In addition, there was no significant difference between ketamine and control groups for adverse effects during 24 hours postoperatively. In the subgroup analyses (systemic and local administration) regarding pain related measurements, peritonsillar infiltration of ketamine was more effective in reducing the postoperative pain severity and need for analgesics. Conclusion Preoperative administration of ketamine systemically or locally could provide pain relief without side-effects in children undergoing tonsillectomy. However, considering the insufficient evaluation of efficacy of ketamine according to the administration methods and high heterogeneity in some parameters, further clinical trials with robust research methodology should be conducted to confirm the results of this study. PMID:24979227

Pain after pediatric otorhinolaryngologic surgery: a prospective multi-center trial.

PubMed

Guntinas-Lichius, Orlando; Volk, Gerd Fabian; Geissler, Katharina; Komann, Marcus; Meissner, Winfried

2014-07-01

The purpose of this study was to describe postoperative pain within the first day after pediatric otorhinolaryngologic surgery and to identify factors influencing postoperative pain. Using a prospective evaluation and a Web-based multi-center registry, children ≥4 years of age (n = 365) rated their pain using questionnaires of the project Quality Improvement in Postoperative Pain Treatment for Children including faces numeric rating scales (FNRS, 0-10) for the determination of patient's pain on ambulation and his/her maximal and minimal pain within 8 h after day case surgery or at the first postoperative day for inpatient cases. Additionally, functional interference and therapy-related side effects were assessed. Half of the children were 4 or 5 years of age. The predominant types of surgery were adenoidectomy and tonsillectomy ± ear ventilation tubes. Although analgesics were applied preoperatively, intraoperatively, in the recovery room and on ward, maximal pain within the first day after surgery reached 4.4 ± 3.3 (FNRS). Pain was highest after oral surgery, especially after tonsillectomy and nose surgery. 39% of the children reported pain interference with breathing (39%). The most frequent side effect was drowsiness (55%). Multivariate analysis revealed that maximal pain was independently associated with the non-standardized use of opioids in the recovery room, or use of non-opioid or opioids on ward. Analgesia and perioperative pain management in pediatric otorhinolaryngologic surgery seems to be highly variable. Tonsillectomy and nose surgery are very painful. After otorhinolaryngologic surgery many children seem to receive less analgesia than needed or ineffective analgesic drug regimes.

The Efficacy of Perioperative Antibiotic Therapy in Tonsillectomy Patients.

PubMed

Orłowski, Krzysztof; Lisowska, Grażyna; Misiołek, Hanna; Paluch, Zbigniew; Misiołek, Maciej

2016-01-01

While the results of early research suggested that perioperative antibiotic prophylaxis in tonsillectomy patients is associated with many benefits, these data were not confirmed by further studies and meta-analyses. The aim of this study was to investigate the usefulness and efficacy of antibiotic monotherapy in the healing of surgical wounds of patients undergoing bilateral resection of the palatine tonsils, based on an analysis of selected objective and subjective characteristics of wound healing during the postoperative period. The study included 50 men and women who underwent routine resection of the palatine tonsils. The patients were randomized into two groups: Group I, undergoing tonsillectomy with cefuroxime prophylaxis (n = 25), and Group II, who were not given perioperative antibiotic therapy (n = 25). The severity of signs and complaints recorded on postoperative days 1-10 was scored on 3- and 10-item scales. The only significant intergroup differences pertained to problems with swallowing food and fluids on postoperative days 4-6, 8 and 9 (less prevalent in Group II), postoperative use of analgesics on postoperative day 9 (less frequent in Group II), the degree of mucosal swelling in the operated area on postoperative days 3 and 7 (less severe in Group II), and the amount of fibrin covering the tonsillar niches on the third postoperative day (significantly higher in Group I). The administration of antibiotics for prevention or control of infection should be preceded by a comprehensive analysis of the potential benefits and risks. Perioperative use of antibiotics is justified only in selected cases, i.e. in individuals with comorbidities.

Automatic anatomy recognition in post-tonsillectomy MR images of obese children with OSAS

NASA Astrophysics Data System (ADS)

Tong, Yubing; Udupa, Jayaram K.; Odhner, Dewey; Sin, Sanghun; Arens, Raanan

2015-03-01

Automatic Anatomy Recognition (AAR) is a recently developed approach for the automatic whole body wide organ segmentation. We previously tested that methodology on image cases with some pathology where the organs were not distorted significantly. In this paper, we present an advancement of AAR to handle organs which may have been modified or resected by surgical intervention. We focus on MRI of the neck in pediatric Obstructive Sleep Apnea Syndrome (OSAS). The proposed method consists of an AAR step followed by support vector machine techniques to detect the presence/absence of organs. The AAR step employs a hierarchical organization of the organs for model building. For each organ, a fuzzy model over a population is built. The model of the body region is then described in terms of the fuzzy models and a host of other descriptors which include parent to offspring relationship estimated over the population. Organs are recognized following the organ hierarchy by using an optimal threshold based search. The SVM step subsequently checks for evidence of the presence of organs. Experimental results show that AAR techniques can be combined with machine learning strategies within the AAR recognition framework for good performance in recognizing missing organs, in our case missing tonsils in post-tonsillectomy images as well as in simulating tonsillectomy images. The previous recognition performance is maintained achieving an organ localization accuracy of within 1 voxel when the organ is actually not removed. To our knowledge, no methods have been reported to date for handling significantly deformed or missing organs, especially in neck MRI.

Tonsillectomy Versus Watchful Waiting for Recurrent Throat Infection: A Systematic Review

PubMed Central

Morad, Anna; Sathe, Nila A.; Francis, David O.; McPheeters, Melissa L.

2017-01-01

CONTEXT: The effectiveness of tonsillectomy or adenotonsillectomy (“tonsillectomy”) for recurrent throat infection compared with watchful waiting is uncertain. OBJECTIVE: To compare sleep, cognitive, behavioral, and health outcomes of tonsillectomy versus watchful waiting in children with recurrent throat infections. DATA SOURCES: MEDLINE, Embase, and the Cochrane Library. STUDY SELECTION: Two investigators independently screened studies against predetermined criteria. DATA EXTRACTION: One investigator extracted data with review by a second. Investigators independently assessed risk of bias and strength of evidence (SOE) and confidence in the estimate of effects. RESULTS: Seven studies including children with ≥3 infections in the previous 1 to 3 years addressed this question. In studies reporting baseline data, number of infections/sore throats decreased from baseline in both groups, with greater decreases in sore throat days, clinician contacts, diagnosed group A streptococcal infections, and school absences in tonsillectomized children in the short term (<12 months). Quality of life was not markedly different between groups at any time point. LIMITATIONS: Few studies fully categorized infection/sore throat severity; attrition was high. CONCLUSIONS: Throat infections, utilization, and school absences improved in the first postsurgical year in tonsillectomized children versus children not receiving surgery. Benefits did not persist over time; longer-term outcomes are limited. SOE is moderate for reduction in short-term throat infections and insufficient for longer-term reduction. SOE is low for no difference in longer-term streptococcal infection reduction. SOE is low for utilization and missed school reduction in the short term, low for no difference in longer-term missed school, and low for no differences in quality of life. PMID:28096515

The effect of IV dexamethasone versus local anesthetic infiltration technique in postoperative nausea and vomiting after tonsillectomy in children: A randomized double-blind clinical trial.

PubMed

Naja, Zoher; Kanawati, Saleh; Al Khatib, Rania; Ziade, Fouad; Naja, Zeina Z; Naja, Ahmad Salah; Rajab, Mariam

2017-01-01

Local anesthetic infiltration and corticosteroids had shown effectiveness in reducing post tonsillectomy nausea, vomiting and pain. To compare the effect of intravenous dexamethasone versus pre-incision infiltration of local anesthesia in pediatric tonsillectomy on postoperative nausea and vomiting (PONV). The secondary objective was postoperative pain. A randomized double-blind clinical trial was conducted at a tertiary care teaching hospital. Children admitted to undergo tonsillectomy aged between 4 and 13 years from January 2015 to August 2015 were enrolled and divided into two groups. Both groups had general anesthesia. Group I received intravenous dexamethasone 0.5 mg/kg (maximum dose 16 mg) with placebo pre-incision infiltration. Group II received pre-incision infiltration a total of 2-4 ml local anesthesia mixture with saline and an equivalent volume of intravenous saline. Group I consisted of 64 patients while group II had 65 patients. In the PACU, 15.6% of patients in group I experienced vomiting compared to 3.1% in group II (p-value = 0.032). After 24 h, the incidence of PONV was significantly higher in group I compared to group II (26.6% vs. 9.2% respectively, p-value = 0.019). At 48 h postoperatively, PONV was significantly higher in group I (p-value = 0.013). The incidence was similar in both groups after three, four and five postoperative days. Baseline pain and pain during swallowing were significantly different at 6, 12 and 24 h as well as days 1 through 5. Pain upon jaw opening was significantly different at 6, 12 and 24 h between the two groups. Pain while eating soft food was significantly different at 24 h and days 2 through 5. In the PACU, 20.3% of patients in group I received diclofenac compared to 3.1% in group II (p-value = 0.005). From day 1 till day 5, analgesic consumption was significantly higher in group I. Local anesthetic infiltration in addition to NSAIDS and paracetamol could serve as a multimodal analgesia and decrease PONV. NCT02355678. Copyright © 2016. Published by Elsevier Ireland Ltd.

The effect of intraoperative dexmedetomidine on postoperative analgesia and sedation in pediatric patients undergoing tonsillectomy and adenoidectomy.

PubMed

Olutoye, Olutoyin A; Glover, Chris D; Diefenderfer, John W; McGilberry, Michael; Wyatt, Matthew M; Larrier, Deidre R; Friedman, Ellen M; Watcha, Mehernoor F

2010-08-01

The immediate postoperative period after tonsillectomy and adenoidectomy, one of the most common pediatric surgical procedures, is often difficult. These children frequently have severe pain but postoperative airway edema along with increased sensitivity to the respiratory-depressant effects of opioids may result in obstructive symptoms and hypoxemia. Opioid consumption may be reduced by nonsteroidal antiinflammatory drugs, but these drugs may be associated with increased bleeding after this operation. Dexmedetomidine has mild analgesic properties, causes sedation without respiratory depression, and does not have an effect on coagulation. We designed a prospective, double-blind, randomized controlled study to determine the effects of intraoperative dexmedetomidine on postoperative recovery including pain, sedation, and hemodynamics in pediatric patients undergoing tonsillectomy and adenoidectomy. One hundred nine patients were randomized to receive a single intraoperative dose of dexmedetomidine 0.75 microg/kg, dexmedetomidine 1 microg/kg, morphine 50 microg/kg, or morphine 100 microg/kg over 10 minutes after endotracheal intubation. There were no significant differences among the 4 groups in patient demographics, ASA physical status, postoperative opioid requirements, sedation scores, duration of oxygen supplementation in the postanesthetic care unit, and time to discharge readiness. The median time to first postoperative rescue analgesic was similar in patients receiving dexmedetomidine 1 microg/kg and morphine 100 microg/kg, but significantly longer compared with patients receiving dexmedetomidine 0.75 microg/kg or morphine 50 microg/kg (P < 0.01). In addition, the number of patients requiring >1 rescue analgesic dose was significantly higher in the dexmedetomidine 0.75 microg/kg group compared with the dexmedetomidine 1 microg/kg and morphine 100 microg/kg groups, but not the morphine 50 microg/kg group. Patients receiving dexmedetomidine had significantly slower heart rates in the first 30 minutes after surgery compared with those receiving morphine (P < 0.05). There was no significant difference in sedation scores among the groups. The total postoperative rescue opioid requirements were similar in tonsillectomy patients receiving intraoperative dexmedetomidine or morphine. However, the use of dexmedetomidine 1 microg/kg and morphine 100 microg/kg had the advantages of an increased time to first analgesic and a reduced need for additional rescue analgesia doses, without increasing discharge times.

Malpractice claims and unintentional outcome of tonsil surgery and other standard procedures in otorhinolaryngology

PubMed Central

Windfuhr, Jochen P.

2015-01-01

Background: Septoplasty, tonsillectomy (with and without adenoidectomy) and cervical lymph node excision are amongst the most common 50 inpatient operations in Germany. Intracapsular tonsillectomies (i.e. tonsillotomies) are increasingly performed. The aim of this study was to evaluate technical traps and pitfalls as well as alleged medical malpractice associated with tonsillectomy (TE), adenoidectomy (AE), tonsillotomy (TT), septoplasty (SP) and cervical lymph node excision (LN). Methods: A questionnaire was sent to the Regional Medical Conciliation Boards, Medical Services of the Health Insurance Companies (MDK) and Regional Institutes of Forensic Medicine in Germany to collect anonymized cases of complications following TE, TT, AE, LN and SP. The results were discussed in the light of the contemporary medical literature and published trials and verdicts in Germany. Results: The response rate of our survey was 55.9%. The Institutes of Forensic Medicine contributed nine cases, 49 cases were submitted by the Regional Conciliation Boards and none by MDK. All forensic cases were associated with exsanguinations following tonsillectomy including two children (5 and 8 years of age) and seven adults (aged 20 to 69 years). The fatal post-tonsillectomy hemorrhage (PTH) had occurred 8.7 days on average; four patients experienced the bleeding episode at home (day 5, 8, 9 and 17, respectively). Repeated episodes of bleeding requiring surgical intervention had occurred in 6 patients. Three Conciliation Boards submitted decicions associated with TT (1), AE (4), LN (3), SP (16) and TE (25). Cases with lethal outcome were not registered. Only three of the 49 cases were assessed as surgical malpractice (6.1%) including lesion of the spinal accessory nerve, wrong indication for TE and dental lesion after insertion of the mouth gag. The review of the medico legal literature yielded 71 published verdicts after AE and TE (29), LN (28) and SP (14) of which 37 resulted in compensation of malpractice after LN (16; 57%), TE (10; 37%), SP (8; 57%) and AE (2; 100%). There were 16 cases of PTH amongst 27 trials after TE resulting either in death (5) or apallic syndrome (5). Bleeding complications had occurred on the day of surgery in only 2 patients. 16 trials were based on malpractice claims following SP encompassing lack of informed consent (6), anosmia (4), septal perforation (2), frontobasal injury (2) and dry nose (2). Trials after LN procedures were associated exclusively with a lesion of the spinal accessory nerve (28), including lack of informed consent in 19 cases. 49 cases (69%) were decided for the defendant, 22 (31%) were decided for the plaintiff with monetary compensation in 7 of 29 AE/TE-trials, 9 of 28 LN-trials and 6 of 14 SP-trials. Lack of informed consent was not registered for AE/TE but LN (11) and SP (2). Conclusion: Complicated cases following TE, TT, ATE, SP and LN are not systematically collected in Germany. It can be assumed, that not every complicated case is published in the medical literature or law journals and therefore not obtainable for scientific research. Alleged medical malpracice is proven for less than 6% before trial stage. Approximately half of all cases result in a plaintiff verdict or settlement at court. Proper documentation of a thourough counselling, examination, indication, informed consent and follow-up assists the surgeon in litigation. An adequate complication management of PTH is essential, including instructions for the patients/parents, instructions for the medical staff and readily available surgical instruments. Successful outcome of life-threatening PTH is widely based on a proper airway management in an interdisciplinary approach. Electrosurgical tonsillectomy techniques were repeatedly labeled as a risk factor for bleeding complications following TE. Institutions should analyse the individual PTH rate on a yearly basis. Contradictory expert opinions and verdicts of the courts concerning spinal accesory nerve lesions following LN are due to a lack of a surgical standard. PMID:24403976

Tonsillectomy in Maine: Regulation Versus Education as Modulators of Medical Care

PubMed Central

Moore, Francis D.; Pratt, Loring W.

1981-01-01

The reduction in the rate of tonsillectomy, using the state of Maine as an example, and the causes thereof are addressed. Are federal and state regulations required to change the behavior of physicians and the public, or is education of greater importance? A study of tonsillectomy in the state of Maine was based on data covering a period of approximately 30 years. The data were based on direct contact with hospitals, in which we achieved the cooperation of virtually all of the hospitals of Maine, encompassing 98% of the hospital beds. These data were placed in context by information provided by the Maine Health Data Service, and by information for the northeastern United States, for the eastern United States, and for the entire United States, from the Department of Health, Education and Welfare. The operation of tonsillectomy and its variants, including adenoidectomy, has declined remarkably in the past 30 years, most drastically in the past eight years. It now occupies only 4.5% of the total operative admissions for the State, where it formerly was 17%. It now has a populational incidence for the State of 3.3 operations per thousand population per year, whereas it formerly was at a level of about 10.0. From this study, as well as from physicians in Maine, to whom an informal questionnaire was sent, it is clear that this reduction has come about largely because of education of physicians and the public. Increased awareness by the public, pediatricians and general practitioners of the limitations of this operation has been significant. In addition, there is a general sense of improved general health of young people in Maine, with fewer chronic respiratory infections. Some negative opinions were expressed, including the possibility that peritonsillar abcesses may be more frequent in the future and that some pediatricians and general practitioners overuse antibiotics. Federal regulations, state regulations, Medicare, Medicaid, Blue Cross or Blue Shield regulations concerning tonsillectomy were not instituted at any point in the State of Maine, during the period under study. There were no alterations in payment, second opinion programs or other restrictions or constraints placed on the operation at any level of official or hospital regulation. Formerly performed in large numbers by general practitioners, family practitioners, and general surgeons, the operation(s) is now predominantly carried out by trained otolaryngologists, largely board certified. Evidence is presented to support the view that concentration of this operation in the hands of fewer, more highly trained surgical specialists has been positively associated with its sharper indications and declining frequency. The conclusion is offered that increased education of physicians, both specialists and general practitioners as well as family doctors, and of the public as a whole, is the most important single factor in producing this significant alteration in the behavior of the health care system in the State of Maine. Effective limitation of the operation to specialists has been an important feature both of this educational process and of the more rational use of the operation(s). PMID:7259351

Tonsillectomy in Maine: regulation versus education as modulators of medical care.

PubMed

Moore, F D; Pratt, L W

1981-08-01

The reduction in the rate of tonsillectomy, using the state of Maine as an example, and the causes thereof are addressed. Are federal and state regulations required to change the behavior of physicians and the public, or is education of greater importance? A study of tonsillectomy in the state of Maine was based on data covering a period of approximately 30 years. The data were based on direct contact with hospitals, in which we achieved the cooperation of virtually all of the hospitals of Maine, encompassing 98% of the hospital beds. These data were placed in context by information provided by the Maine Health Data Service, and by information for the northeastern United States, for the eastern United States, and for the entire United States, from the Department of Health, Education and Welfare. The operation of tonsillectomy and its variants, including adenoidectomy, has declined remarkably in the past 30 years, most drastically in the past eight years. It now occupies only 4.5% of the total operative admissions for the State, where it formerly was 17%. It now has a populational incidence for the State of 3.3 operations per thousand population per year, whereas it formerly was at a level of about 10.0. From this study, as well as from physicians in Maine, to whom an informal questionnaire was sent, it is clear that this reduction has come about largely because of education of physicians and the public. Increased awareness by the public, pediatricians and general practitioners of the limitations of this operation has been significant. In addition, there is a general sense of improved general health of young people in Maine, with fewer chronic respiratory infections. Some negative opinions were expressed, including the possibility that peritonsillar abcesses may be more frequent in the future and that some pediatricians and general practitioners overuse antibiotics. Federal regulations, state regulations, Medicare, Medicaid, Blue Cross or Blue Shield regulations concerning tonsillectomy were not instituted at any point in the State of Maine, during the period under study. There were no alterations in payment, second opinion programs or other restrictions or constraints placed on the operation at any level of official or hospital regulation. Formerly performed in large numbers by general practitioners, family practitioners, and general surgeons, the operation(s) is now predominantly carried out by trained otolaryngologists, largely board certified. Evidence is presented to support the view that concentration of this operation in the hands of fewer, more highly trained surgical specialists has been positively associated with its sharper indications and declining frequency. The conclusion is offered that increased education of physicians, both specialists and general practitioners as well as family doctors, and of the public as a whole, is the most important single factor in producing this significant alteration in the behavior of the health care system in the State of Maine. Effective limitation of the operation to specialists has been an important feature both of this educational process and of the more rational use of the operation(s).

Sleep-disordered breathing and its management in children with achondroplasia.

PubMed

Tenconi, Rossana; Khirani, Sonia; Amaddeo, Alessandro; Michot, Caroline; Baujat, Geneviève; Couloigner, Vincent; De Sanctis, Livio; James, Syril; Zerah, Michel; Cormier-Daire, Valérie; Fauroux, Brigitte

2017-04-01

Sleep-disordered breathing is a common feature in children with achondroplasia. The aim of our study was to review the poly(somno)graphic (P(S)G) findings and consequent treatments in children with achondroplasia followed in the national reference center for skeletal dysplasia. A retrospective review of the clinical charts and P(S)G of 43 consecutive children (mean age 3.9 ± 3.5 years) with achondroplasia seen over a period of 2 years was performed. Twenty four (59%) children had obstructive sleep apnea (OSA). Thirteen children had an obstructive apnea-hypopnea index (OAHI) < 5/hr, four had an OAHI between 5 and 10/hr, and seven had an OAHI ≥ 10/hr. Ten of the 15 children who had previous upper airway surgery still had an abnormal P(S)G. All the patients with an AHI ≥ 10/hr were under 7 years of age and none had a prior tonsillectomy. The children who underwent adeno-tonsillectomy, coupled in most cases with turbinectomy, were significantly older (mean age 7.5 ± 3.5 vs. 3.5 ± 1.7 years old, P = 0.015) and had significantly better P(S)G results than those who underwent only adeno-turbinectomy. No correlation was observed between the mean AHI value at the baseline P(S)G and the type of academic course (standard, supported or specialized). In conclusion, OSA is common in children with achondroplasia. The observation of a reduced prevalence of OSA after (adeno-)tonsillectomy is in favor of this type of surgery when possible. © 2017 Wiley Periodicals, Inc.

Midline posterior glossectomy and lingual tonsillectomy in obese and nonobese children with down syndrome: Biomarkers for success.

PubMed

Propst, Evan J; Amin, Reshma; Talwar, Natasha; Zaman, Michele; Zweerink, Allison; Blaser, Susan; Zaarour, Christian; Luginbuehl, Igor; Karsli, Cengiz; Aziza, Albert; Forrest, Christopher; Drake, James; Narang, Indra

2017-03-01

To examine outcomes following midline posterior glossectomy (MPG) plus lingual tonsillectomy (LT) for the treatment of significant obstructive sleep apnea (OSA) in children with Down syndrome (DS). Patients with DS who had persistent OSA following tonsillectomy and adenoidectomy (TA) and were relatively intolerant of positive airway pressure (PAP) therapy were evaluated by physical examination and sleep/CINE magnetic resonance imaging to determine the etiology of upper airway obstruction. Patients with relative macroglossia underwent MPG plus LT if required. Successful surgical outcome was defined as the resolution of OSA or the ability to tolerate PAP. Thirteen children (8 male, 5 female), mean (standard deviation) age 14.2 (4.0) years underwent MPG plus LT. Fifty-four percent of patients were obese (Body mass index [BMI] > 95th centile) and 8% were overweight (BMI 85th-95th centile) preoperatively. All patients underwent pre- and postoperative polysomnography. Postoperatively, the obstructive apnea-hypopnea index fell significantly from 47.0/hour to 5.6/hour (P <.05) in normal weight individuals who did not become obese, but not in obese patients or those who became obese postoperatively. Successful surgical outcome was seen in all (N = 6) children who were normal weight or overweight preoperatively compared with none who were obese preoperatively (N = 7). Midline posterior glossectomy and LT are beneficial in normal weight and overweight children with DS who have persistent OSA following TA and are intolerant of PAP therapy. Obesity pre- or postoperatively portends a worse prognosis following MPG, suggesting that aggressive weight loss initiatives should be considered as an adjunct to surgery in this population. 4. Laryngoscope, 127:757-763, 2017. © 2016 The American Laryngological, Rhinological and Otological Society, Inc.

Comparison of different administration of ketamine and intravenous tramadol hydrochloride for postoperative pain relief and sedation after pediatric tonsillectomy.

PubMed

Yenigun, Alper; Et, Tayfun; Aytac, Sirin; Olcay, Betul

2015-01-01

Tonsillectomy is the oldest and most frequently performed surgical procedure practiced by ear, nose, and throat physicians. In this study, our aim was to compare the analgesic effects of peritonsillar, rectal, as well as intravenous infiltration of ketamine and intravenous tramadol hydrochloride infiltration for postoperative pain relief and sedation after tonsillectomy in children. This randomized controlled study evaluated the effects of peritonsillar, intravenous, and rectal infiltration of ketamine in children undergoing adenotonsillectomy. One hundred twenty children who were categorized under American Society of Anesthesiologists classes I to II were randomized to 4 groups of 30 members each. Group 1 received intravenous (IV) ketamine (0.5 mg/kg), group 2 received rectal ketamine (0.5 mg/kg), group 3 received local peritonsillar ketamine (2 mg/kg), and the control group received IV tramadol hydrochloride infiltration (2 mg/kg). Children's Hospital of Eastern Ontario Pain Scale scores and Wilson sedation scale were recorded at minutes 1, 15, 30, 60 as well as hours 2, 12, and 24 postoperatively. The patients were interviewed on the day after the surgery to assess the postoperative pain and sedation. All the routes of infiltration of ketamine were as effective as those of tramadol hydrochloride (P > 0.05). A statistically significant difference was observed between IV infiltrations and all groups during the assessments at hours 6 and 24. The analgesic efficacy of IV ketamine was found especially higher at hours 6 and 24 (P(6) = 0.045, P(24) = 0.011). Perioperative, low-dose IV, rectal, or peritonsillar ketamine infiltration provides efficient pain relief without any adverse effects in children who would undergo adenotonsillectomy.

Examining the effects of enhanced provider-patient communication on postoperative tonsillectomy pain: protocol of a randomised controlled trial performed by nurses in daily clinical care.

PubMed

van Vliet, Liesbeth M; van Dulmen, Sandra; Thiel, Bram; van Deelen, Gerard W; Immerzeel, Stephanie; Godfried, Marc B; Bensing, Jozien M

2017-11-03

Placebo effects (true biopsychological effects not attributable to the active ingredients of medical technical interventions) can be attributed to several mechanisms, such as expectancy manipulation and empathy manipulation elicited by a provider's communication. So far, effects have primarily been shown in laboratory settings. The aim of this study is to determine the separate and combined effects of expectancy manipulation and empathy manipulation during preoperative and postoperative tonsillectomy analgesia care on clinical adult patients' outcomes. Using a two-by-two randomised controlled trial, 128 adult tonsillectomy patients will be randomly assigned to one out of four conditions differing in the level of expectancy manipulation (standard vs enhanced) and empathy manipulation (standard vs enhanced). Day care ward nurses are trained to deliver the intervention, while patients are treated via the standard analgesia protocol and hospital routines. The primary outcome, perceived pain, is measured via hospital routine by a Numeric Rating Scale, and additional prehospitalisation, perihospitalisation and posthospitalisation questionnaires are completed (until day 3, ie, 2 days after the operation). The manipulation is checked using audio recordings of nurse-patient interactions. Although communication is manipulated, the manipulations do not cross norms or values of acceptable behaviour. Standard medical care is provided. The ethical committee of the UMC Utrecht and the local OLVG hospital committee approved the study. Results will be published via (inter)national peer-reviewed journals and a lay publication. NTR5994; Pre-results. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Causes, costs, and risk factors for unplanned return visits after adenotonsillectomy in children.

PubMed

Duval, Melanie; Wilkes, Jacob; Korgenski, Kent; Srivastava, Rajendu; Meier, Jeremy

2015-10-01

To review the causes, costs, and risk factors for unplanned return visits and readmissions after pediatric adenotonsillectomy (T&A). Review of administrative database of outpatient adenotonsillectomy performed at any facility within a vertically integrated health care system in the Intermountain West on children age 1-18 years old between 1998 and 2012. Data reviewed included demographic variables, diagnosis associated with return visit and costs associated with return visits. Data from 39,906 children aged 1-18 years old were reviewed. A total of 2499 (6.3%) children had unplanned return visits. The most common reasons for return visits were bleeding (2.3%), dehydration, (2.3%) and throat pain (1.2%). After multivariate analysis, the main risk factors for any type of return visits were Medicaid insurance (OR=1.64 95% CI 1.47-1.84), Hispanic race (OR=1.36 95% CI 1.13-1.64), and increased severity of illness (SOI) (OR=11.29 95% CI 2.69-47.4 for SOI=3). The only factor associated with increased odds of requiring an inpatient admission on return visit was length of time spent in PACU (p<0.001). A linear relationship was also observed between the child's age and the risk of post-tonsillectomy hemorrhage. Children with increased severity of illness, those insured with Medicaid, and children of Hispanic ethnicity should be targeted with increased education and interventions in order to reduce unplanned visits after T&A. Further studies on post-tonsillectomy complications should include evaluating the effect of surgical technique and post-operative pain management on all complications and not solely post-tonsillectomy hemorrhage. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.

Appendectomy, tonsillectomy, and risk for sarcoidosis - A hospital-based case-control study in Japan.

PubMed

Sawahata, Michiru; Nakamura, Yosikazu; Sugiyama, Yukihiko

2017-05-01

The role of surgery in the onset of sarcoidosis is unclear. We investigated whether surgery is an internal environmental factor for sarcoidosis onset within the Japanese population. We enrolled 222 patients diagnosed with sarcoidosis (78 men, 144 women) who were admitted to our department between 1984 and 2012. We also enrolled 529 control subjects (251 men, 278 women), who were matched for sex, age at admission, and year of admission. Surgical history, family history, and smoking status were evaluated. Multivariate analysis correlated history of appendectomy (OR, 1.55; 95% CI, 1.05-2.29) and tonsillectomy (OR, 2.79; 95% CI, 0.91-8.56) with the occurrence of sarcoidosis; other surgical procedures had no correlation. In women, appendectomy had a stronger association with sarcoidosis (OR, 1.69; 95% CI, 1.05-2.73), as opposed to that in men (OR, 1.39; 95% CI, 0.68-2.85). This association was greater in women aged ≥45 years than in those aged <45 years. There was a stronger correlation between tonsillectomy and sarcoidosis in women (OR, 3.30; 95% CI, 0.88-12.39), than in men (OR, 1.26; 95% CI, 0.10-16.52). ORs for sarcoidosis were 5.55 (95% CI, 2.02-15.27) and 0.97 (95% CI, 0.52-1.84) in women aged ≥45 years with a history of appendectomy at <20 years and ≥20 years, respectively, with the former being statistically significant. Appendix and tonsil removal was associated with sarcoidosis onset, suggesting their potential protective role against sarcoidosis development. Further studies are needed to minimize possible confounding factors. Copyright © 2017 The Japanese Respiratory Society. Published by Elsevier B.V. All rights reserved.

Paediatric obstructive sleep apnoea: is our operative management evidence-based?

PubMed

Pabla, L; Duffin, J; Flood, L; Blackmore, K

2018-04-01

Despite the plethora of publications on the subject of paediatric obstructive sleep apnoea, there seems to be wide variability in the literature and in practice, regarding recourse to surgery, the operation chosen, the benefits gained and post-operative management. This may reflect a lack of high-level evidence. A systematic review of four significant controversies in paediatric ENT was conducted from the available literature: tonsillectomy versus tonsillotomy, focusing on the evidence base for each; anaesthetic considerations in paediatric obstructive sleep apnoea surgery; the objective evidence for the benefits of surgical treatment for obstructive sleep apnoea; and the medical treatment options for residual obstructive sleep apnoea after surgical treatment. There are many gaps in the evidence base for the surgical correction of obstructive sleep apnoea. There is emerging evidence favouring subtotal tonsillectomy. There is continuing uncertainty around the prediction of the level of post-operative care that any individual child might require. The long-term benefit of surgical correction is a particularly fertile ground for further research.

Plasma-mediated ablation for the management of obstructive sleep apnea

NASA Astrophysics Data System (ADS)

Puchalski, Robert; Shah, Udayan K.

2000-05-01

Plasma-mediated ablation (PMA) removes tissue by developing an electrically induced plasma layer between the instrument and target tissue. Charged particles within the plasma field then accelerate toward the tissue, breaking the molecular bonds within the top layer of tissue. Thermal damage to collateral tissue is minimal, resulting in the moniker, 'cold' ablation, for this method. Recently, instrumentation has been developed to permit application for soft tissue resection in Otolaryngology. Presentation of the theory, as well as the benefits and disadvantages associated with CoblationTM technology will be followed by examples of its use. A brief videotape will demonstrate the application of PMA for UPPP, tonsillectomy and nasal turbinate reduction. Preliminary experience from our institution, including eighteen children treated with tonsillectomy and followed for at least one month post-operatively, has provided an initial cohort for comparing the risks and benefits of the approach. The advantage of CoblationTM technology identified thus far, that of less thermal damage, is balanced against a decreased level of hemostasis (compared to MES) and an increased cost.

Comparison between consecutive and intermittent steroid pulse therapy combined with tonsillectomy for clinical remission of IgA nephropathy.

PubMed

Kamei, Daigo; Moriyama, Takahito; Takei, Takashi; Wakai, Sachiko; Nitta, Kosaku

2014-04-01

In recent years, tonsillectomy and steroid pulse (TSP) therapy have been widely performed in Japan. However, there is no consensus about the treatment protocol and indication. In this retrospective analysis, we compared patients who received tonsillectomy plus intermittent steroid pulse (SP) therapy three times in 6 months (ISP group, n = 44) with patients who received tonsillectomy plus 3 weeks of consecutive SP therapy (CSP group, n = 46) within 1 year after renal biopsy. These two different protocols were performed at two different institutions. We analyzed the clinical and histological background and clinical remission (CR), defined as disappearance of urine abnormalities at 18 months after starting treatment. Before treatment, there was no significant difference in the clinical findings except for sex between the two groups. In ISP group and CSP group, mean estimated glomerular filtration rate was 82.1 ± 20.9 and 85.9 ± 19.1 ml/min/1.73 m(2), median proteinuria was 0.55 and 0.56 g/day, and median urinary red blood cells were 20 (10-20) and 20 (6-30)/high power filed. The histological (H) grade was lower in the CSP than the ISP group (p = 0.022). The remission rate of proteinuria, hematuria, and rate of CR by the Kaplan-Meier method and logrank test were significantly higher in the CSP group than in the ISP group (CSP vs. ISP group; proteinuria: 97.8 vs. 77.3 %, p < 0.001, hematuria: 97.8 vs. 75.0 %, p = 0.005, CR: 95.6 vs. 63.6 %, p < 0.001). In the Cox proportional hazard model (forced entry), SP protocol and proteinuria before treatment were significantly associated with CR [SP protocol: hazard ratio (HR) 2.50, 95 % confidence interval (CI) 1.46-4.30, p = 0.001, proteinuria: HR 0.81, 95 % CI 0.68-0.96, p = 0.013)]. However H-grade was associated with remission of proteinuria (H-grade: hazard ratio (HR) 0.56, 95 % confidence interval (CI) 0.37-0.85, p = 0.006), and this result meant histological bias affected the remission of proteinuria. The difference of the protocol of TSP therapy may have some effect on the CR of IgAN, though the histological bias was observed in this study. The appropriate protocol and indication of TSP therapy must be analyzed and determined in the randomized controlled trial.

Reducation of Anxiety in Children Facing Hospitalization and Surgery by Use of Filmed Modeling

ERIC Educational Resources Information Center

Melamed, Barbara G.; Siegel, Lawrence J.

1975-01-01

A group of children (N=60) about to undergo elective surgery for hernias, tonsillectomies, or urinary-genital tract difficulties were shown on hospital admission either a relevant peer modeling film of a child being hospitalized and receiving surgery or an unrelated control film. (Author)

Severe obstructive sleep apnea in a child with osteopetrosis.

PubMed

Carter, M; Stokes, D; Wang, W

1988-02-01

The clinical features of a 5-year-old patient with osteopetrosis and severe obstructive sleep apnea are presented. The patient responded to tonsillectomy, adenoidectomy, uvulectomy, and tracheostomy. The tracheostomy was later removed. Osteopetrosis, while rare, may be added to the list of causes of obstructive sleep apnea.

Chronic cough and tonsillar hypertrophy: a case series.

PubMed

Gurgel, Richard K; Brookes, James T; Weinberger, Miles M; Smith, Richard J

2008-11-01

Two patients with intractable chronic cough were found to have tonsillar tissue impinging on their epiglottis. In both case, tonsillectomy was curative. The observations in these patients are consistent with a previous report indicating chronic cough from the uvula in contact with the epiglottis with cough cessation following uvulectomy. (c) 2008 Wiley-Liss, Inc.

[Analgesic effect of TES therapy in the early postoperative period in patients who underwent tonsillectomy].

PubMed

Semënov, F V; Kade, A Kh; Banashek-Meshchiarkova, T V; Vartanian, M S

2013-01-01

The objective of the present work was to study peculiarities of the analgesic action of therapeutic electrical stimulation (TES therapy) in the early postoperative period in the patients who underwent tonsillectomy. A total of 60 patients admitted for this surgery to the specialized otorhinolaryngological department were available for observation. They were divided into two groups depending on the pain relief strategy. The patients of the study group (n=30) underwent courses of transcranial electrical stimulation on a daily basis (from the onset of hospitalization) in addition to the administration of a standard analgetic. The standard dose of tramadol (2.0 ml) was given to the patients of the control group (n=30) who complained of strong pain. The results of the objective and subjective estimations indicate that the degree of pharyngeal pain in the patients treated with TES therapy and the standard analgetic was significantly different. The patients receiving TES therapy could sooner resume their habitual diet and required smaller amounts of the analgetic which makes this modality a cost-effective supplement to the standard postoperative treatment.

Overuse of preoperative laboratory coagulation testing and ABO blood typing: a French national study.

PubMed

Beloeil, H; Ruchard, D; Drewniak, N; Molliex, S

2017-12-01

Following publication of guidelines on routine preoperative tests, the French Society of Anaesthesiology and Intensive Care (SFAR), in association with French national public health insurance, conducted a survey to evaluate adherence to guidelines and the economic consequences. Using the French Hospital Discharge Database and National Health Insurance Information system, tests performed during the 30 days before surgery were analysed for two situations: (1) standard laboratory coagulation tests and ABO blood typing in children able to walk and scheduled for tonsillectomy/adenoidectomy; and (2) ABO blood typing in adults before laparoscopic cholecystectomy, thyroidectomy, lumbar discectomy or breast surgery. Guidelines do not recommend any preoperative tests in these settings. Between 2013 and 2015, a coagulation test was performed in 49% of the 241 017 children who underwent tonsillectomy and 39% of the 133 790 children who underwent adenoidectomy. A similar pattern was observed for ABO blood typing although re-operation rates for bleeding on the first postoperative day were very low (0.12-0.31% for tonsillectomy and 0.01-0.02% for adenoidectomy). Between 2012 and 2015, ABO blood typing was performed in 32-45% of the 1 114 082 patients who underwent one of the four selected procedures. The transfusion rate was very low (0.02-0.31%). The mean cost for the four procedures over the 4 yr period was €5 310 000 (sd €325 000). Standard laboratory coagulation tests and ABO blood typing are still routinely prescribed before surgery and anaesthesia despite current guidelines. This over-prescription represents a high and unnecessary cost, and should therefore be addressed. © The Author 2017. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. For Permissions, please email: journals.permissions@oup.com

Self-reported postoperative recovery in children after tonsillectomy compared to tonsillotomy.

PubMed

Eriksson, Mats; Nilsson, Ulrica; Bramhagen, Ann-Cathrine; Idvall, Ewa; Ericsson, Elisabeth

2017-05-01

Tonsil surgery is associated with significant morbidity during recovery. Patient-reported outcome measures (PROM) are the golden standard for the planning and follow-up of delivered care, which should also be an axiom for children. The current aims were to describe self-reported postoperative recovery in children after tonsil surgery, and to compare tonsillotomy and tonsillectomy in this respect. In total, 238 children (4-12 years old) with a history of obstructive problems and/or recurrent tonsillitis, and undergoing tonsil surgery were included. Forty-eight per cent were operated with partial tonsil resection/tonsillotomy (TT) and 52% with total tonsillectomy (TE), all in day surgery. Postoperative recovery was assessed on days 1, 4 and 10 using the validated self-rating instrument PRiC, Postoperative Recovery in Children. This includes 23 items covering different aspects of recovery after tonsil surgery. A higher score indicates worse status in the respective items. Daily life activities (sleeping, eating and playing), physical symptoms (e.g., headache, stomach ache, sore throat, otalgia, dizziness, nausea, defecation, urination), and emotional aspects (sadness, frightening dreams) were affected during the recovery period. The TE-girls showed higher scores than the boys regarding stomach ache, defecation and dizziness. Children above 6 years of age reported higher values for the physical comfort variables, while the younger group showed worse emotional states. Postoperative recovery improved from day 1-10 in all surgical groups. The TE-group showed lower recovery compared to the TT-group (p < 0.01-0.001) in most items. The goal of postoperative management is to minimize or eliminate discomfort, facilitating the recovery process and avoiding complications. Children are able to describe their recovery, and thus, PRiC seems to be able to serve as a PROM to obtain patient-centered data after tonsil surgery. The recovery process after TT causes less postoperative morbidity and a quicker return to normal activity compared to TE. Copyright © 2017 Elsevier B.V. All rights reserved.

Risk factors for post-tonsillectomy hemorrhage.

PubMed

Ikoma, Ryo; Sakane, Sayaka; Niwa, Kazutomo; Kanetaka, Sayaka; Kawano, Toshiro; Oridate, Nobuhiko

2014-08-01

The aim of the present study was to investigate the rate of post-tonsillectomy hemorrhage (PTH) in a single institution and to evaluate the clinical risk factors for PTH. We reviewed the records of 692 patients who underwent tonsillectomy (TE) at Yokohama Minami Kyosai Hospital in Japan. PTH grades were grouped into three categories according to the severity of the hemorrhagic episode: (I) minimal hemorrhage that stopped after noninvasive treatment, (II) hemorrhage requiring treatment with local anesthesia, and (III) hemorrhage requiring reoperation under general anesthesia in the operating room. Clinical risk factors such as sex, age (adults vs. children), TE indication, surgeon's skill level, operative time, ligature type, and duration of antibiotic administration for PTH were investigated. Among the 692 patients, 80 (11.6%) showed PTH, with primary and secondary hemorrhage accounting for 1.6% and 10.0%, respectively. A category III PTH was observed in 18 patients; thus, the overall risk of reoperation was 2.6%. The PTH episode most frequently occurred on postoperative days 5 and 6. The frequency of PTH was significantly higher in male patients and in adults (P<0.01, for both factors). Surgeon's skill was also associated with PTH rate. A stepwise multivariate logistic regression revealed that adult age (odds ratio [OR]=18.9) and male gender (OR=3.78) were the clinical risk factors for PTH. It also revealed that male gender (OR=82065335), adult age (OR=10.6), and surgeon's skill level (OR=7.50) were the clinical risk factors for the category III PTH. The risk of PTH was higher in this report compared with previous reports, which may be associated with the definition of PTH. Clinical risk factors for PTH were adult age and male gender. The surgeon's skill level was an additional risk factor for category III PTH. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.

Post-tonsillectomy hemorrhagic outcomes in children with bleeding disorders at a single institution.

PubMed

Patel, Priyesh N; Arambula, Alexandra M; Wheeler, Allison P; Penn, Edward B

2017-09-01

To report on the post-tonsillectomy bleeding outcomes and factors associated with hemorrhage among children with pre- or post-operatively diagnosed bleeding disorders treated with an institutional protocol. Retrospective cohort study of patients with hematologic disorders who underwent tonsillectomy between 2003 and 2016 and were treated with perioperative desmopressin or factor replacement and/or aminocaproic acid. Postoperative outcomes were compared to controls matched for age, sex, and indication for surgery. Analysis of factors associated with hemorrhage was performed in patients with bleeding disorders using Mann-Whitney U or chi-squared tests. 45 patients with hematologic disorders met inclusion criteria. Platelet dysfunction, including von Willebrand Disease (vWD), was the most common diagnosis (77.8%). Most patients had a preoperative diagnosis of a bleeding disorder and received perioperative hematologic medications (86.7%). Compared to matched controls, patients with hematologic disorders experienced more postoperative bleeding (15.5%; 12 bleeds, 7 patients vs. 1.7%; 1 bleed, 1 patient, p = 0.05) and had longer postoperative stays (1.3 days vs. 0.4 days, p < 0.001). Among the patients with hematologic disorders, patients who experienced a postoperative bleed were significantly more likely to have a factor deficiency (e.g. Hemophilia over vWD) and have a postoperative diagnosis (compared to preoperative diagnosis) for which they did not receive perioperative hematologic medication. Of patients with a postoperative bleed, all those diagnosed postoperatively required at least one surgical intervention to control bleeding compared to 33% of patients with a preoperative diagnosis. A history of post-surgical bleeding, male sex, age at surgery, and pharyngitis as surgical indication were not associated with higher hemorrhage rates in this group. This study suggests a clinically important magnitude of increased bleeding risk in patients with hematologic disease. This risk appears to decrease with the use of an institutional protocol consisting of desmopressin or factor replacement and an antifibrinolytic agent extending through postoperative day 10. Copyright © 2017 Elsevier B.V. All rights reserved.

An unusual presentation of an unusual complication of infectious mononucleosis: haematemesis and melaena.

PubMed

Koay, C B; Norval, C

1995-04-01

Tonsillar haemorrhage is a rare complication of infectious mononucleosis. We present a case of life-threatening tonsillar haemorrhage secondary to infectious mononucleosis in a young man whose predominant symptoms at presentation were haematemesis and melaena. The origin of the haemorrhage was not obvious until the patient was examined under anaesthesia. The bleeding was controlled by emergency tonsillectomy.

Celecoxib Versus Placebo in Tonsillectomy: A Prospective, Randomized, Double-Blind Placebo-Controlled Trial.

PubMed

Van Daele, Douglas J; Bodeker, Kellie L; Trask, Douglas K

2016-10-01

Celecoxib is a cyclooxygenase-2-specific inhibitor indicated to treat acute pain and pain secondary to osteoarthritis and rheumatoid arthritis. Surgical models of acute pain have demonstrated superior pain relief to placebo. The objective of this study was to test the safety and efficacy of celecoxib for pain relief after tonsillectomy compared to placebo. Adult subjects were randomized to 200 mg celecoxib versus placebo with a loading dose the night before surgery then twice daily for 10 days. Subjects were instructed to supplement the study drug with hydrocodone/acetaminophen liquid or acetaminophen for pain as needed. Subjects completed a daily diary regarding their pain, nausea, vomiting, diet, and activity. Seventeen subjects enrolled. Intraoperative blood loss was similar between groups, and no subject had postoperative bleeding. Three patients returned to the emergency department for treatment, and 2 patients could not complete the diaries, all in the placebo group. Subjects in the placebo group required statistically significant (P < .05) higher doses of narcotic and acetaminophen to control pain. Pain and diet rating scores were slightly better in the celecoxib group compared to placebo. In this small cohort, celecoxib reduced postoperative narcotic and acetaminophen requirements compared to placebo without complications. © The Author(s) 2016.

Relation of Actinomyces with Tonsillar Hypertrophy and Antibiotic Use

PubMed Central

Kansu, Leyla

2017-01-01

Objective This study aimed to investigate the incidence of Actinomyces in tonsillar tissues of patients undergoing tonsillectomy and to determine the association among tonsillar volume, preoperative antibiotic use, and presence of Actinomyces in tonsil tissues. Methods In this study, 142 patients who underwent tonsillectomy in last four years were included. Of the total patients, 97 (66.9%) were children and 47 (33.1%) were adults. The patients’ age, sex, preoperative antibiotic use, tonsillar volume, and presence of actinomyces in tonsillar tissues were recorded. Results Actinomyces was identified in tonsillar tissues of 16 (16.4%) pediatric and 21 (44.6%) adult patients. Of all pediatric patients positive for Actinomyces, 13 were males and three were females whereas of all adult patients positive for actinomyces, 14 were males and seven were females. Tonsillar tissue volumes in both pediatric and adult patients positive for Actinomyces were statistically higher than the Actinomyces negative ones. Antibiotic use was higher and the incidence of Actinomyces was lower in pediatric patients than in adult patients positive for Actinomyces. Conclusion Our study results revealed that Actinomyces was prominent in adult patients with tonsillar hypertrophy. In addition, the frequent use of antibiotic decreased the incidence of Actinomyces in tonsillar tissues. PMID:29392046

Bloody traditional procedures performed during infancy in the oropharyngeal area among HIV+ children: implication from the perspective of mother-to-child transmission of HIV.

PubMed

Mitke, Yifru Berhan

2010-12-01

Although bloody traditional procedures are very common in Ethiopia, this is the first report on infants. None of the literature attributed such practices as risk factor for mother-to-child transmission (MTCT) of HIV. Analysis was done to 1,163 children and found that 552 (47.5%) bloody traditional procedures were performed in the oral cavity to 399 (34.3%): uvulectomy 41.8%, milk tooth extraction 33.7% and tonsillectomy 24.5%. Multinomial logistic regression showed strong association of uvulectomy with Tigray ethnicity. Milk teeth extractions were highest among girls, rural residence, Tigray and Amhara ethnicity. When procedures performed, children were under 1 month (88.9% of tonsillectomies), under 6 months (83.5% of uvulectomies) and 4-6 months (54.3% of milk tooth extractions) of age. More than 97% for whom procedures performed were breast fed, and about 88% were from the northern part of the country. Taking into account the deep invasiveness of the procedures, they are assumed as one of the strong risk factors for MTCT of HIV during lactation.

Surgical management of obstructive sleep apnea in children with cerebral palsy.

PubMed

Magardino, T M; Tom, L W

1999-10-01

To evaluate the surgical management of obstructive sleep apnea in children with cerebral palsy. Retrospective review of 27 children with cerebral palsy who underwent surgical treatment for obstructive sleep apnea. Charts were reviewed. Data gathered included primary complaint, coexisting illnesses, initial procedure performed, age at initial surgery, number of days the child was monitored postoperatively in the intensive care unit, notation of postoperative respiratory distress and management, and outcome. Nineteen children underwent adenotonsillectomy for initial treatment of obstructive sleep apnea. Three of these children also had a uvulectomy. Six children had an adenoidectomy alone as their initial procedure. Neither uvulopalatopharyngoplasty nor tracheostomy was performed as an initial procedure. Mean follow-up was 34 months. Seventy-six percent of these children have not required any further surgery. Of the six children who have undergone further surgery, one has required a revision adenoidectomy, and another underwent a tonsillectomy and uvulectomy 2 months after the initial adenoidectomy. Four children ultimately required a tracheotomy. Eighty-four percent of these children were successfully managed without a tracheotomy. We recommend tonsillectomy and/or adenoidectomy for initial surgical treatment of obstructive sleep apnea in children with cerebral palsy.

Parents' experiences managing their child's complicated postoperative recovery.

PubMed

Purcell, Mary; Longard, Julie; Chorney, Jill; Hong, Paul

2018-03-01

Tonsillectomy is commonly performed as same-day surgery and parents are heavily relied upon for management of children's postoperative recovery. The objective of this study was to provide an in-depth description of the experiences parents face when managing their child's complicated postoperative recoveries at home. An exploratory qualitative study at an academic pediatric hospital in Eastern Canada was performed. Participants included 12 parents of children aged 3-6 years who underwent adeno/tonsillectomy and experienced unexpected outcomes or complications during the postoperative recovery period. Parents participated in semi-structured interviews within 6 months of their child's surgery. Interviews were transcribed verbatim and thematic analysis was used to identify themes in the parents' experiences. Parents described struggling to make the decision to come back to hospital, that adequate information does not prevent emotional difficulties, and feeling somewhat responsible for the unexpected outcome or complicated course of recovery. Communication with healthcare providers was considered very important in helping with the recovery process. This research helps to inform healthcare professionals about how they might better support families during complicated recovery processes. Areas of action may include clear communication, setting expectations, and psychosocial support. Copyright © 2018 Elsevier B.V. All rights reserved.

Engraftment of tonsillar mononuclear cells in human skin/SCID mouse chimera--validation of a novel xenogeneic transplantation model for autoimmune diseases.

PubMed

Yamanaka, N; Yamamoto, Y; Kuki, K

2001-01-01

Pustulosis palmaris et plantaris (PPP) has been considered as one of the typical tonsillar focal infections, based on the marked clinical improvement of the skin lesions after tonsillectomy. Despite the accumulation of data showing the clinical efficacy of tonsillectomy for this skin lesion, fundamental etiological and pathophysiological issues have yet to be addressed. One primary obstacle hindering investigators has been the lack of an appropriate animal model for this human skin disorder. In the early stage of PPP, it has been reported that lymphocytes, predominantly CD4+ T lymphocytes, infiltrate the palmar and plantar skins. However, the origin and mechanism of infiltration by these lymphocytes is not clear and there are very few reports on whether tonsillar mononuclear cells react directly with the skin. We have been intrigued by the ability to engraft human cells onto severe combined immunodeficiency (SCID) mice, together with the opportunity for long-term graft survival and ability to adoptively transfer various human immunocompetent cells. In this review, we addressed the existing deficiencies in our understanding of the relationship between tonsils and PPP by using emerging transplantation technology involving SCID mice.

Obstructive sleep apnea syndrome and growth failure.

PubMed

Esteller, E; Villatoro, J C; Agüero, A; Lopez, R; Matiñó, E; Argemi, J; Girabent-Farrés, M

2018-05-01

Obstructive sleep apnea syndrome is a common problem among children and is recognized as a cause of significant medical morbidity. Since the 1980s, it has been suggested that obstructive sleep apnea syndrome is a risk factor for growth failure in children. In many cases, it has been shown that growth failure is reversible once the obstructive sleep apnea syndrome is resolved. The objectives of this study were to analyze and compare growth failure prevalence in a Mediterranean population of children with obstructive sleep apnea syndrome and healthy children matched in age and sex, and to assess the effectiveness of tonsillectomy and adenoidectomy in resolving growth retardation. We compared 172 children with obstructive sleep apnea syndrome (apnea-hypopnea index ≥ 3) who had undergone tonsillectomy and adenoidectomy with 172 healthy controls in terms of key anthropometric parameters. Most of the criteria used for growth failure were higher to a statistically significant degree in the study group vs the control group: height-for-age ≤ 3rd percentile (7.56% vs 2.91%; p = 0.044), weight-for-age ≤ 5th percentile (9.30% vs 2.33%; p = 0.005), weight-for-age ≤ 3rd percentile (8.14% vs 2.33%; p = 0.013) and height and/or weight for-age ≤ 5th percentile (13.95% vs 5.81%; p = 0.009). The height-for-age ≤ 5th percentile was almost at the limit of statistical significance (8.72% for the study group vs 4.65% for the control group; p = 0.097). At one-year post-surgery follow-up, 10 of 15 children with height-for-age ≤ 5th percentile had achieved catch-up growth (66.6%), and 14 of 24 children with height- and/or weight-for-age ≤ 5th percentile had normalized growth (58.33%). For children with failure to thrive or who have growth failure, physicians should consider the possibility of obstructive sleep apnea. A significant number of children with obstructive sleep apnea concurrent with growth failure could benefit from tonsillectomy and adenoidectomy to recover and normalize their growth rate. Copyright © 2018 Elsevier B.V. All rights reserved.

Granistron and dexamethasone provide more improved prevention of postoperative emesis than granisetron alone in children.

PubMed

Fujii, Y; Tanaka, H; Toyooka, H

1996-12-01

Dexamethasone decreases chemotherapy-induced emesis when added to antiemetic regimens. This study was designed to compare the effectiveness of granisetron and dexamethasone with granisetron alone in the prevention of post-operative vomiting after strabismus repair, tonsillectomy with or without adenoidectomy in children. In a randomized, double-blind study, 60 healthy children, 4-10 yr of age, received either granisetron 40 micrograms.kg-1 and saline (Group S) or granisetron 40 micrograms.kg-1 and dexamethasone 4 mg (Group D) iv immediately after the induction of anaesthesia. All subjects received anaesthetics consisting of sevoflurane and nitrous oxide in oxygen Postoperative pain was treated with acetaminophen pr or pentazocine iv. Postoperatively, during the first 24 hr after anaesthesia, the frequencies of retching and vomiting, and the incidence of adverse events were recorded by nursing staff. There were no differences between the treatment groups with regard to demographics, surgical procedure, anaesthetic administered or analgesics used for postoperative pain. The frequency of the symptoms was 27% and 7% in Groups S and D, respectively (P < 0.05). The incidence of adverse events was comparable in the two groups. The prophylactic administration of granisetron and dexamethasone was more effective than granisetron alone in the prevention of postoperative vomiting in paediatric subjects undergoing strabismus repair, tonsillectomy and adenoidectomy.

[Tonsillotomy with the argon-supported monopolar needle--first clinical results].

PubMed

Huber, K; Sadick, H; Maurer, J T; Hörmann, K; Hammerschmitt, N

2005-09-01

Primary management of tonsillar hyperplasia in children is tonsillectomy. Recent data from clinical case-series are clearly in support of the hypothesis that tonsillotomy with the CO2-laser seems to be effective and is noted to have less postoperative bleeding and less pain as compared to tonsillectomy. For the first time we used a monopolar argon-supported needle for tonsillotomy in the following study. Fifty patients (age: 4.58 years; SD +/- 2.33) with benign tonsillar hyperplasia were recruited. For tonsillotomy we used the monopolar argon-supported needle. The outcome measures were postoperative pain, capability of oral intake, consumption of analgesics and postoperative bleeding. No postoperative bleeding occurred. Post-operative pain hardly occurred and could easily be controlled. The third postoperative day analgesics intake was under one portion per day (mean: 0.91; SD +/- 1.26). Capability of oral intake and swallowing was normal on the seventh postoperative day. It was concluded that tonsillotomy, using the monopolar argon-supported needle, is a valid treatment for benign tonsillar hyperplasia in children, which can be performed with slight post-operative pain and a low risk for postoperative bleeding. It offers good dissection and haemostasis abilities. Compared to the CO2-laser the monopolar argon-supported needle does not require any laser safety precautions.

Cribriform adenocarcinoma of the tongue and minor salivary gland: transoral robotic surgical resection.

PubMed

Worrall, Douglas M; Brant, Jason A; Chai, Raymond L; Weinstein, Gregory S

2015-01-01

Cribriform adenocarcinoma of the tongue and minor salivary gland (CATMSG) is a rare, locally invasive, and poorly recognized tumor, typically occurring on the base of the tongue. This case report describes the previously unreported use of transoral robotic surgery (TORS) for the local resection of CATMSG in a novel location, the palatine tonsil, and leverages follow-up information to compare TORS to conventional surgical approaches. We performed transoral radical tonsillectomy, limited pharyngectomy, and base-of-tongue resection with staged left selective neck dissection. Tumor pathology revealed an infiltrating salivary gland carcinoma with perineural invasion and a histologically similar adenocarcinoma in 1 of 64 left neck lymph nodes. TORS was performed with no perioperative complications, and the patient was subsequently discharge on postoperative day 3 with a Dobhoff tube. Postoperatively, the Dobhoff tube was removed at 1 month, the patient was advanced to soft foods by mouth at 2 months, and 3-month positron emission tomography-computed tomography scan showed no evidence of distant metastases and evolving postsurgical changes in the left tonsillectomy bed. This case report highlights the use of TORS resection with minimal acute and long-term morbidity compared to conventional approaches for the resection of this rare, locally invasive salivary gland carcinoma in the palatine tonsil. © 2015 S. Karger AG, Basel.

Airway management in a bleeding adult following tonsillectomy: a case report.

PubMed

Brar, Manjit Singh

2009-12-01

A 37-year-old morbidly obese man with a history of obstructive sleep apnea underwent elective tonsillectomy. The patient was successfully intubated with an 8.0-mm regular cuffed endotracheal tube. A large video laryngoscope (GlideScope, Verathon Inc, Bothell, Washington) was used for intubation, as airway assessment indicated a potentially difficult airway. The surgery was uneventful, but active bleeding was noticed in the oropharynx after extubation. The patient was reintubated, again with the use of a GlideScope. The bleeding site was cauterized, and the patient was extubated after meeting the criteria for an awake extubation. He was discharged home the following day. Eight days postoperatively, the patient returned to the emergency center with spontaneous bleeding from the oropharynx. He was taken to the operating room and, based on the previous GlideScope use, an attempt was made to intubate the patient with a GlideScope. The attempt failed, as the GlideScope screen was blurred by the presence of blood in the oropharynx, even though the oropharynx was suctioned. Resuctioning and reinsertion of the GlideScope probe did not provide an adequate visual field. After 2 failed attempts, the use of the GlideScope was abandoned. Subsequently, the patient's trachea was successfully intubated with a size 4 Macintosh blade.

Treating pediatric post-tonsillectomy pain and nausea with complementary and alternative medicine.

PubMed

Keefe, Katherine R; Byrne, Kevin J; Levi, Jessica R

2018-05-04

Although tonsillectomy is a common and largely safe procedure, pain management in children remains a controversial topic. In addition to the challenge of choosing appropriate analgesia, there is often low parent and child adherence. This article presents a review, and evaluates the potential role, of a range of complementary and alternative therapies that may be sought out by parents. A literature review of complementary and alternative interventions performed using PubMed, Cochrane Library, and EMBASE, supplemented by searches from Google and hand searches of cross-references of selected articles, yielded 32 studies for qualitative analysis. The studies included for analysis investigated a wide variety of alternative treatment modalities: acupuncture and related therapies, aromatherapy, homeopathy, honey, intravenous fluid, speech therapy, hyaluronic acid, behavioral therapies, ice/cold, hydrogen peroxide rinse, and chewing gum. At this time, stronger conclusions cannot be made about the therapies investigated because there are many methodology limitations of the studies analyzed. However, our results suggest merit for these treatments as adjuvant therapies that can enhance analgesia and decrease requirements of controversial medications. Honey and acupuncture have the greatest amount of evidence for postoperative pain and nausea; however, all interventions examined were cost-effective and safe. We recommend against hydrogen peroxide rinses and chewing gum. Laryngoscope, 2018. © 2018 The American Laryngological, Rhinological and Otological Society, Inc.

Unique migration of a dental needle into the parapharyngeal space: successful removal by an intraoral approach and simulation for tracking visibility in X-ray fluoroscopy.

PubMed

Okumura, Yuri; Hidaka, Hiroshi; Seiji, Kazumasa; Nomura, Kazuhiro; Takata, Yusuke; Suzuki, Takahiro; Katori, Yukio

2015-02-01

The first objective was to describe a novel case of migration of a broken dental needle into the parapharyngeal space. The second was to address the importance of simulation elucidating visualization of such a thin needle under X-ray fluoroscopy. Clinical case records (including computed tomography [CT] and surgical approaches) were reviewed, and a simulation experiment using a head phantom was conducted using the same settings applied intraoperatively. A 36-year-old man was referred after failure to locate a broken 31-G dental needle. Computed tomography revealed migration of the needle into the parapharyngeal space. Intraoperative X-ray fluoroscopy failed to identify the needle, so a steel wire was applied as a reference during X-ray to locate the foreign body. The needle was successfully removed using an intraoral approach with tonsillectomy under surgical microscopy. The simulation showed that the dental needle was able to be identified only after applying an appropriate compensating filter, contrasting with the steel wire. Meticulous preoperative simulation regarding visual identification of dental needle foreign bodies is mandatory. Intraoperative radiography and an intraoral approach with tonsillectomy under surgical microscopy offer benefits for accessing the parapharyngeal space, specifically for cases medial to the great vessels. © The Author(s) 2014.

Effect of carboxyhemoglobin on postoperative complications and pain in pediatric tonsillectomy patients.

PubMed

Koyuncu, Onur; Turhanoglu, Selim; Tuzcu, Kasım; Karcıoglu, Murat; Davarcı, Isil; Akbay, Ercan; Cevik, Cengiz; Ozer, Cahit; Sessler, Daniel I; Turan, Alparslan

2015-03-01

Carbon monoxide (CO) is a product of burning solid fuel in stoves and smoking. Exposure to CO may provoke postoperative complications. Furthermore, there appears to be an association between COHb concentrations and pain. We thus tested the primary hypothesis that children with high preoperative carboxyhemoglobin (COHb) concentrations have more postoperative complications and pain after tonsillectomies, and secondarily that high-COHb concentrations are associated with more pain and analgesic use. 100 children scheduled for elective tonsillectomy were divided into low and high carbon monoxide (CO) exposure groups: COHb ≤3 or ≥4 g·dl(-1) . We considered a composite of complications during the 7 days after surgery which included bronchospasm, laryngospasm, persistent coughing, desaturation, re-intubation, hypotension, postoperative bleeding, and reoperation. Pain was evaluated with Wong-Baker Faces pain scales, and supplemental tramadol use recorded for four postoperative hours. There were 36 patients in the low-exposure group COHb [1.8 ± 1.2 g·dl(-1) ], and 64 patients were in the high-exposure group [6.4 ± 2.1 g·dl(-1) ]. Indoor coal-burning stoves were reported more often by families of the high- than low-COHb children (89% vs 72%, P < 0.001). Second-hand cigarette smoke exposure was reported by 54% of the families with children with high COHb, but only by 24% of the families of children with low COHb. Composite complications were more common in patients with high COHb [47% vs 14%, P = 0.0001, OR:7.4 (95% Cl, lower = 2.5-upper = 21.7)], with most occurring in the postanesthesia care unit. Pain scores in postanesthesia care unit and one hour after surgery were statistically significantly lower in the low-exposure group [respectively, P = 0.020 (95%CI, lower = -1.21-upper = -0.80), P = 0.026 (95% CI, lower = -0.03-upper = 0.70)], and tramadol use increased at 4 h (3.5 (interquartile range: 0-8) vs 6 (5-9) mg, P = 0.012) and 24 h (3.5 (0-8) vs 6 (5-9) mg, P = 0.008). High preoperative COHb concentrations are associated with increased postoperative complications and pain. © 2014 John Wiley & Sons Ltd.

Online Tonsillectomy Resources: Are Parents Getting Consistent and Readable Recommendations?

PubMed

Wozney, Lori; Chorney, Jill; Huguet, Anna; Song, Jin Soo; Boss, Emily F; Hong, Paul

2017-05-01

Objective Parents frequently refer to information on the Internet to confirm or broaden their understanding of surgical procedures and to research postoperative care practices. Our study evaluated the readability, comprehensiveness, and consistency around online recommendations directed at parents of children undergoing tonsillectomy. Study Design A cross-sectional study design was employed. Setting Thirty English-language Internet websites. Subjects and Methods Three validated measures of readability were applied and content analysis was employed to evaluate the comprehensiveness of information in domains of perioperative education. Frequency effect sizes and percentile ranks were calculated to measure dispersion of recommendations across sites. Results The mean readability level of all sites was above a grade 10 level with fewer than half of the sites (n = 14, 47%) scoring at or below the eight-grade level. Provided information was often incomplete with a noted lack of psychosocial support and skills-training recommendations. Content analysis showed 67 unique recommendations spanning the full perioperative period. Most recommendations had low consensus, being reported in 5 or fewer sites (frequency effect size <16%). Conclusion Many online parent-focused resources do not meet readability recommendations, portray incomplete education about perioperative care and expectations, and provide recommendations with low levels of consensus. Up-to-date mapping of the research evidence around recommendations is needed as well as improved efforts to make online information easier to read.

The Effect of Tonsillectomy and Adenoidectomy on Right Ventricle Function and Pulmonary Artery Pressure by Using Doppler Echocardiography in Children.

PubMed

Acar, Onur Çağlar; Üner, Abdurrahman; Garça, Mehmet Fatih; Ece, İbrahim; Epçaçan, Serdar; Turan, Mahfuz; Kalkan, Ferhat

2016-06-01

The purpose of the present study is to emphasize the efficacy of the myocardial performance index and tricuspid annular plane systolic excursion (TAPSE) in the determination of impaired cardiac functions and recovery period following the treatment in children with adenoid and/or tonsillar hypertrophy. Fifty-three healthy children after routine laboratory, imaging and clinical examinations, with adenoid and/or tonsillar hypertrophy were evaluated before and 3 months after adenotonsillectomy for cardiac functions using M mode and Doppler echocardiography. The mean age of cases was 6.4±3.0 years, 34 (65%) were male, and 19 (35%) were female. Pulmonary hypertension was observed to be mild in 3 patients and moderate in 1 patient preoperatively. When the preoperative and postoperative echocardiographic measurements of the patients were compared, the tricuspid valve E wave velocity, the E/A ratio (E, early diastolic flow rate; A, late diastolic flow rate), and the TAPSE values were determined to be significantly higher postoperatively (P<0.05). The tricuspid valve deceleration time, the isovolumetric relaxation time and the systolic pulmonary artery pressure were found to be significantly lower compared to the preoperative values (P<0.05). Adenoidectomy and/or tonsillectomy may prevent cardiac dysfunctions that can develop in the later periods due to adenoid and/or tonsil hypertrophy in children, before the appearance of the clinical findings of cardiac failure.

Systematic review of tonsil surgery quality registers and introduction of the Nordic Tonsil Surgery Register Collaboration.

PubMed

Ruohoalho, Johanna; Østvoll, Eirik; Bratt, Mette; Bugten, Vegard; Bäck, Leif; Mäkitie, Antti; Ovesen, Therese; Stalfors, Joacim

2018-06-01

Surgical quality registers provide tools to measure and improve the outcome of surgery. International register collaboration creates an opportunity to assess and critically evaluate national practices, and increases the size of available datasets. Even though millions of yearly tonsillectomies and tonsillotomies are performed worldwide, clinical practices are variable and inconsistency of evidence regarding the best clinical practice exists. The need for quality improvement actions is evident. We aimed to systematically investigate the existing tonsil surgery quality registers found in the literature, and to provide a thorough presentation of the planned Nordic Tonsil Surgery Register Collaboration. A systematic literature search of MEDLINE and EMBASE databases (from January 1990 to December 2016) was conducted to identify registers, databases, quality improvement programs or comprehensive audit programs addressing tonsil surgery. We identified two active registers and three completed audit programs focusing on tonsil surgery quality registration. Recorded variables were fairly similar, but considerable variation in coverage, number of operations included and length of time period for inclusion was discovered. Considering tonsillectomies and tonsillotomies being among the most commonly performed surgical procedures in otorhinolaryngology, it is surprising that only two active registers could be identified. We present a Nordic Tonsil Surgery Register Collaboration-an international tonsil surgery quality register project aiming to provide accurate benchmarks and enhance the quality of tonsil surgery in Denmark, Finland, Norway and Sweden.

The impact of recurrent throat infection on children and their families.

PubMed

Howel, Denise; Webster, Simon; Hayes, Jane; Barton, Andrew; Donaldson, Liam

2002-06-01

Recurrent throat problems in children are common and have an impact on the family. The appropriateness of surgery will depend on both clinical and social factors. The aim of this study was to assess the impact on the whole family when a child is suffering from recurrent throat problems, and investigate related parental attitudes. A total of 1190 parents of children in northern England for whom tonsillectomy or adeno-tonsillectomy was a possible treatment option were sent a questionnaire covering social and clinical issues such as children's symptoms, the impact on family life and parental attitudes. The majority of children had experienced more than four episodes in the previous year, had their sleep affected and time off school. Most parents were worried and reported disruption to the family, including taking time off work and cross-infection. Parental disruption, worry and eagerness for surgery were significantly associated with the duration of episodes of throat problems and the number of episodes in the previous year, but not with duration of tonsillitis. Time off school, or parental time off work was significantly associated with parental worry and disruption, but not with eagerness for surgery. This work highlights the impact of recurrent throat problems and related parental attitudes, and will aid in striking a balance between clinical requirements and the needs and wishes of the family.

Tonsillar colonization is unlikely to play important role in Helicobacter pylori infection in children.

PubMed

Jelavic, Boris; Bevanda, Miljenko; Ostojic, Maja; Leventic, Miro; Vasilj, Mirjana; Knezevic, Ervin

2007-04-01

To determine (i) seroprevalence of Helicobacter pylori (HP) infection in children undergoing tonsillectomy, (ii) possible HP colonization on tonsils of children and its importance in HP transmission, and (iii) if four examined socio-economic factors are the risk factors for HP transmission and HP colonization on tonsils in children. Rapid urease test (RUT) of tonsils, and serologic blood tests for HP were performed in 77 children (aged 4-14 years) in Bosnia and Herzegovina (B-H), undergoing tonsillectomy. RUT positive tonsils were cultured for HP. RUT positive children were tested using (13)Carbon-urea breath test ((13)C-UBT). Information about socio-economic potential risk factors was obtained from the parents. Out of 139 pharyngeal and palatine tonsils, 17 palatine tonsils in 14 children were RUT positive and had negative HP culture. Eight children had positive both RUT and (13)C-UBT. There was no significant difference between children with hypertrophy and those with recurrent tonsillitis comparing their serologic tests results. There was no significant difference between seronegative (n=61) and seropositive (n=16) children comparing their age, sex, parental education level, owning a family courtyard, attending a children's collective, and owning a pet cat. The results in this prospective study do not support the notion that tonsils are an important reservoir for HP transmission in children in B-H. The examined socio-economic factors did not enhance HP seropositivity rate in children.

Peritonsillar abscess: clinical aspects of microbiology, risk factors, and the association with parapharyngeal abscess.

PubMed

Klug, Tejs Ehlers

2017-03-01

PTA is a collection of pus located between the tonsillar capsule and the pharyngeal constrictor muscle. It is considered a complication of acute tonsillitis and is the most prevalent deep neck infection (approximately 2000 cases annually in Denmark) and cause of acute admission to Danish ENT departments. Teenagers and young adults are most commonly affected and males may predominate over females. However, no studies of age- and gender-stratified incidence rates have previously been published. Furthermore, smoking may be associated with increased risk of peritonsillar abscess (PTA) development, although the magnitude of the association has not been estimated. Complications are relatively rare. They include parapharyngeal abscess (PPA), upper airway obstruction, Lemierre´s syndrome, necrotizing fasciitis, mediastinitis, erosion of the internal carotid artery, brain abscess, and streptococcal toxic shock syndrome. The treatment consists of abscess drainage and antimicrobial therapy. There are three accepted methods of surgical intervension: needle aspiration, incision and drainage (ID), and acute tonsillectomy (á chaud). Internationally, there is a strong trend towards less invasive surgical approach to PTA treatment with avoidance of acute tonsillectomy, needle aspiration instead of ID, and in some cases even antibiotic treatment without surgical drainage. The preferred antibiotic regimen varies greatly between countries and centers. Group A streptococcus (GAS) is the only established pathogen in PTA. However, GAS is only recovered from approximately 20% of PTA patients. The pathogens in the remaining 80% are unknown. Culturing of PTA pus aspirates often yields a polymicrobial mixture of aerobes and anaerobes. As the tonsils of healthy individuals are already heavily and diversely colonized, the identification of significant pathogens is challenging. In addition, when studying PTA microbiology, one must consider diagnostic precision, collection, handling, and transportation of appropriate specimens, choice of methodology for detection and quantification of microorganisms, current or recent antibiotic treatment of patients, potential shift in significant pathogens during the course of infection, and factors associated with increased risk of PTA development.  The trend towards de-escalated surgical intervention and increasing reliance on antibiotic treatment, require studies defining the significant pathogens in PTA in order to determine optimal antibiotic regimens. Complications secondary to PTA may be avoided or better controlled with improved knowledge concerning the significant pathogens in PTA. Furthermore, identification of pathogens other than GAS, may lead the way for earlier bacterial diagnosis and timely intervention before abscess formation in sore throat patients. The identification and quantification of risk factors for PTA development constitutes another approach to reduce the incidence of PTA. As clinicians, we noticed that FN was recovered from PTA patients with increasing frequency and that patients infected with Fusobacterium necrophorum (FN) seemed to be more severely affected than patients infected with other bacteria. Furthermore, we occationally observed concomitant PPA in addition to a PTA, which made us hypothesize that PPA and PTA is often closely related and may share significant pathogens. Hence, our aims were: 1. To explore the microbiology of PTA with a special attention to Fusobacterium necrophorum (FN). 2. To elucidate whether smoking, age, gender, and seasons are risk factors for the development of PTA. 3. To characterize patients with PPA, explore the relationship between PPA and PTA, identify the pathogens associated with PPA, and review our management of PPA. In a retrospective study on all 847 PTA patients admitted to the ENT department at Aarhus University Hospital (AUH) from 2001 to 2006, we found that FN was the most prevalent (23%) bacterial strain in pus specimens. FN-positive patients displayed significantly higher infection markers (CRP and neutrophil counts) than patients infected with other bacteria (P = 0.01 and P < 0.001, respectively). In a subsequent prospective and comparative study on 36 PTA patients and 80 patients undergoing elective tonsillectomy (controls), we recovered FN from 58% of PTA aspirates. Furthermore, FN was detected significantly more frequently in the tonsillar cores of PTA patients (56%) compared to the tonsillar cores of the controls (24%) (P = 0.001). We also analysed sera taken acutely and at least two weeks after surgery for the presence of anti-FN antibodies. We found increasing levels (at least two-fold) of anti-FN antibodies in eight of 11 FN-positive (in the tonsillar cultures) PTA patients, which was significantly more frequent compared to none of four FN-negative PTA patients and nine of 47 electively tonsillectomized controls (P = 0.026 and P < 0.001, respectively). Blood cultures obtained during acute tonsillectomy mirrored the bacterial findings in the tonsillar specimens with 22% of patients having bacteremia with FN. However, bacteremia during elective tonsillectomy was at least as prevalent as bacteremia during quinsy tonsillectomy, which challenges the distinction made by the European Society of Cardiology between quinsy and elective tonsillectomy, namely that antibiotic prophylaxis is only recommended to patients undergoing procedures to treat an established infection (i.e. PTA). Using PCR analysis for the presence of herpes simplex 1 and 2, adenovirus, influenza A and B, Epstein-Barr virus (EBV), and respiratory syncytial virus A and B, we explored a possible role of viruses in PTA. However, our results did not indicate that any of these viruses are involved in the development of PTA. Privious studies have documented an association between EBV and PTA in approximately 4% of PTA cases. In addition to the involvement of GAS, the following findings suggest a pathogenic role for FN in PTA: 1. Repeated high isolation rates of FN in PTA pus aspirates. 2. Higher isolation rates in PTA patients compared to electively tonsillectomised controls. 3. Development of anti-FN antibodies in FN-positive patients with PTA. 4. Significantly higher inflammatory markers in FN-positive patients compared to PTA patients infected with other bacteria. We studied the smoking habits among the same 847 PTA patients admitted to the ENT department, AUH from 2001 to 2006. We found that smoking was associated with increased risk of PTA for both genders and across all age groups. The increased risk of PTA among smokers was not related to specific bacteria. Conclusions on causality cannot be drawn from this retrospective study, but the pathophysiology behind the increased risk of PTA in smokers may be related to, previously shown, alterations in the tonsillar, bacterial flora or the local and systemical inflammatory and immunological milieu. Studying all 1,620 patients with PTA in Aarhus County from 2001 to 2006 and using population data for Aarhus County for the same six years, age- and gender-stratified mean annual incidence rates of PTA were calculated. The incidence of PTA was highly related to age and gender. The seasonal variation of PTA was insignificant. However, the microbiology of PTA fluctuated with seasons: GAS-positive PTA cases were significantly more prevalent in the winter and spring compared to the summer, while FN-positive PTA patients exhibited a more even distribution over the year, but with a trend towards higher prevalence in the summer than in the winter. In a series of 63 patients with PPA, we found that 33 (52%) patients had concomitant PTA. This association between PPA and PTA was much higher than previously documented. We therefore suggest that combined tonsillectomy and intrapharyngeal incision in cases where PTA is present or suspected. The results of our routine cultures could not support a frequent role of FN in PPA. Based on our findings suggesting that FN is a frequent pathogen in PTA, we recommend clindamycin instead of a macrolide in penicillin-allergic patients with PTA. Furthermore, cultures made from PTA aspirates should include a selective FN-agar plate in order to identify growth of this bacterium. Recent studies of sore throat patients document an association between recovery of FN and acute tonsillitis. Studying the bacterial flora of both tonsils in study II, we found almost perfect concordance between the bacterial findings of the tonsillar core at the side of the abscess and contralaterally. This finding suggests that FN is not a subsequent overgrowth phenomenon after abscess development, but that FN can act as pathogen in severe acute tonsillitis. Future studies of patients with FN-positive acute tonsillitis focusing on the optimal methods (clinical characteristics, culture, polymerase chain reaction, or other) for diagnosis and whether antibiotics (and which) can reduce symptoms and avoid complications are warranted. Until further studies are undertaken, we recommend clinicians to have increased focus on acute tonsillitis patients aged 15-24 years with regards to symptoms and findings suggestive of incipient peritonsillar involvement. We have conducted a number of studies with novel findings: 1. FN is a significant and prevalent pathogen in PTA. 2. Bacteremia during abscess tonsillectomy is no more prevalent than during elective tonsillectomy. 3. The development of anti-FN antibodies in FN-positive PTA patients. We have used novel approaches as principles to suggest pathogenic significance of candidate microorganisms: 1. Comparative microbiology between PTA patients and "normal tonsils". 2. Measurements indicating larger inflammatory response compared to clinically equivalent infection.

Infectious mononucleosis and bilateral peritonsillar abscesses resulting in airway obstruction.

PubMed

Burstin, P P; Marshall, C L

1998-12-01

Upper airway obstruction is an uncommon but recognized complication of infectious mononucleosis. The management depends upon the degree of airway compromise. In the case described, severe airway obstruction was treated by securing the airway with awake fibre-optic endoscopic intubation and then proceeding to tonsillectomy. Bilateral inferiorly loculated quinsies were encountered unexpectedly and drained. This is the first report of 'bilateral' quinsies, associated with infectious mononucleosis and severe airway obstruction. The association, pathogenesis and significance of this finding are also discussed.

WITHDRAWN: Post-tonsillectomy haemorrhage-Do coagulation tests and coagulopathy history have predictive value?

PubMed

Zagólski, Olaf

2010-03-16

El editor lamenta que este artículo es un duplicado accidental del artículo publicado, doi:10.1016/j.otorri.2010.01.017. Por este motivo, el artículo duplicado ha sido retirado The Publisher regrets that this article is an accidental duplication of an article that has already been published, doi:10.1016/j.otorri.2010.01.017. The duplicate article has therefore been withdrawn. Copyright © 2009. Published by Elsevier Espana.. All rights reserved.

Tonsillitis with acute myeloid leukemia: a case series for caution.

PubMed

Thakur, Jagdeep S; Mohindroo, N K; Sharma, D R; Mohindroo, Shobha; Thakur, Anamika

2013-01-01

Worldwide, tonsillitis is very common. The most common etiology is cross-infection with bacteria and viruses. These cases are managed with antibiotics and anti-inflammatory drugs without any further investigation because the diagnosis is based on simple clinical examination. Usually, leukemia presents with bleeding, weight loss, lymphadenopathy, fever, and frequent infection. Tonsillitis is a rare first presentation of leukemia. We present 3 cases in which the diagnosis of leukemia was made on routine examination, and in 1 case diagnosis was suspected during tonsillectomy.

The Hygiene Hypothesis and Breast Cancer: A Novel Application of an Etiologic Theory for Allergies, Asthma, and Other Immune Disorders

DTIC Science & Technology

2009-05-01

splenectomy • Current consumption of fermented or probiotic foods (e.g., yogurt , kim chee) • Lifetime number of insect stings b. Translate...tonsillectomy, appendectomy, or splenectomy; current consumption of yogurt or kimchee; or number of lifetime insect stings. However, suggestively...21 5.56 27 7.14 p value 0.3708 Average number of days/month in last year reported eating yogurt None 108 28.57 109 28.76 1-5

A retrospective observational study of glucocorticoid-induced diabetes mellitus with IgA nephropathy treated with tonsillectomy plus methylprednisolone pulse therapy

PubMed Central

Katsuyama, Takayuki; Sada, Ken-Ei; Hiramatsu, Sumie; Ohashi, Keiji; Morishita, Michiko; Katsuyama, Eri; Watanabe, Haruki; Takano-Narazaki, Mariko; Toyota-Tatebe, Noriko; Sunahori-Watanabe, Katsue; Kawabata, Tomoko; Inoue, Tatsuyuki; Kinomura, Masaru; Sugiyama, Hitoshi; Wada, Jun

2017-01-01

Aims To evaluate the incidence of GC-DM among patients with immunoglobulin A nephropathy (IgAN) and to confirm the risk factors for the development of GC-DM. Methods The medical records of patients with IgAN newly treated with the protocol of tonsillectomy combined with steroid pulse therapy were reviewed. The primary outcome was the development of GC-DM within the hospitalization period and during one year of follow-up. Results During hospitalization, 19 of the 95 patients developed GC-DM (20.0%), and the patients with GC-DM were significantly older and had a higher rate of family history of diabetes and higher HbA1c levels. The prevalence of hypertension was higher and the eGFR was numerically lower in patients with GC-DM than in those without. Older age (≥45 years) and a family history of diabetes emerged as independent risk factors for the development of GC-DM (odds ratio [OR], 6.3 and 95% confidence interval [CI], 1.6–27.6; OR, 4.4 and 95% CI, 1.2–16.6, respectively). No patients were newly diagnosed with GC-DM during 1-year observation period at out-patient clinic. Conclusions Among the patients with IgAN, 20% developed GC-DM during the hospitalization period, confirming the family history of diabetes is clinically necessary before starting GC therapy. PMID:28562629

The hidden cost of deep neck space infections

PubMed

Hurley, R H; Douglas, C M; Montgomery, J; Clark, L J

2018-02-01

Introduction The incidence of deep neck space infection (DNSI) is rising and appears to be related to falling rates of tonsillectomy. The purpose of this study was to assess demographics of patients presenting with DNSI and the financial burden to the National Health Service (NHS). Methods Data were collected retrospectively on patients aged over 16 years admitted to NHS Greater Glasgow and Clyde with DNSI between 2012 and 2016. Demographics, aetiology and use of hospital resources were reviewed. The cost of hospital admissions was calculated using data from NHS Scotland's Information Services Division, the local diagnostics division and the British National Formulary. Results Seventy-four patients were admitted with DNSI during the study period. Forty (54%) were male. The mean age was 44.0 years (range: 16-86 years). The most frequent source of infection was the tonsil (n=30, 40.5%). The most common infective organism was Streptococcus constellatus (n=9, 12.2%). The mean length of stay was 11 days. Fifty-five patients (74.3%) required operative intervention. The mean cost of admission per patient was £5,700 (range: £332-£46,700). Conclusions This study highlights the high cost burden of DNSI to the NHS. The incidence of DNSI in Glasgow has risen over the study period; contributing factors may include the reduced tonsillectomy rate and a reduction in antibiotic prescribing. As the incidence of DNSI continues to rise, there will be an increase in cost to the NHS, which must be planned for.

The prevalence of human papillomavirus in pediatric tonsils: a systematic review of the literature.

PubMed

Wojtera, Monika; Paradis, Josee; Husein, Murad; Nichols, Anthony C; Barrett, John W; Salvadori, Marina I; Strychowsky, Julie E

2018-01-30

HPV-related head and neck cancer rates have been increasing in recent years, with the tonsils being the most commonly affected site. However, the current rate of HPV infection in the pediatric population remains poorly defined. The objective of this study was to systematically review and evaluate the prevalence and distribution of HPV in the tonsils of pediatric patients undergoing routine tonsillectomy. The literature was searched using PubMed, EMBASE, Scopus, CINAHL, Cochrane Library, and ProQuest Dissertations & Theses Global databases (inception to December 2017) by two independent review authors. Inclusion criteria included articles which evaluated the prevalence of HPV in a pediatric cohort without known warts or recurrent respiratory papillomatosis, those which used tonsil biopsy specimens for analysis, and those with six or more subjects and clear outcomes reported. Eleven studies met the inclusion criteria. Using the Oxford Clinical Evidence-based Medicine (OCEBM) guidelines, two reviewers appraised the level of evidence of each study, extracted data, and resolved discrepancies by consensus. The systematic review identified 11 articles (n = 2520). Seven studies detected HPV in the subject population, with prevalence values ranging from 0 to 21%. The level of evidence for all included studies was OCEBM Level 3. HPV may be present in pediatric tonsillectomy specimens; however, the largest included study demonstrated a prevalence of 0%. Future testing should be performed using methods with high sensitivities and specificities, such as reverse transcript real-time PCR or digital droplet PCR.

Comparing the effects of peritonsillar infiltration of tramadol before and after the surgery on post-tonsillectomy pain.

PubMed

Maryam, Hatami; Amin, Jesmani; Sedighe, Vaziribozorg; Vida, Ayatollahi

2017-06-01

The aim of the study was to compare the effects of peritonsillar infiltration of tramadol before and after the surgery on post-tonsillectomy pain. In this double-blinded clinical trial study, 80 children aged 5-12 years old with ASA (American Society of Anesthesiologists) class I or II undergoing tonsillectomy involved. In group A (n = 40), after anesthesia induction and before starting the surgery, tramadol 2 mg/kg diluted in normal saline up to 2 cc total volume was injected into the tensile bed by the anesthesiologist using a 25 gauge needle. Surgery began 3 min later and the tonsils were removed using the sharp dissection method. In children of group B (n = 40), anesthesia induction was performed. When surgery was completed, tramadol 2 mg/kg diluted in normal saline up to 2 cc total volume was injected at the site of removing each tonsil using a 25 gauge needle by the anesthesiologist. Using the CHEOPS (Children's Hospital of Eastern Ontario Pain Scale) Scale, pain recorded at different times. Patient sedation was recorded using the RAMSAY Sedation Scale. All the data were analyzed using SPSS 17 statistical software. Two groups significantly felt different pain intensities at different times following the surgery. At the three times, the mean sedation score in the group receiving tramadol infiltration before surgery was a little higher compared to the other group, but this difference was not significant (p > 0.05). As for the relative frequency of nausea and vomiting, the difference was not significant (p = 0.793). Request for analgesics between the groups was not significant (p = 0.556). The mean time of the first feeding after the surgery was not significant between the groups (p = 0.062). Surgical duration was almost the same for both groups (p > 0.05). Systolic blood pressures (before surgery, before extubation, and after extubation) were statistically the same in both groups (p < 0.05). Furthermore, systolic blood pressures 10, 15, and 30 min after entry into the recovery room were the same in both groups. We concluded that peritonsillar infiltration of tramadol before surgery controlled postoperative pain better from 8 h after the surgery to hospital discharge (late effect), but that local infiltration of tramadol after surgery controlled postoperative pain better up to 2 h after the operation (early effect).

[Questions in Ent].

PubMed

Marchal, F

2006-03-22

Role of Helicobacter Pylori and nasopharyngeal bacteries in the pathogenesis of otitis media. Interest of Tonsillectomy in MRSA positive patients. Sleep apnea syndrome increases sudden death during night. Prevalence of Acoustic Neuroma, and surgical difficulties in case of conservative treatment failures. Role of CRP in the sinus treatment's decision. Is sinusitis influenced by anatomical factors? Do we have to treat with antibiotics? Role of mycosis? Are the sprays for snorers efficient? Is the facial nerve now radiologically visible? Are systematic punctures of thyroid nodules mandatory and with what frequency? Cetuximab is a promessing treatment in ENT.

Drug-induced sedation endoscopy in pediatric obstructive sleep apnea syndrome.

PubMed

Boudewyns, A; Verhulst, S; Maris, M; Saldien, V; Van de Heyning, P

2014-12-01

To describe the pattern of upper airway (UA) obstruction during drug-induced sedation endoscopy (DISE) and to evaluate the outcome of DISE-directed treatment. Prospective study of DISE in surgically naive obstructive sleep apnea syndrome (OSAS) children without syndromic comorbidity or craniofacial abnormalities. Treatment was individually tailored according to UA findings during DISE and polysomnographic data. Reported values are median (lower-upper quartile). Thirty-seven children aged 4.1 years (2.1-6.0), with body mass index z-score 0.3 (-0.9 to 0.9), and obstructive apnea-hypopnea index (oAHI) 9.0/h (6.1-19.3) were included. Adenotonsillar obstruction was found in 33 cases (89%) as an isolated entity or as part of a multi-level obstruction. These children were treated with adenotonsillectomy (n = 28), adenoidectomy (n = 3), or tonsillectomy (n = 2). The remaining four patients received non-surgical treatment. Pre-postoperative polysomnographic data in 22 patients showed a significant improvement in oAHI from 8.6/h (6.7-20.7) to 1.0/h (0.6-2.0) (P = 0.001). Only two of these 22 children had residual OSAS (oAHI ≥ 5/h), indicating a success rate of 91%. Based on UA findings during DISE, a non-surgical treatment was proposed for 11% of children. A 91% success rate was obtained in those treated with (adeno)tonsillectomy. These data suggest that DISE may be helpful to identify patients most likely to benefit from UA surgery. Copyright © 2014 Elsevier B.V. All rights reserved.

Tonsillectomy remains a questionable option for pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS)

PubMed Central

Windfuhr, Jochen P.

2016-01-01

Background: Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) is a disease attributed to children with obsessive compulsive disorders (OCD) or tic disorders associated with streptococcal infections. Because otolaryngologists examine a large number of pediatric patients with recurrent streptococcal infections, tonsillectomy (TE) is a common option of therapy. This study was conducted to evaluate the efficacy of TE in patients presenting with verified PANDAS. Material and methods: A PubMed review was performed using search terms “tonsillectomy” and “PANDAS”, “OCD”, “compulsive” “pediatric autoimmune”, “chorea” and “tic” limited by publication date of January 1, 1995, to July 31, 2015. Reviews without patients were not included in the review. Results: Nine papers matched our search criteria, including 6 case reports with 8 patients and 3 case series. Most case reports were in favor of TE, but this was by far not supported by the findings in the case series. The follow-up ranged from 2 to 36 months in case reports and from 24 to 36 in case series. Conclusion: Establishing the diagnosis of PANDAS is complicated because of underlying comorbidities in the field of neurology-psychiatry and the lack of a reliable biomarker. The positive outcome after TE as reported in case studies may be influenced by the postoperative medication and is not supported by the results of large-scale studies. In the light of the considerable postoperative morbidity rate, it appears wise to indicate TE for PANDAS only in supervised clinical studies. PMID:28025607

Tissue welding tonsillectomy provides an enhanced recovery compared to that after monopolar electrocautery technique in adults: a prospective randomized clinical trial.

PubMed

Silvola, Juha; Salonen, Aarre; Nieminen, Jouko; Kokki, Hannu

2011-02-01

We have compared tonsillectomy (TE) with tissue welding (TW) technology using a specially designed forceps versus conventional monopolar electrocautery to evaluate whether this new technology may improve recovery after TE. This was a single-blind, randomized clinical trial with two parallel groups. Sixty healthy adult day-surgery patients were allocated into the TW-TE group (n = 31) and the monopolar electrocautery-TE group (n = 29). We recorded intraoperative events and short- and long-term recovery for 2 weeks postoperatively. The patients and study nurses evaluating patients during recovery were blinded to the operation method used. All patients in the TW-TE group completed the study as per protocol, but in the monopolar electrocautery-TE group, there was one drop-out in the hospital and another after discharge. There was no difference in the perioperative parameters and early recovery between the two groups. After discharge, recovery was significantly faster in the TW group than in the monopolar group: (1) the duration of postoperative pain was 2 days shorter, and (2) activities of normal daily living were less affected, and (3) the need for hospital contacts after discharge, and (4) the incidence of postoperative bleeding was less in the TW group than that in the monopolar group. No patients in the TW group developed secondary bleeding versus three patients in the monopolar group requiring electrocautery to control bleeding. In conclusion; our results indicate that, TW technique may provide reduced pain, faster recovery, and fewer complications compared to electrocautery TE.

Clinical value of antistreptolysin O levels in adult patients with tonsillitis: report I.

PubMed

Trushin, Vladimir; Englender, Moshe

2017-04-01

To assess the clinical value of antistreptolysin O (ASO) level in adult patients with acute tonsillitis of group A beta-hemolytic streptococcus (GABHS) etiology and its interaction with the Centor score and throat cultures data. ASO antibody titers and throat cultures were obtained from 260 adult patients with acute tonsillitis of GABHS etiology initially proven by the Centor score. The results were compared with the group of 100 adult patients with recurrent tonsillitis who underwent tonsillectomy and with the group of 100 healthy adults. Throat cultures revealed GABHS-positive results in 69 acute cases (26.5%) and in 24 recurrent cases (24%), i.e., with no significant differences between the groups (p = 0.845). There was no significant difference between cases with GABHS-positive and with GABHS-negative throat culture in ASO titers results (mean 250 and 280, respectively, p = 0.44) but these titers were significantly higher than established normative data (p < 0.01). For the group of recurrent tonsillitis cases, the mean ASO titer was 363 being significantly higher in comparison with acute cases (p = 0.015). The ASO antibody titers are significantly higher than normative ranges in cases of acute tonsillitis in adults. The detection of the elevated titers may lead to early antibiotherapy to tonsillitis. The Centor score is supported by the ASO data and less supported by throat cultures data. Further research should reveal if these titers might have predictive value for possible further recurrence or serve as an indicator for tonsillectomy in cases of recurrent tonsillitis.

Adeno-tonsillectomy and rapid maxillary distraction in pre-pubertal children, a pilot study.

PubMed

Guilleminault, Christian; Monteyrol, Pierre-Jean; Huynh, Nelly T; Pirelli, Paola; Quo, Stacey; Li, Kasey

2011-05-01

When both narrow maxilla and moderately enlarged tonsils are present in children with obstructive sleep apnea, the decision of which treatment to do first is unclear. A preliminary randomized study was done to perform a power analysis and determine the number of subjects necessary to have an appropriate response. Thirty-one children, 14 boys, diagnosed with OSA based on clinical symptoms and polysomnography (PSG) findings had presence of both narrow maxillary complex and enlarged tonsils. They were scheduled to have both adeno-tonsillectomy and RME for which the order of treatment was randomized: group 1 received surgery followed by orthodontics, while group 2 received orthodontics followed by surgery. Each child was seen by an ENT, an orthodontist, and a sleep medicine specialist. The validated pediatric sleep questionnaire and PSG were done at entry and after each treatment phase at time of PSG. Statistical analyses were ANOVA repeated measures and t tests. The mean age of the children at entry was 6.5 ± 0.2 years (mean ± SEM). Overall, even if children presented improvement of both clinical symptoms and PSG findings, none of the children presented normal results after treatment 1, at the exception of one case. There was no significant difference in the amount of improvement noted independently of the first treatment approach. Thirty children underwent treatment 2, with an overall significant improvement shown for PSG findings compared to baseline and compared to treatment 1, without any group differences. This preliminary study emphasizes the need to have more than subjective clinical scales for determination of sequence of treatments.

Trends and changes in paediatric tonsil surgery in Sweden 1987–2013: a population-based cohort study

PubMed Central

Borgström, Anna; Nerfeldt, Pia; Friberg, Danielle; Sunnergren, Ola; Stalfors, Joacim

2017-01-01

Objectives The objective of this study was to longitudinally describe the history of tonsil surgery in Swedish children and adolescents regarding incidence, indications for surgery, surgical methods and the age and gender distributions. Setting A retrospective longitudinal population-based cohort study based on register data from the Swedish National Patient Register (NPR) and population data from Statistics Sweden. Participants All Swedish children 1–<18 years registered in the NPR with a tonsil surgery procedure 1987–2013. Results 167 894 tonsil surgeries were registered in the NPR 1987–2013. An increase in the total incidence rate was observed, from 22/10 000 person years in 1987 to 47/10 000 in 2013. The most marked increase was noted in children 1–3 years of age, increasing from 17 to 73/10 000 person years over the period. The proportion children with obstructive/sleep disordered breathing (SDB) indications increased from 42.4% in 1987 to 73.6% in 2013. Partial tonsillectomy, tonsillotomy (TT), increased since 1996 and in 2013 55.1% of all tonsil procedures were TTs. Conclusions There have been considerable changes in clinical practice for tonsil surgery in Swedish children over the past few decades. Overall, a doubling in the total incidence rate was observed. This increase consisted mainly of an increase in surgical procedures due to obstructive/SDB indications, particularly among the youngest age group (1–3 years old). TT has gradually replaced tonsillectomy as the predominant method for tonsil surgery. PMID:28087550

The Glasgow Benefit Inventory: a systematic review of the use and value of an otorhinolaryngological generic patient-recorded outcome measure

PubMed Central

Hendry, J.; Chin, A.; Swan, I.R.C.; Akeroyd, M.A.; Browning, G.G.

2018-01-01

Background The Glasgow Benefit Inventory (GBI) is a validated, generic patient-recorded outcome measure widely used in otolaryngology to report change in quality of life post-intervention. Objectives of review To date, no systematic review has made (i) a quality assessment of reporting of Glasgow Benefit Inventory outcomes; (ii) a comparison between Glasgow Benefit Inventory outcomes for different interventions and objectives; (iii) an evaluation of subscales in describing the area of benefit; (iv) commented on its value in clinical practice and research. Type of review Systematic review. Search strategy ‘Glasgow Benefit Inventory’ and ‘GBI’ were used as keywords to search for published, unpublished and ongoing trials in PubMed, EMBASE, CINAHL and Google in addition to an ISI citation search for the original validating Glasgow Benefit Inventory paper between 1996 and January 2015. Evaluation method Papers were assessed for study type and quality graded by a predesigned scale, by two authors independently. Papers with sufficient quality Glasgow Benefit Inventory data were identified for statistical comparisons. Papers with <50% follow-up were excluded. Results A total of 118 eligible papers were identified for inclusion. A national audit paper (n = 4325) showed that the Glasgow Benefit Inventory gave a range of scores across the specialty, being greater for surgical intervention than medical intervention or ‘reassurance’. Fourteen papers compared one form of surgery versus another form of surgery. In all but one study, there was no difference between the Glasgow Benefit Inventory scores (or of any other outcome). The most likely reason was lack of power. Two papers took an epidemiological approach and used the Glasgow Benefit Inventory scores to predict benefit. One was for tonsillectomy where duration of sore throat episodes and days with fever were identified on multivariate analysis to predict benefit albeit the precision was low. However, the traditional factor of number of episodes of sore throat was not predictive. The other was surgery for chronic rhinosinusitis where those with polyps on univariate analysis had greater benefit than those without. Forty-three papers had a response rate of >50% and gave sufficient Glasgow Benefit Inventory total and subscales for meta-analysis. For five of the 11 operation categories (vestibular schwannoma, tonsillectomy, cochlear implant, middle ear implant and stapes surgery) that were most likely to have a single clear clinical objective, score data had low-to-moderate heterogeneity. The value in the Glasgow Benefit Inventory having both positive and negative scores was shown by an overall negative score for the management of vestibular schwannoma. The other six operations gave considerable heterogeneity with rhinoplasty and septoplasty giving the greatest percentages (98% and 99%) most likely because of the considerable variations in patient selection. The data from these operations should not be used for comparative purposes. Five papers also reported the number of patients that had no or negative benefit, a potentially a more clinically useful outcome to report. Glasgow Benefit Inventory subscores for tonsillectomy were significantly different from ear surgery suggesting different areas of benefit Conclusions The Glasgow Benefit Inventory has been shown to differentiate the benefit between surgical and medical otolaryngology interventions as well as ‘reassurance’. Reporting benefit as percentages with negative, no and positive benefit would enable better comparisons between different interventions with varying objectives and pathology. This could also allow easier evaluation of factors that predict benefit. Meta-analysis data are now available for comparison purposes for vestibular schwannoma, tonsillectomy, cochlear implant, middle ear implant and stapes surgery. Fuller report of the Glasgow Benefit Inventory outcomes for non-surgical otolaryngology interventions is encouraged. PMID:26264703

The Glasgow Benefit Inventory: a systematic review of the use and value of an otorhinolaryngological generic patient-recorded outcome measure.

PubMed

Hendry, J; Chin, A; Swan, I R C; Akeroyd, M A; Browning, G G

2016-06-01

The Glasgow Benefit Inventory (GBI) is a validated, generic patient-recorded outcome measure widely used in otolaryngology to report change in quality of life post-intervention. To date, no systematic review has made (i) a quality assessment of reporting of Glasgow Benefit Inventory outcomes; (ii) a comparison between Glasgow Benefit Inventory outcomes for different interventions and objectives; (iii) an evaluation of subscales in describing the area of benefit; (iv) commented on its value in clinical practice and research. Systematic review. 'Glasgow Benefit Inventory' and 'GBI' were used as keywords to search for published, unpublished and ongoing trials in PubMed, EMBASE, CINAHL and Google in addition to an ISI citation search for the original validating Glasgow Benefit Inventory paper between 1996 and January 2015. Papers were assessed for study type and quality graded by a predesigned scale, by two authors independently. Papers with sufficient quality Glasgow Benefit Inventory data were identified for statistical comparisons. Papers with <50% follow-up were excluded. A total of 118 eligible papers were identified for inclusion. A national audit paper (n = 4325) showed that the Glasgow Benefit Inventory gave a range of scores across the specialty, being greater for surgical intervention than medical intervention or 'reassurance'. Fourteen papers compared one form of surgery versus another form of surgery. In all but one study, there was no difference between the Glasgow Benefit Inventory scores (or of any other outcome). The most likely reason was lack of power. Two papers took an epidemiological approach and used the Glasgow Benefit Inventory scores to predict benefit. One was for tonsillectomy where duration of sore throat episodes and days with fever were identified on multivariate analysis to predict benefit albeit the precision was low. However, the traditional factor of number of episodes of sore throat was not predictive. The other was surgery for chronic rhinosinusitis where those with polyps on univariate analysis had greater benefit than those without. Forty-three papers had a response rate of >50% and gave sufficient Glasgow Benefit Inventory total and subscales for meta-analysis. For five of the 11 operation categories (vestibular schwannoma, tonsillectomy, cochlear implant, middle ear implant and stapes surgery) that were most likely to have a single clear clinical objective, score data had low-to-moderate heterogeneity. The value in the Glasgow Benefit Inventory having both positive and negative scores was shown by an overall negative score for the management of vestibular schwannoma. The other six operations gave considerable heterogeneity with rhinoplasty and septoplasty giving the greatest percentages (98% and 99%) most likely because of the considerable variations in patient selection. The data from these operations should not be used for comparative purposes. Five papers also reported the number of patients that had no or negative benefit, a potentially a more clinically useful outcome to report. Glasgow Benefit Inventory subscores for tonsillectomy were significantly different from ear surgery suggesting different areas of benefit The Glasgow Benefit Inventory has been shown to differentiate the benefit between surgical and medical otolaryngology interventions as well as 'reassurance'. Reporting benefit as percentages with negative, no and positive benefit would enable better comparisons between different interventions with varying objectives and pathology. This could also allow easier evaluation of factors that predict benefit. Meta-analysis data are now available for comparison purposes for vestibular schwannoma, tonsillectomy, cochlear implant, middle ear implant and stapes surgery. Fuller report of the Glasgow Benefit Inventory outcomes for non-surgical otolaryngology interventions is encouraged. © 2015 The Authors. Clinical Otolaryngology Published by John Wiley & Sons Ltd.

Surgery on the larynx and pharynx in Byzantium (AD 324-1453): early scientific descriptions of these operations.

PubMed

Lascaratos, J; Assimakopoulos, D

2000-04-01

We present the techniques of various operations on the larynx and pharynx (incision of abscesses of the tonsils, tonsillectomy, tracheotomy, uvulectomy, and removal of foreign bodies) found in the Greek texts of Byzantine physicians. The techniques of these operations were the first to be so meticulously described and were compiled from the texts, now lost, of the ancient Greek physicians. These medical texts, which followed and enriched the Hippocratic, Hellenistic, Roman, and Galenic medical traditions, later influenced medieval European surgery, either directly through Latin translations or indirectly through works of Arab physicians.

Harris P. Mosher Award thesis. Peritonsillar abscess: incidence, current management practices, and a proposal for treatment guidelines.

PubMed

Herzon, F S

1995-08-01

Currently there is no agreement on the treatment of patients who develop a peritonsillar abscess (PTA). This lack of consensus results in highly variable and possibly expensive therapeutic regimens that may not provide optimum quality patient care at reasonable cost. The present study evaluates surgical, medical, diagnostic, and cost factors that affect the management of PTA based on the following: 1. a cohort study of 123 patients with PTA treated using needle aspiration as the initial surgical drainage; 2. a national survey of the PTA management practices of otolaryngologists; and 3. meta-analyses of various components of the treatment regimen for PTA. In the cohort study, patients diagnosed with PTA were treated by both otolaryngologists and emergency medicine specialists with needle aspiration as the primary surgical modality resulting in a 96% acute resolution rate for PTA. In the national survey, questionnaires were sent to 2000 randomly selected members of the American Academy of Otolaryngology-Head and Neck Surgery regarding their management of PTA. The return rate was 73%. Ninety-six percent of the physicians who returned survey forms treated an average of seven PTAs per year using either needle aspiration, incision and drainage, or abscess tonsillectomy to drain the abscess initially. The incidence of PTA in the United States and Puerto Rico among patients 5 to 59 years of age treated by survey practitioners is 30.1 per 100,000 person years, accounting for approximately 45,000 cases per year. Four meta-analyses were completed to quantify the success rate of needle aspiration in the treatment of PTA (94%), the recurrence rate of PTA (10% to 15%), the rate at which penicillin-resistant microorganisms are found in patients with PTA (0% to 56%), and the rate of prior oropharyngeal infections associated with PTA (11% to 56%). The recurrence rate for PTA in the United States is 10%, which is significantly different from the recurrence rate of 15% reported from the rest of the world (P < .002). A clinical intervention for PTA is proposed based on the clinical series, the national survey data, and the meta-analyses. These clinical guidelines recommend that needle aspiration be used as the initial surgical drainage procedure for all patients with a PTA other than those who have indications for abscess tonsillectomy. Patients should be treated in an outpatient setting, should receive penicillin if they are not allergic to it, and should receive adequate pain medication. The evidence does not suggest that there is any benefit in examining the abscess contents for microorganisms. Approximately 30% of patients with PTA can be expected to exhibit relative indications for a tonsillectomy.(ABSTRACT TRUNCATED AT 400 WORDS)

Pediatric Price Transparency: Still Opaque With Opportunities for Improvement.

PubMed

Faherty, Laura J; Wong, Charlene A; Feingold, Jordyn; Li, Joan; Town, Robert; Fieldston, Evan; Werner, Rachel M

2017-10-01

Price transparency is gaining importance as families' portion of health care costs rise. We describe (1) online price transparency data for pediatric care on children's hospital Web sites and state-based price transparency Web sites, and (2) the consumer experience of obtaining an out-of-pocket estimate from children's hospitals for a common procedure. From 2015 to 2016, we audited 45 children's hospital Web sites and 38 state-based price transparency Web sites, describing availability and characteristics of health care prices and personalized cost estimate tools. Using secret shopper methodology, we called children's hospitals and submitted online estimate requests posing as a self-paying family requesting an out-of-pocket estimate for a tonsillectomy-adenoidectomy. Eight children's hospital Web sites (18%) listed prices. Twelve (27%) provided personalized cost estimate tool (online form n = 5 and/or phone number n = 9). All 9 hospitals with a phone number for estimates provided the estimated patient liability for a tonsillectomy-adenoidectomy (mean $6008, range $2622-$9840). Of the remaining 36 hospitals without a dedicated price estimate phone number, 21 (58%) provided estimates (mean $7144, range $1200-$15 360). Two of 4 hospitals with online forms provided estimates. Fifteen (39%) state-based Web sites distinguished between prices for pediatric and adult care. One had a personalized cost estimate tool. Meaningful prices for pediatric care were not widely available online through children's hospital or state-based price transparency Web sites. A phone line or online form for price estimates were effective strategies for hospitals to provide out-of-pocket price information. Opportunities exist to improve pediatric price transparency. Copyright © 2017 by the American Academy of Pediatrics.

Determinants of physiological uptake of 18F-fluorodeoxyglucose in palatine tonsils.

PubMed

Birkin, Emily; Moore, Katherine S; Huang, Chao; Christopher, Marshall; Rees, John I; Jayaprakasam, Vetrisudar; Fielding, Patrick A

2018-06-01

To determine the extent of physiological variation of uptake of F-flurodeoxyglucose (FDG) within palatine tonsils. To define normal limits for side-to-side variation and characterize factors affecting tonsillar uptake of FDG.Over a period of 16 weeks 299 adult patients at low risk for head and neck pathology, attending our center for FDG positron emission tomography/computed tomography (PET/CT) scans were identified. The maximum standardized uptake value (SUVmax) was recorded for each palatine tonsil. For each patient age, gender, smoking status, scan indication and prior tonsillectomy status as well as weather conditions were noted.There was a wide variation in palatine tonsil FDG uptake with SUVmax values between 1.3 and 11.4 recorded. There was a strong left to right correlation for tonsillar FDG uptake within each patient (P < .01). The right palatine tonsil showed increased FDG uptake (4.63) compared to the left (4.47) (P < .01). In multivariate analysis, gender, scan indication, and prevailing weather had no significant impact of tonsillar FDG uptake. Lower tonsillar uptake was seen in patients with a prior history of tonsillectomy (4.13) than those without this history (4.64) (P < .01). Decreasing tonsillar FDG uptake was seen with advancing age (P < .01). Significantly lower uptake was seen in current smokers (SUVmax 4.2) than nonsmokers (SUV 4.9) (P = .03).Uptake of FDG in palatine tonsils is variable but shows a strong side-to-side correlation. We suggest the left/ right SUVmax ratio as a guide to normality with a first to 99th percentiles of (0.70-1.36) for use in patients not suspected to have tonsillar pathology.

Expression of cutaneous lymphocyte-associated antigen (CLA) in tonsillar T-cells and its induction by in vitro stimulation with alpha-streptococci in patients with pustulosis palmaris et plantaris (PPP).

PubMed

Nozawa, Hayabusa; Kishibe, Kan; Takahara, Miki; Harabuchi, Yasuaki

2005-07-01

Pustulosis palmaris et plantaris (PPP) is known to be a one of the tonsil-related diseases because tonsillectomy is quite effective in curing this condition. However etiological association between tonsils and PPP have not fully clarified yet. Cutaneous lymphocyte-associated antigen (CLA) is known to be a specific homing receptor that facilitates T-cell migration into skin. In this study, we investigated the expression of CLA on T-cells in tonsil, peripheral blood, and skin from patients with PPP. Two-color flow cytometric and two-color immunohistological analyses revealed that the numbers of CLA/CD3 double-positive cells in freshly isolated tonsillar mononuclear cells (TMC) and in tonsillar tissues were significantly higher in patients with PPP than in patients without PPP (P<0.01, each). In vitro stimulus with alpha-streptococcal antigens enhanced CLA expression of tonsillar T-cells and TGF-beta production of TMC in patients with PPP (P<0.01, each), but did not in patients without PPP. In peripheral blood from PPP patients, the number of the CLA/CD3 double-positive cells significantly decreased at 6 months after tonsillectomy (P<0.05). The CLA/CD3 double-positive cells and the postcapillary venule that expressed with a ligand of CLA, E-selectin, were found more frequently in the plantar skin from patients with PPP as compared to that from healthy volunteers (P<0.01, each). These data suggest that a novel immune response to alpha-streptococci may enhance CLA expression on tonsillar T-cells through TGF-beta production in patients with PPP, resulting in moving of CLA-positive tonsillar T-cells to skin and tissue damages. This may play a key role in pathogenesis of PPP.

[Detection of human papillomavirus in the upper respiratory tract in children without recurrent respiratory papillomatosis].

PubMed

Sun, Yue-feng; Wu, Yi-dong; Wu, Lei; Jiang, Juan-juan; Gao, Rong; Xu, Bin; Chen, Xiao-wei; Zhao, Zheng-yan

2012-12-01

The purpose of this prospective study was to investigate the presence of human papillomavirus (HPV) in tonsillectomy and adenoidectomy specimens from pediatric patients without juvenile-onset recurrent respiratory papillomatosis (JORRP), so as to understand the effect of HPV infection in the upper respiratory tract in children. Two hundred and forty-one pediatric patients without known JORRP or other HPV-related diseases undergoing tonsillectomy and/or adenoidectomy for hypertrophy or chronic tonsillitis were enrolled in this prospective study. One hundred and seventy-seven fresh samples of tonsillar tissues and 195 samples of adenoid tissues were collected and then examined for the presence of HPV DNA with the polymerase chain reaction (PCR) technique and typing. Laryngeal papilloma specimens from 17 patients obtained during routine debulking procedures were also analyzed and served as positive controls. All 17 papilloma specimens were positive for HPV DNA and the type was 6 or 11. This result confirmed that the methods used were valid for detecting HPV infection. HPV DNA was detected in 2 of the 177 tonsillar specimens and zero of the 195 adenoid specimens. The two positive samples were confirmed with typing. One was positive for HPV6 and the other for HPV11. Review of the medical records of these two cases confirmed that there were no history of HPV-related diseases. Histologic analysis of their specimens showed lymphoid hyperplasia, no specific changes suggesting HPV infection and no signs of malignancy. The HPV infection rate in upper respiratory tract was 0.8% (2/241). There is HPV infection in upper respiratory tract in Chinese children without JORRP, but maybe is not sufficient for the formation of JORRP.

Characteristics and Disease Course in a Cohort of Children With PFAPA Syndrome in the Community of Madrid, Spain.

PubMed

Ibáñez Alcalde, María de Las Mercedes; Caldevilla Asenjo, Laura; Calvo Rey, Cristina; García-Mon Marañés, Fernando; Blázquez Gamero, Daniel; Saavedra Lozano, Jesús; Navarro Gómez, María Luisa; Hernández-Sampelayo Matos, Teresa; Santos Sebastián, Mar

2017-12-08

PFAPA syndrome is an autoinflammatory disease whose diagnosis is mainly clinical. Several treatments have been proposed; among them, tonsillectomy could be an effective one. Retrospective multicenter study. Patients included were diagnosed with PFAPA syndrome, according to the Thomas criteria, in 3 hospitals in Madrid between 2009-2013. Thirty-two cases were included. Median age at onset and at diagnosis were 32 months (IQR 24-44) and 47.5 months (IQR 37-60), respectively. There were increases in leukocytes (13,580/μL [IQR 8,200-16,600] vs. 8,300/μL [IQR 7,130-9,650], P=.005), neutrophils (9,340/μL [IQR 5,900-11,620] vs. 3,660/μL [IQR 2,950-4,580], P=.002) and C-reactive protein (11.0mg/dL [IQR 6.6-12.7] vs. 0.2mg/dL [IQR 0.1-0.6], P=.003) during febrile episodes. In all, 80.8% of patients reported remission of symptoms within 24h after oral corticosteroid therapy. Fourteen patients were tonsillectomized. In 11, the febrile episodes stopped while, in 3, the frequency was reduced; there were 2 cases of postoperative bleeding. The disease was resolved in 56.3% of the patients, at a median age of 60 months (IQR 47-95), with similar duration in patients who were tonsillectomized and those who were not. We present a large cohort of children with PFAPA syndrome, with clinical and analytical features similar to those described in the literature, and a good response to corticosteroids and a high resolution rate of symptoms after tonsillectomy. Copyright © 2017 Elsevier España, S.L.U. and Sociedad Española de Reumatología y Colegio Mexicano de Reumatología. All rights reserved.

Intracellular Persisting Staphylococcus aureus Is the Major Pathogen in Recurrent Tonsillitis

PubMed Central

Zautner, Andreas E.; Krause, Merit; Stropahl, Gerhard; Holtfreter, Silva; Frickmann, Hagen; Maletzki, Claudia; Kreikemeyer, Bernd; Pau, Hans Wilhelm; Podbielski, Andreas

2010-01-01

Background The two major indications for tonsillectomy are recurrent tonsillitis (RT) and peritonsillar abscess (PTA). Unlike PTAs, which are primarily treated surgically, RT is often cured by tonsillectomy only after a series of failed drug therapy attempts. Although the bacteriological background of RT has been studied, the reason for the lack of success of conservative therapeutic approaches is not well understood. Methods In a prospective study, tonsil specimens from 130 RT patients and 124 PTA patients were examined for the presence of extra- and intracellular bacteria using antibiotic protection assays. Staphylococcus aureus isolates from RT patients were characterized by pulsed-field gel electrophoresis (PFGE), spa-typing and MSCRAMM-gene-PCR. Their ability for biofilm formation was tested and their cell invasiveness was confirmed by a flow cytometric invasion assay (FACS), fluorescent in situ hybridization (FISH) and immunohistochemistry. Findings S. aureus was the predominant species (57.7%) in RT patients, whereas Streptococcus pyogenes was most prevalent (20.2%) in PTA patients. Three different assays (FACS, FISH, antibiotic protection assay) showed that nearly all RT-associated S. aureus strains were located inside tonsillar cells. Correspondingly, the results of the MSCRAMM-gene-PCRs confirmed that 87% of these S. aureus isolates were invasive strains and not mere colonizers. Based upon PFGE analyses of genomic DNA and on spa-gene typing the vast majority of the S. aureus isolates belonged to different clonal lineages. Conclusions Our results demonstrate that intracellular residing S. aureus is the most common cause of RT and indicate that S. aureus uses this location to survive the effects of antibiotics and the host immune response. A German translation of the Abstract is provided as supplementary material (Abstract S1). PMID:20209109

[Polythelia and renal malformation].

PubMed

Jójárt, G; Seres, E

1992-07-12

The authors found 241 polythelia (5.86) among 4113 schoolchildren (aged 6-14 years). They investigated 236 of the 241 with ultrasound and found 10 renal malformations (4.24%). Among 280 controls with respiratory infection, accident or tonsillectomy they found 9 renal malformations (3.21%). With screening of 1635 neonates they found 66 with accessory nipples (4.05%). Two of the 66 had renal malformations (3.03%), while among the 1957 control neonates 37 had renal malformations (1.89%). In the hospital and ambulancy the authors found 106 polythelia, five of them had renal abnormalities (4.72%). The authors did not found association of polythelia and renal malformation with ultrasound investigation of 408 children with polythelia.

Clinical Factors Associated with PANDAS

PubMed Central

Murphy, Tanya K.; Storch, Eric A.; Lewin, Adam B.; Edge, Paula J.; Goodman, Wayne K.

2011-01-01

Objective To explore associated clinical factors in children with pediatric autoimmune neuropsychiatric disorders associated with streptococcus (PANDAS). Study design Children with tics and/or OCD (n = 109) were examined by personal and family history, diagnostic interview, physical examination, medical record review, and measurement of baseline levels of streptococcal antibodies. Results Significant group differences were found on several variables, such that those diagnosed with PANDAS (versus without PANDAS) were more likely to have had dramatic onset; definite remissions; remission of neuropsychiatric symptoms during antibiotic therapy; a history of tonsillectomies/adenoidectomies; evidence of GAS infection, and clumsiness. Conclusion The identification of clinical features associated with PANDAS should assist in delineating risks for this subtype of OCD/tics. PMID:21868033

Lymphangiomatous Polyp of Tonsil: A Case Report.

PubMed

Sayar, Hamide; Sayar, Çağdaş; Adamhasan, Fulya; Uğuz, Aysun

2016-01-01

Lymphangiomatous polyps of the palatine tonsils are uncommon hamartomatous proliferations that could be clinically misdiagnosed as malignant neoplasms. These polyps consist of dilated lymphatic vessels located inside fibrous and/or adipose tissue. In this paper, a 27-year-old man who presented to the outpatient clinic with a complaint of dysphagia is presented. On physical examination, the patient had a smooth, polypoid mass extending from the posterior section of the right palatine tonsil into the oropharynx. The patient underwent right tonsillectomy. Histopathological examination of the specimen showed typical features of a lymphangiomatous polyp of the tonsil. The case is reported with the accompanying literature to avoid the possibility of misdiagnosing it as a malignant lesion clinically.

Novel use of tissue expander for dilation of oropharyngeal stenosis.

PubMed

Banerjee, Debdeep; Wang, James C; Demke, Joshua C

2014-11-01

Naso/oropharyngeal stenoses are uncommon surgical complications. We present a child having undergone previous adenoidectomy without complication who developed naso/oropharyngeal scarring after subsequent tonsillectomy. She presented with nasal obstruction and frequent gasping at night worrisome for obstructive sleep apnea. Scar was initially excised and the defect allografted. Conventional esophageal dilators were undersized, and ultimately a tissue expander was used intraoperatively as a balloon dilator. The patient's symptoms and sleep apnea resolved. We found use of a tissue expander as a balloon dilator to be at least minimally effective in dilating the oropharynx when all other methods at our disposal proved ineffective. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.

The comparison of preincisional peritonsillar infiltration of ketamine and tramadol for postoperative pain relief on children following adenotonsillectomy.

PubMed

Ugur, Kadriye Serife; Karabayirli, Safinaz; Demircioğlu, Rüveyda İrem; Ark, Nebil; Kurtaran, Hanifi; Muslu, Bunyamin; Sert, Hüseyin

2013-11-01

To investigate and compare the effectiveness of preincisional peritonsillar infiltration of ketamine and tramadol for post-operative pain on children following adenotonsillectomy. Prospective randomized double blind controlled study. Seventy-five children aged 3-10 years undergoing adenotonsillectomy were included in study. Patients received injections in peritonsillar fossa of tramadol (2 mg/kg-2 ml), ketamine (0.5 mg/kg-2 ml) or 2 ml serum physiologic. During operation heart rate, oxygen saturation, average mean blood pressures were recorded in every 5 min. Operation, anesthesia and the time that Alderete scores 9-10, patient satisfaction, analgesic requirements were recorded. Postoperatively nausea, vomiting, sedation, dysphagia, bleeding scores were recorded at 0, 10, 30, 60 min and 2, 4, 8, 12, 18, 24h postoperatively. Pain was evaluated using modified Children's Hospital of Eastern Ontario Pain Scale (mCHEOPS) at fixed intervals after the procedure (15 min and 1, 4, 12, 16, and 24h postoperatively). The recordings of heart rate, mean arterial pressure, nausea, vomiting, sedation and bleeding scores were similar in all groups (p>0.05). The mCHEOPS scores at 10 min, 30 min, 1h, 8h were significantly lower in both tramadol and ketamine group when compared with control (p<0.05). Use of additional analgesia at 10 min and 18 h were higher in control group than ketamine, tramadol group (p<0.05). Dysphagia scores were significantly lower for both ketamine and tramadol group when compared with control group (p<0.05). mCHEOPS, additional analgesia, dysphagia, patient satisfaction scores were similar in tramadol, ketamine groups (p>0.05). Preincisional injection of ketamine and tramadol prior to tonsillectomy is safe, effective method and equivalent for post-tonsillectomy pain, patient satisfaction, postoperative nausea, vomiting, dysphagia. Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.

The effectiveness of a storybook in lessening anxiety in children undergoing tonsillectomy and adenoidectomy in Northern Ireland.

PubMed

Tunney, Anne Marie; Boore, Jennifer

2013-12-01

This study aimed to assess the effectiveness of a storybook, entitled, The Tale of Woody's Tonsils, written by Anne Marie Tunney, on reducing the level of anxiety of children aged 5-11 years who were undergoing tonsillectomy and adenoidectomy in one hospital in Northern Ireland. BACKGROUND/LITERATURE REVIEW: Psychological preparation of children for surgery impacts coping. There is evidence, in both adult and pediatric studies, that effective psychological preparation for a surgical procedure has an impact on the individuals' coping ability with reduced levels of anxiety leading to better post-operative outcome, faster recovery and a reduction in long term sequelae associated with admission to hospital. A storybook, as a method of preparation, has been recommended by a number of researchers but the effectiveness of this in reducing anxiety has not yet been investigated in the UK. Previous studies have mainly used only one research instrument for anxiety measurement and child self-report is not a commonly used feature of such research. A quasi-experimental study involving 80 children was conducted using a repeated measures design. Children attending a pre-assessment clinic were randomly allocated to either an experimental group (received the storybook) or a control group (did not get the storybook). Anxiety was tested both pre- and post-intervention using a self-report Hospital Fears Rating Scale and Child Drawing: Hospital, a projective technique based on children's drawings. The storybook was found to be effective in reducing pre-operative anxiety and was found to be particularly effective for females and in the 7-year-old age group. Practice Implications; This study demonstrates the storybook's effectiveness for alleviating anxiety and advocates the use of child focused anxiety measurement tools. It reinforces the need for pre assessment to include exploration of anxiety triggers so that preoperative preparation and nursing care can be individualized for each child.

Reconstructive procedures for disturbed functions within the upper airway: pharyngeal breathing/snoring

PubMed Central

Verse, Thomas

2005-01-01

Breathing disorders which have their origin within the pharynx mainly occur during sleep. These so-called obstructive sleep-related breathing disorders include three different disturbances which have to be distinguished properly: simple snoring, upper airway resistance syndrome (UARS) and obstructive sleep apnea (OSA). Each disturbance requires a different treatment. Simple snoring does not affect the physical health of the snorer himself, but often leads to social problems due to the annoying character of the breathing sounds. Appropriate treatment modalities are oral devices and transcutaneous or ttransmucosal electrical stimulation of the muscles of the floor of the mouth via surface electrodes. As reconstructive surgical procedures adenotomies, tonsillectomies, tonsillotomies, or adenotonsillectomies are successfully used in children. Moreover, in adults radiofrequency treatments of the tonsils, the soft palate and of the base of tongue, as well as uvulopalatopharyngoplasty (UPPP), laser-assisted uvulopalatoplasty (LAUP) and palatal implants are adequate treatments for simple snoring. Adequate therapies for UARS and mild OSA (less than 20 breathing events per hour of sleep) are oral appliances. Nasal continuos positive airway pressure (NCPAP) ventilation is a very successful treatment modality, but shows low compliance in these patients, as daytime symptoms like excessive sleepiness or or impaired cognitive functions are often unincisive in patients with mild OSA. Reconstructive procedures like UPPP, radiofrequency surgery of the tonsils or the base of tongue, hyoid suspension, mandibular osteotomy with genioglossus advancement (MO) are successful treatment options either as isolated procedures or in combination within so-called multi-level surgery concepts. Goldstandard for the treatment of moderate to severe OSA is the nCPAP ventilation. All patients should at least try this treatment modality. Only in the rare cases of nCPAP failure (2%) and in the relatively frequent cases of nCPAP incompliance (30%) reconstructive surgical procedures become necessary as second choice treatments. These are adenectomies, tonsillectomies, tonsillotomies in children and hyoid suspension, MO, multi-level surgery concepts, or maxillomandibular advancement osteotomies in adults. PMID:22073056

Utilization of a postoperative adenotonsillectomy teaching video: A pilot study.

PubMed

Khan, Sarah; Tumin, Dmitry; King, Adele; Rice, Julie; Jatana, Kris R; Tobias, Joseph D; Raman, Vidya T

2017-11-01

Pediatric tonsillectomies are increasingly being performed as an outpatient procedure thereby increasing the parental role in post-operative pain management. However, it is unclear if parents receive adequate teaching regarding pain management. We introduced a video teaching tool and compared its efficacy alone and in combination with the standard verbal instruction. A prospective study which randomized parents or caregivers of children undergoing tonsillectomy ± adenoidectomy into three groups: 1) standard verbal post-operative instructions; 2) watching the video teaching tool along with standard verbal instructions or 3) video teaching tool only. Parents completed pre and post-instruction assessments of their knowledge of post-operative pain management with responses scored from 0 to 8. Telephone assessments were conducted within 48 post-operative hours with a subjective rating of the helpfulness of the video teaching tool. The study cohort included 99 patients and their families. The median pre-instruction score was 5 of 8 points (Interquartile range [IQR]: 4, 6) and this remained at 5 following instruction. (IQR:4, 6; p = 0.702 difference from baseline). Baseline scores did not vary across the groups (p = 0.156) and there was no increase in the knowledge score from pre to post-test across the three groups. Groups B and C rated the helpfulness of the video teaching tool with a median score of 4 of 5. (IQR: 4, 5). A baseline deficit exists in parental understanding of post-operative pain management that did not statistically improve regardless of the form post-operative instruction used (verbal vs. video-based instruction). However, the high helpfulness scores in both video groups support the use of video instruction as an alternative to or to complement to verbal instruction. However, further identification of knowledge deficits is required for optimization of post-operative educational materials. Copyright © 2017 Elsevier B.V. All rights reserved.

Indications for tonsillectomy stratified by the level of evidence

PubMed Central

Windfuhr, Jochen P.

2016-01-01

Background: One of the most significant clinical trials, demonstrating the efficacy of tonsillectomy (TE) for recurrent throat infection in severely affected children, was published in 1984. This systematic review was undertaken to compile various indications for TE as suggested in the literature after 1984 and to stratify the papers according to the current concept of evidence-based medicine. Material and methods: A systematic Medline research was performed using the key word of “tonsillectomy“ in combination with different filters such as “systematic reviews“, “meta-analysis“, “English“, “German“, and “from 1984/01/01 to 2015/05/31“. Further research was performed in the Cochrane Database of Systematic Reviews, National Guideline Clearinghouse, Guidelines International Network and BMJ Clinical Evidence using the same key word. Finally, data from the “Trip Database” were researched for “tonsillectomy” and “indication“ and “from: 1984 to: 2015“ in combination with either “systematic review“ or “meta-analysis“ or “metaanalysis”. Results: A total of 237 papers were retrieved but only 57 matched our inclusion criteria covering the following topics: peritonsillar abscess (3), guidelines (5), otitis media with effusion (5), psoriasis (3), PFAPA syndrome (6), evidence-based indications (5), renal diseases (7), sleep-related breathing disorders (11), and tonsillitis/pharyngitis (12), respectively. Conclusions: 1) The literature suggests, that TE is not indicated to treat otitis media with effusion. 2) It has been shown, that the PFAPA syndrome is self-limiting and responds well to steroid administration, at least in a considerable amount of children. The indication for TE therefore appears to be imbalanced but further research is required to clarify the value of surgery. 3) Abscesstonsillectomy as a routine is not justified and indicated only for cases not responding to other measures of treatment, evident complications, or with a significant history of tonsillitis. In particular, interval-tonsillectomy is not justified as a routine. 4) TE, with or without adenoidectomy, is efficacious to resolve sleep-related breathing disorders resulting from (adeno)tonsillar hypertrophy in children. However, the benefit is reduced by co-morbidities, such as obesity, and further research is required to identify prognostic factors for this subgroup of patients. Further research is indicated to clarify selection criteria not only for this subpopulation that may benefit from less invasive procedures such as tonsillotomy in the long-term. 5) Further trials are also indicated to evaluate the efficacy of TE on the clinical course in children with psoriasis guttata as well as on psoriasis vulgaris in adults, not responding to first-line therapy. 6) Conflicting results were reported concerning the role of TE in the concert to treat Ig-A nephropathy, mandating further clinical research. 7) Most importantly, randomized-controlled clinical trials with an adequate long-term follow-up are desirable to clarify the benefit of TE in patients with recurrent episodes of tonsillitis, with or without pharyngitis. Factors like age, spontaneous healing rate and postoperative quality of life have to be included when comparing TE with antibiotic therapy. PMID:28025609

Tissue welding forceps usage in superficial parotidectomy: a clinical assessment.

PubMed

Michel, Randall G; Tsau, Kang; Weinstock, Bernard I

2008-01-01

Tissue welding forceps (TWF) have been used effectively in a number of surgical procedures including blood vessel harvesting and tonsillectomy. Our objective was to assess the safety and efficacy of TWF usage in superficial parotidectomy. We performed a retrospective review of 25 patients between November 2002 and July 2006 who underwent superficial parotidectomy using TWF. The inpatient and outpatient records were reviewed for diagnosis, operative times, estimated blood loss, and postoperative facial paresis. Only one of the 25 patients (4%) who underwent superficial parotidectomy using TWF had transient postoperative facial weakness and no procedure had blood loss of greater than 150 cc. This initial evaluation suggests that use of TWF is safe in superficial parotidectomy and may help reduce the development of postoperative facial paresis.

A radical proposition: the brief but exceptional history of the Seattle school clinic, 1914-21.

PubMed

Woolworth, Stephen

2013-04-01

This article examines the history of the Seattle school clinic (1914-21) and the efforts of public school administrators to institutionalize a full-service medical program for poor and working class children. At its height, thirty-six volunteer physicians and thirteen partially paid dentists organized within nine departments performed a range of diagnostic and "corrective" surgical procedures, including tonsillectomies, circumcisions, and eye surgeries. These practices were not funded by other public school systems across the United States, almost all of which delineated between prevention and treatment services. This article explains the exceptional nature of the clinic, examines the institutional tensions instigated by the expression of medical authority within the schools, and considers how clinic technologies influenced state-school-child relations.

Clinical factors associated with pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections.

PubMed

Murphy, Tanya K; Storch, Eric A; Lewin, Adam B; Edge, Paula J; Goodman, Wayne K

2012-02-01

To explore associated clinical factors in children with pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS). Children with tics, obsessive-compulsive disorder, or both (n=109) were examined with personal and family history, diagnostic interview, physical examination, medical record review, and measurement of baseline levels of streptococcal antibodies. Significant group differences were found on several variables, such that children in whom PANDAS (versus without PANDAS) were more likely to have had dramatic onset, definite remissions, remission of neuropsychiatric symptoms during antibiotic therapy, a history of tonsillectomies/adenoidectomies, evidence of group A streptococcal infection, and clumsiness. The identification of clinical features associated with PANDAS should assist in delineating risks for this subtype of obsessive-compulsive disorder/tics. Copyright © 2012 Mosby, Inc. All rights reserved.

Traditional practices and other socio-cultural factors affecting the health of children in Saudi Arabia.

PubMed

Abdullah, M A

1993-01-01

The medical services in Saudi Arabia have improved tremendously over the last two decades, and health centres are easily accessible to more than 93% of the population. Nevertheless, folk medicine, including cautery, bone setting, manual tonsillectomy, uvulectomy, use of herbal medicines and use of harmful teething powders, in addition to religious healing, is widely practised. Reasons include influence of grandparents, religious beliefs and failure of modern medicine to find an answer to some chronic disorders. These problems, and measures to counteract them, are discussed. Attention is also drawn to some of the harmful 'imported' practices that are affecting the health of children, including smoking, children driving cars and problems resulting from dependence on housemaids to bring up children. Some nutritional beliefs and taboos are also mentioned.

Streptococcal toxic shock syndrome complicating a peritonsillar abscess.

PubMed

Aalling, Mathilde; Klug, Tejs Ehlers

2015-02-01

A 68-year-old man was admitted to hospital in an acute confusional state with a 2-week history of fever, influenza-like illness and sore throat. He quickly developed coagulation disturbances, hypotension and renal function impairment. Despite broad-spectrum antibiotic therapy, he deteriorated. Group A streptococcus (GAS) was recovered from blood cultures, which gave the diagnosis streptococcal toxic shock syndrome (STSS). A computed tomography scan showed a right-sided peritonsillar abscess (PTA). Acute tonsillectomy was carried out and the patient recovered. STSS complicating PTA has not previously been described in the literature, but GAS is a common pathogen in PTA. Clinicians should be aware that STSS can develop secondary to tonsillar infections and that abscess development should be suspected in STSS patients who do not respond to antibiotic treatment.

Relevance of the hygiene hypothesis to early vs. late onset allergic rhinitis.

PubMed

Matheson, M C; Walters, E H; Simpson, J A; Wharton, C L; Ponsonby, A-L; Johns, D P; Jenkins, M A; Giles, G G; Hopper, J L; Abramson, M J; Dharmage, S C

2009-03-01

The hygiene hypothesis proposes that reduced exposure to infections in early life increases the risk of developing allergic conditions including allergic rhinitis. We examined the association between markers of the hygiene hypothesis and allergic rhinitis that developed before 7 years of age and allergic rhinitis that developed after 7 years of age. The Tasmanian Longitudinal Health Study (TAHS) is a population-based cohort (n=8583) study of respiratory disease. Participants have been followed from 7 to 44 years of age. Information on potential risk factors, allergies and respiratory symptoms was collected longitudinally. Using multi-nomial logistic regression, exposure to siblings, infections, tonsillectomy and farm residence during childhood were examined as risk factors for allergic rhinitis that developed before or after 7 years of age. All analyses were adjusted for gender, maternal and paternal atopy, mother's age at participant's birth, paternal socio-economic status in 1968 and personal socio-economic status in 2004. Greater cumulative exposure to siblings before the age of 2 years was strongly inversely associated with early onset allergic rhinitis (<1 year sib exposure: OR=0.6, 95% CI 0.3-1.0; 1-3 years sib exposure: OR=0.6, 95% CI 0.4-0.9; >3 years sib exposure: OR=0.4, 95% CI 0.3-0.8) less so with later onset allergic rhinitis. The risk of early onset allergic rhinitis decreased with increasing viral infections (OR=0.7, 95% CI 0.5-0.9) during childhood. Having a tonsillectomy before 7 years of age increased the risk of early onset allergic rhinitis (OR=1.7, 95% CI 1.2-2.5). None of these factors was associated with later onset allergic rhinitis. Exposures relevant to the hygiene hypothesis were important predictors for the development of early onset but less so for later onset allergic rhinitis. The exact mechanisms by which siblings and infections protect against allergic rhinitis are unclear. The stronger findings for earlier onset allergic rhinitis suggest that family structure and infections have most impact on disease risk in early life. Further research should focus on early onset allergic rhinitis when exploring causal explanations for any sibling effect.

Tonsillectomy and Adenoidectomy in Children with Sleep-Related Breathing Disorders: Consensus Statement of a UK Multidisciplinary Working Party

PubMed Central

Robb, PJ; Bew, S; Kubba, H; Murphy, N; Primhak, R; Rollin, A-M; Tremlett, M

2009-01-01

During 2008, ENT-UK received a number of professional enquiries from colleagues about the management of children with upper airway obstruction and uncomplicated obstructive sleep apnoea (OSA). These children with sleep-related breathing disorders (SRBDs) are usually referred to paediatricians and ENT surgeons. In some district general hospitals, (DGHs) where paediatric intensive care (PICU) facilities to ventilate children were not available, paediatrician and anaesthetist colleagues were expressing concern about children with a clinical diagnosis of OSA having routine tonsillectomy, with or without adenoidectomy. As BAPO President, I was asked by the ENT-UK President, Professor Richard Ramsden, to investigate the issues and rapidly develop a working consensus statement to support safe but local treatment of these children. The Royal Colleges of Anaesthetists and Paediatrics and Child Health and the Association of Paediatric Anaesthetists nominated expert members from both secondary and tertiary care to contribute and develop a consensus statement based on the limited evidence base available. Our terms of reference were to produce a statement that was brief, with a limited number of references, to inform decision-making at the present time. With patient safety as the first priority, the working party wished to support practice that facilitated referral to a tertiary centre of those children who could be expected, on clinical assessment alone, potentially to require PICU facilities. In contrast, the majority of children who could be safely managed in a secondary care setting should be managed closer to home in a DGH. BAPO, ENT-UK, APA, RCS-CSF and RCoA have endorsed the consensus statement; the RCPCH has no mechanism for endorsing consensus statements, but the RCPCH Clinical Effectiveness Committee reviewed the statement, concluding it was a ‘concise, accurate and helpful document’. The consensus statement is an interim working tool, based on level-five evidence. It is intended as the starting point to catalyze further development towards a fully structured, evidence-based guideline; to this end, feedback and comment are welcomed. This and the constructive feedback from APA and RCPCH will be incorporated into a future guideline proposal. PMID:19622257

Oropharyngeal examination to predict sleep apnea severity.

PubMed

Barceló, Xavier; Mirapeix, Rosa M; Bugés, Jordi; Cobos, Albert; Domingo, Christian

2011-10-01

To evaluate the usefulness of the examination of the upper airway, paying special attention to the Friedman tongue position (FTP), to confirm obstructive sleep apnea syndrome (OSAS) and its severity. Prospective, single-center, cross-sectional study. Sleep disorders unit of a community hospital. A total of 301 consecutive patients admitted to the sleep disorders unit due to suspicion of OSAS. Assessments included body mass index calculated as weight in kilograms divided by height in meters squared (BMI); neck perimeter measurement; oropharyngeal examination; fiberendoscopy; rhinomanometry; and a sleep study. Apnea-hypopnoea index (AHI), FTP, the uvula size, and certain complementary examinations (sex, age, BMI, cervical perimeter, nasal flow) whose importance has not been clearly established, and to explore their potential value as predictors of the AHI. Findings included the following: the mean (SD) age of the patients was 51 (12) years; 71.1% were male; the mean (SD) BMI was 29.8 (4.6); and the mean (SD) cervical perimeter, 40.5 (3.7) cm. In 94.0% of the patients the AHI value was at least 5.0/hour. Patients with FTP scores of 2 and 3 accounted for 74.1% of the whole cohort: 14.3% had an FTP score of 1, and only 11.6% had a score of 4. Of the 6.0% of cases with a normal AHI, 16 patients were classified as having FTP scores of 1, and 2 as having a score of 2. Tonsil size score (P = .005), uvula score (P = .003), BMI (P < .001), cervical perimeter (P < .001), nasal flow at 150 Pa (P = .02), and age (P = .007) were related to OSAS severity. Curiously, AHI in patients who had undergone tonsillectomy was higher than in the TS1 group (tonsils inside the tonsillar fossa) and quite similar to the TS 2 group (tonsils that extend beyond the tonsillar pillars). In the multiple regression model, only the FTP score showed a relevant relationship to OSAS severity. First, since the FTP score is almost the only parameter related to OSAS severity, a simple oropharyngeal examination can provide key information on this issue. Second, tonsillectomy does not seem to protect against development of OSAS.

Tonsillectomy and adenoidectomy in children with sleep-related breathing disorders: consensus statement of a UK multidisciplinary working party.

PubMed

Robb, P J; Bew, S; Kubba, H; Murphy, N; Primhak, R; Rollin, A-M; Tremlett, M

2009-07-01

During 2008, ENT-UK received a number of professional enquiries from colleagues about the management of children with upper airway obstruction and uncomplicated obstructive sleep apnoea (OSA). These children with sleep-related breathing disorders (SRBDs) are usually referred to paediatricians and ENT surgeons. In some district general hospitals, (DGHs) where paediatric intensive care (PICU) facilities to ventilate children were not available, paediatrician and anaesthetist colleagues were expressing concern about children with a clinical diagnosis of OSA having routine tonsillectomy, with or without adenoidectomy. As BAPO President, I was asked by the ENT-UK President, Professor Richard Ramsden, to investigate the issues and rapidly develop a working consensus statement to support safe but local treatment of these children. The Royal Colleges of Anaesthetists and Paediatrics and Child Health and the Association of Paediatric Anaesthetists nominated expert members from both secondary and tertiary care to contribute and develop a consensus statement based on the limited evidence base available. Our terms of reference were to produce a statement that was brief, with a limited number of references, to inform decision-making at the present time. With patient safety as the first priority, the working party wished to support practice that facilitated referral to a tertiary centre of those children who could be expected, on clinical assessment alone, potentially to require PICU facilities. In contrast, the majority of children who could be safely managed in a secondary care setting should be managed closer to home in a DGH. BAPO, ENT-UK, APA, RCS-CSF and RCoA have endorsed the consensus statement; the RCPCH has no mechanism for endorsing consensus statements, but the RCPCH Clinical Effectiveness Committee reviewed the statement, concluding it was a 'concise, accurate and helpful document'. The consensus statement is an interim working tool, based on level-five evidence. It is intended as the starting point to catalyze further development towards a fully structured, evidence-based guideline; to this end, feedback and comment are welcomed. This and the constructive feedback from APA and RCPCH will be incorporated into a future guideline proposal.

Up-regulation of CC chemokine receptor 6 on tonsillar T cells and its induction by in vitro stimulation with α-streptococci in patients with pustulosis palmaris et plantaris

PubMed Central

Yoshizaki, T; Bandoh, N; Ueda, S; Nozawa, H; Goto, T; Kishibe, K; Takahara, M; Harabuchi, Y

2009-01-01

Pustulosis palmaris et plantaris (PPP) is a tonsil-related disease; tonsillectomy is somewhat effective in treating the condition. However, the aetiological association between the tonsils and PPP has not yet been elucidated fully. Recently, some chemokines and chemokine receptors, including CC chemokine receptor (CCR) 4, CCR6 and CX chemokine receptor (CXCR) 3, have been reported to play important roles in the development of psoriasis, a disease related closely to PPP. In this study, we found that CCR6 expression on both tonsillar and peripheral blood T cells was up-regulated more intensively in PPP patients than in non-PPP patients (P < 0·001 for both), but CCR4 and CXCR3 expressions were not. In vitro stimulation with α-streptococcal antigen enhanced CCR6 expression significantly on tonsillar T cells in PPP patients (P < 0·05), but this was not observed in non-PPP patients. The chemotactic response of tonsillar T cells to the CCR6 ligand CC chemokine ligand (CCL) 20 was significantly higher in PPP patients than in non-PPP patients (P < 0·05). The percentage of CCR6-positive peripheral blood T cells decreased after tonsillectomy in PPP patients (P < 0·01); this decrease correlated with an improvement of skin lesions (P < 0·05, r = −0·63). The numbers of CCR6-positive cells and the expression of CCL20 were increased significantly in pathological lesions compared with non-pathological lesions in PPP skin (P < 0·01, P < 0·05 respectively). These results suggest that a novel immune response to α-streptococci may enhance CCR6 expression on T cells in tonsils and that CCR6-positive T cells may move to peripheral blood circulation, resulting in recruitment to target skin lesions expressing CCL20 in PPP patients. This may be one of the key roles in pathogenesis of the tonsil-related disease PPP. PMID:19659772

Adenoid and tonsil surgeries in children: how relevant is pre-operative blood grouping and cross-matching?

PubMed

Onotai, Lucky; Lilly-Tariah, Opubo da

2013-01-01

As a part of pre-operative evaluation, several otolaryngologists group and cross-match blood routinely for children undergoing adenoid and tonsil surgeries. This practice has generated several debates either in support or against this practice. The aim of this study is to critically evaluate the incidence of post-tonsillectomy (with or without adenoidectomy) bleeding and blood transfusions in otherwise healthy children with adenoid/tonsil pathologies conducted in the University of Port Harcourt Teaching Hospital (UPTH). A descriptive retrospective study of children who underwent adenoid and tonsil surgeries in the Department of Ear, Nose and Throat (ENT) surgery of UPTH from January 2003 to December 2012. Children with family history of bleeding disorders and derangement of clotting profile as well as different co-morbidity like sickle cell disease were excluded from this study. The patients' data were retrieved from the registers of ENT out-patient clinics, theatre registers and patients case notes. Demographic data, indications for surgery, preoperative investigations, complications and management outcomes were recorded and analyzed. Out of 145 children that had adenoid and tonsil surgeries; only 100 met the criteria for this study. The study subjects included 65 males and 35 females (male: female ratio 1.9:1) belonging to 0-16 years age group (mean age: 3.46 ± 2.82 years). The age group of 3-5 years had the highest (n = 40, 40%) number of surgeries. Adenotonsillectomy was the commonest (n = 85, 85%) surgery performed on patients who had obstructive sleep apnea (OSA). The commonest (n = 6, 6%) complication was haemorrhage, and only few (n = 3, 3%) patients had blood transfusion. However, mortality was recorded in some (n = 3, 3%) patients. This study confirms that the incidence of post adenoidectomy/tonsillectomy bleeding in otherwise healthy children is low and rarely requires blood transfusion. We can conclude that routine preoperative blood grouping and cross-matching of blood for all children undergoing elective adenoid and tonsil surgeries seemed irrelevant and not cost effective. However, it could be carried out in only special circumstances.

Trend in otolaryngological surgeries in an era of super-aging: Descriptive statistics using a Japanese inpatient database.

PubMed

Suzuki, Sayaka; Yasunaga, Hideo; Matsui, Hiroki; Fushimi, Kiyohide; Yamasoba, Tatsuya

2018-03-27

To reveal the age distribution and capture the longitudinal trend in otolaryngological surgeries performed in Japan, where society is rapidly aging. Using the Diagnosis Procedure Combination database, we extracted data on patients who were hospitalized and underwent any type of otolaryngological surgery in departments of otolaryngology or head and neck surgery from fiscal year 2007 to fiscal year 2013. Type of surgery, patient's age, and fiscal year were compared. We categorized >200 types of surgeries into eight specialties: ear surgery, functional endoscopic sinus surgery (FESS), other types of paranasal surgery (except for malignancy), head and neck cancer surgery, benign tumor surgery, upper airway surgery (including pharynx and larynx), removal of foreign body, and other. In total, 558,732 patients were included. The proportions of patients in each age category formed two peaks in middle age and in children aged ≤9years. The proportion of all surgeries made up by FESS, other paranasal surgery, benign tumor surgery, and head and neck cancer surgery gradually increased with age, forming a peak in patients in their 60s. The proportion of ear surgery was highest in patients aged ≤9years (34.0% of all surgeries, mostly myringotomy and transtympanic ventilation tube insertion) and formed a gradual peak in patients in their 60s (mostly tympanoplasty). The proportion of upper airway surgery (tonsillectomy and adenoidectomy) was highest in patients aged ≤9years (25.3% of all surgeries). The proportion of foreign body removal was highest in patients aged ≤9years (52.2% of all surgeries) and increased slightly with age. In 2013, compared with 2007, those aged 65-74 years and ≥75years made up a larger percentage of patients undergoing each specific surgery, including tympanoplasty, stapedectomy/stapedotomy, FESS, head and neck cancer surgery, pharyngolaryngectomy, total/subtotal glossectomy, thyroid lobectomy, parotidectomy (for a benign tumor), submandibular gland resection, tonsillectomy, and vocal fold polypectomy. The age distribution of otolaryngological surgeries varied by specialty. We found an increased proportion of patients aged 65-74 and ≥75years in most specific surgeries. Copyright © 2018 Elsevier B.V. All rights reserved.

A case of synovitis, acne, pustulosis, hyperostosis, and osteitis (SAPHO) syndrome presenting with hypertrophic pachymeningitis.

PubMed

Shiraishi, Wataru; Hayashi, Shintaro; Iwanaga, Yasutaka; Murai, Hiroyuki; Yamamoto, Akifumi; Kira, Jun-ichi

2015-02-15

A 43-year-old woman with a 3-year history of headache, fever, and swelling of the forehead, presented to our hospital. A general examination revealed palmar and plantar pustules. Blood analyses showed an elevated white blood cell count, C-reactive protein level, and erythrocyte sedimentation rate. Brain MRI revealed a partially thickened cranial bone with gadolinium enhancement, and also abnormally enhanced dura mater. Bone scintigraphy showed involvement of the cranial bone and bilateral sternoclavicular joints. Palmar skin biopsy indicated palmoplantar pustulosis. From these results, SAPHO (synovitis, acne, pustulosis, hyperostosis and osteitis) syndrome with associated hypertrophic pachymeningitis was diagnosed. After corticosteroid therapy and tonsillectomy, the clinical symptoms and radiological abnormalities were improved. Clinicians should be aware of SAPHO as a potential unusual cause of hypertrophic pachymeningitis. Copyright © 2014 Elsevier B.V. All rights reserved.

Radiofrequency ablation versus electrocautery in tonsillectomy.

PubMed

Hall, Daniel J; Littlefield, Philip D; Birkmire-Peters, Deborah P; Holtel, Michael R

2004-03-01

The objective of this study was to compare the safety, difficulty of removal, and postoperative pain profile of radiofrequency ablation versus standard electrocautery removal of tonsils. A prospective, blinded study was designed to remove 1 tonsil with each of the 2 methods. Time of operation, estimated blood loss, difficulty of operation, postoperative pain, rate of postoperative hemorrhage, and the patient's preferred technique were evaluated. The operating time was significantly longer (P < 0.007) and the patients reported significantly less pain (P < 0.001) with radiofrequency ablation. There were no differences in blood loss, difficulty of operation, or postoperative hemorrhage rates. The patients preferred the radiofrequency ablation technique (P < 0.001). Radiofrequency ablation is a viable method to remove tonsillar tissue. Operating time for this procedure will likely decrease with experience. There was significantly less pain reported with radiofrequency ablation compared with standard electrocautery.

A painful stiff neck following an ear, nose, and throat surgical procedure: case report.

PubMed

Pavlidis, Elena; Copioli, Cristiana; Spagnoli, Carlotta; Mazzotta, Silvia; Ormitti, Francesca; Crisi, Girolamo; Pisani, Francesco

2015-02-01

Grisel syndrome is a rare, nontraumatic atlantoaxial subluxation, typical of developmental ages and characterized by head flexion/rotation and painful fixation. Neurological symptoms may occur. It is secondary to head/neck infections and ear, nose, and throat surgery (adenoidectomy, tonsillectomy, and mastoidectomy). Here, we report the case of a child who presented a painful stiff neck following an adenotonsillectomy, with imaging evidencing an atlantoaxial subluxation. The child showed improvement in his condition following a conservative treatment with antibiotics, anti-inflammatory, and analgesic therapy and cervical collar. We believe it is of great significance for clinicians taking into account this peculiar condition in the differential diagnosis of a stiff neck in pediatric patients, thus avoiding misdiagnosis and delays. Indeed, its diagnosis is mainly based on a focused anamnesis associated with the detection of the typical neuroradiological findings. Georg Thieme Verlag KG Stuttgart · New York.

Streptococcal toxic shock syndrome secondary to a deep neck space infection presenting with no throat or neck symptoms.

PubMed

Rahman, Habib; Illing, Elizabeth; Webb, Christopher; Banhegyi, Gyorgy

2013-05-24

A previously fit and well 44-year-old gentleman was admitted with a 3-week history of parotid swelling, malaise and feeling generally unwell. His only medical history was α-thalassaemia trait. Initial ear, nose and throat examination was unremarkable. Routine observations highlighted tachycardia, hypotension and a raised respiratory rate. Despite fluid resuscitation, his hypotension failed to resolve and he was admitted to intensive care for inotropic support. He was started on broad spectrum antibiotics and blood cultures isolated Lancefield group A Streptococcus. No obvious source of sepsis was identified. A CT scan from neck to pelvis highlighted a collection around the right tonsil, splenomegaly and widespread small volume lymphadenopathy. A right tonsillectomy, intraoral drainage of parapharyngeal and retropharyngeal abscesses and excision of an axillary lymph node were performed. With continued intravenous antibiotics and supportive measures, he recovered fully. Histology showed reactive lymphadenitis, but no cause of immunocompromise.

Obstructive sleep apnea in a 5 month old with tonsillar hypertrophy secondary to congenital neutropenia: Case report and literature review.

PubMed

Ahmed, O G; Lambert, E M

2017-05-01

Tonsillectomy and adenoidectomy (T&A) is the primary surgical treatment for obstructive sleep apnea (OSA) in children with tonsillar and adenoid hypertrophy (TAH). We present the case of a 5-month old male with congenital neutropenia who developed severe TAH during treatment with granulocyte colony-stimulating factor (G-CSF). He had severe OSA, decreased oral intake, and failure to thrive (FTT) which all improved after undergoing a successful intracapsular T&A. We describe a successful procedure to help alleviate symptoms of OSA and FTT in this young infant with congenital neutropenia who developed TAH during treatment with G-CSF. It highlights the need for further research into the pathophysiology of TAH in immunocompromised children and the effects of G-CSF on Waldeyer's Ring. Copyright © 2017 Elsevier B.V. All rights reserved.

Adherence to Swedish guidelines for pain treatment in relation to pediatric tonsil surgery: A survey of the multidisciplinary team.

PubMed

Alm, F; Jaensson, M; Lundeberg, S; Ericsson, E

2017-10-01

Pain management in children after tonsil surgery is essential, and optimal pain treatment has been discussed for many years. Data from the National Tonsil Register in Sweden (NTRS) and a national mapping have demonstrated the need for national pain treatment guidelines for pediatric tonsil surgery. As a result, Swedish national guidelines, together with updated patient information on the website tonsilloperation.se, were developed and implemented in 2013. The objective of this study was to evaluate the professionals' opinions of and adherence to pain treatment guidelines for pediatric tonsil surgery patients in a two-year follow-up. This descriptive cross-sectional study was based on data from an inter-professional questionnaire, which was validated by an expert group using a content validity index (S-CVI 0.93). The questionnaire was sent to all Swedish ear, nose and throat (ENT) departments (n = 49) that the NTRS identified as performing tonsil surgery on children younger than 18 years of age. In each clinic, we asked for responses from staff in each of the following professions: ENT physicians, anesthesia physicians, registered nurse anesthetists, and registered nurses in the ENT departments. Respondents from 48 ENT departments participated, and 139/163 (85%) completed questionnaires were returned. The guidelines were reported as being clear, ensuring patient safety and providing optimal pharmacological treatment. Treatment was given according to the guidelines: Half of the departments gave pre- or intraoperative treatment with clonidine, betamethasone and high-dose paracetamol (acetaminophen). A multimodal pain approach (paracetamol and COX-inhibitors) after hospital discharge was prescribed by all departments after tonsillectomy and, extensively, after tonsillotomy. One-third of the departments prescribed paracetamol with a higher normal dose for the first three postoperative days. Half of the departments prescribed rescue analgesics, clonidine or opioids after tonsillectomy. None of the departments prescribed codeine or tramadol, drugs that are discouraged in the guidelines. The majority of the departments used the website tonsilloperation.se to provide information to the patients and their caregivers. The respondents' opinions of and the ENT departments adherence to the Swedish national guidelines were considered to be good. The national implementation process in Sweden has impacted the manner in which ENT departments treat pain after tonsil surgery. Copyright © 2017 Elsevier B.V. All rights reserved.

Investigation of Helicobacter pylori in tonsillary tissue with Pronto Dry test and pathologic examination.

PubMed

Aslan, Sundus; Yilmaz, Ismail; Bal, Nebil; Sener, Mesut; Butros, Reha; Demirhan, Beyhan; Ozluoglu, Levent N

2007-09-01

The objectives of this clinical study were to identify, by means of the Pronto Dry test and pathologic examination, Helicobacter pylori (HP) in tonsillary tissue and to establish the role of HP in tonsillary microbiology by identifying that bacterium in the tonsillary mucosa or within the tonsil core. The subjects consisted of 52 patients (25 men and 27 women; age range, 3-65 years; mean age, 15.1+/-14.5 years) who were scheduled to undergo tonsillectomy for the treatment of chronic tonsillitis and who had not been treated with an antibiotic or a bismuth-containing compound for 6 months before the initiation of the study. In each patient, two specimens (one 4 mm x 4 mm tissue sample from the nonmucosal tonsil core and one 4 mm x 4 mm sample of mucosal tissue) were excised from both tonsils immediately after tonsillectomy. The specimens were placed in the Pronto Dry test kit, and the test results were obtained 1 h later. The remaining tonsillary tissues were submitted for pathologic analysis via hematoxylin-eosin stain, Giemsa stain, Warthin-Starry silver stain, and staining for inducible nitric oxide synthase (iNOS). The results of the Pronto Dry test were positive for HP in 42% (n=22) of the excised mucosal tissue and in 47% (n=24) of the excised core tissue. In 27% (n=14) of the patients, both the core and the mucosal tissues tested positive for HP. There was no significant difference between the positive Pronto Dry test ratios of the biopsies obtained from the mucosa and those obtained from the core (P=0.693). iNOS staining showed that macrophage iNOS activity was significantly higher (P=0.025) in biopsied mucosal tissues with a positive Pronto Dry test result than in those with a negative result. Light microscopy revealed no HP in samples stained with hematoxylin-eosin stain, Giemsa stain, or Warthin-Starry silver stain. Positive Pronto Dry test results and the results of iNOS staining showed that HP contributes to chronic tonsillitis, especially at the mucosal layer. Although HP does not colonize, it contributes to the chronic tonsillary inflammatory process as a triggering agent by affecting macrophages in the tonsil and thus increasing iNOS expression.

Lymphoid papillary hyperplasia of the palatine tonsil: a Chinese case report

PubMed Central

Zhao, Ming; Yu, Jingjing; Li, Changshui

2013-01-01

Lymphoid papillary hyperplasia is a rare abnormality of the tonsils with a predilection for affecting young Asian girls. Herein, we report a 31-year-old Chinese woman presented as right lateral recurrent tonsillar hypertrophy with odynophagia and dysphagia over the past 5 years, worsening over a period of for half a year. Clinically, this lesion was similar to papillomatosis or lymphoid polyposis. However, histopathologic study showed a distinctive form of lymphoid hyperplasia with considerable distinct finger-like projections composed of many phyllodes which contained remarkable follicular lymphoid hyperplasia. This is the only Chinese case of lymphoid papillary hyperplasia of the palatine tonsils that has been reported in the most recent English literature so far. The importance of recognizing this disorder rests in the fact that in spite of the clinical features suggestive of both a benign and a malignant tumor, however, the process is a benign tumor-like proliferation, probably non-neoplastic, could easily be cured by tonsillectomy. PMID:24040465

The prevalence of childhood dysphonia: a cross-sectional study.

PubMed

Carding, Paul N; Roulstone, Sue; Northstone, Kate

2006-12-01

There is only very limited information on the prevalence of voice disorders, particularly for the pediatric population. This study examined the prevalence of dysphonia in a large cohort of children (n = 7389) at 8 years of age. Data were collected within a large prospective epidemiological study and included a formal assessment by one of five research speech and language therapists as well as a parental report of their child's voice. Common risk factors that were also analyzed included sex, sibling numbers, asthma, regular conductive hearing loss, and frequent upper respiratory infection. The research clinicians identified a dysphonia prevalence of 6% compared with a parental report of 11%. Both measures suggested a significant risk of dysphonia for children with older siblings. Other measures were not in agreement between clinician and parental reports. The clinician judgments also suggested significant risk factors for sex (male) but not for any common respiratory or otolaryngological conditions that were analyzed. Parental report suggested significant risk factors with respect to asthma and tonsillectomy. These results are discussed in detail.

Gizmo is a mean word!

PubMed

Koltai, Peter J

2015-04-01

The editorial titled "Gizmos" in the April issue of Otolaryngology-Head and Neck Surgery was unfortunate. Intracapsular tonsillectomy is a rational surgical option for managing tonsillar hypertrophy causing obstructive sleep apnea in selected children. It is performed routinely by surgeons across the globe and has become the standard of care across northern Europe due to the high safety profile of the operation. The semirigid, dartlike design of the sinuplasty devices suggested the idea for an airway-specific set of high-pressure balloons. We began working on these in 2007 and had FDA approval in 2009. They are in wide use by many airway surgeons. Lingual tonsils are a frequent cause of obstructive sleep apnea, and there is no tool that manages this as effectively as endoscopic plasma ablation. We are all engaged in an honorable effort to improve care; surgical and creative skills are as important as analytical skills. Both are necessary for the continuous improvement of our work. Both are worthy of respect. © American Academy of Otolaryngology—Head and Neck Surgery Foundation 2014.

Common management issues in pediatric patients with mild bleeding disorders.

PubMed

O'Brien, Sarah H

2012-10-01

Type 1 von Willebrand disease and mild platelet function defects are among the most common disorders seen by pediatric hematologists. The management and prevention of bleeding in these patients can be challenging, as there are limited published data to guide clinical practice, and a complete lack of randomized clinical trials. Desmopressin (DDAVP) and antifibrinolytics are the mainstays of treatment in these patients, yet the optimal dosing and timing of these agents to prevent or resolve bleeding, while minimizing adverse side effects, is sometimes unclear. DDAVP-induced hyponatremia is a particularly under-recognized complication in children with bleeding disorders who undergo surgery. Clinicians need to be aware of local measures that are equally important in treating problems such as epistaxis and surgical bleeding. This review will discuss the published literature and provide practical suggestions regarding four common management issues in the care of children and adolescents with mild bleeding disorders: epistaxis, heavy menstrual bleeding, dental extractions, and tonsillectomy. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Holmium:YAG laser: 12-year study of indications for use and outcomes in benign and malignant otolaryngological conditions.

PubMed

Joseph, J; Jaberoo, M-C; Dilkes, M

2010-08-01

We present the largest recorded case series of holmium:YAG laser use in otolaryngology. This laser's hand-held delivery device is easier to manipulate compared with other ENT lasers, and its pulsed delivery mode gives it enhanced cutting and coagulation properties. We conducted a 12-year, retrospective study of holmium:YAG laser use in a tertiary referral centre. Sixty-eight patients were included. Nineteen received primary laser treatment of squamous cell carcinoma of the upper aerodigestive tract (nine with simultaneous neck dissection), and 49 underwent either palatine or lingual tonsillectomy for benign disease. One cancer patient developed a pharyngo-cutaneous fistula, and a second suffered a secondary haemorrhage. No other complications were recorded. There were no local recurrences. The holmium:YAG laser is safe and effective for benign and malignant otolaryngological conditions. In cancer treatment, it may be best to delay neck dissection until the primary site has healed, in order to avoid fistula formation.

Snippets from the past: the evolution of Wade Hampton Frost's epidemiology as viewed from the American Journal of Hygiene/Epidemiology.

PubMed

Morabia, Alfredo

2013-10-01

Wade Hampton Frost, who was a Professor of Epidemiology at Johns Hopkins University from 1919 to 1938, spurred the development of epidemiologic methods. His 6 publications in the American Journal of Hygiene, which later became the American Journal of Epidemiology, comprise a 1928 Cutter lecture on a theory of epidemics, a survey-based study of tonsillectomy and immunity to Corynebacterium diphtheriae (1931), 2 papers from a longitudinal study of the incidence of minor respiratory diseases (1933 and 1935), an attack rate ratio analysis of the decline of diphtheria in Baltimore (1936), and a 1936 lecture on the age, time, and cohort analysis of tuberculosis mortality. These 6 American Journal of Hygiene /American Journal of Epidemiology papers attest that Frost's personal evolution mirrored that of the emerging "early" epidemiology: The scope of epidemiology extended beyond the study of epidemics of acute infectious diseases, and rigorous comparative study designs and their associated quantitative methods came to light.

Snippets From the Past: The Evolution of Wade Hampton Frost's Epidemiology as Viewed From the American Journal of Hygiene/Epidemiology

PubMed Central

Morabia, Alfredo

2013-01-01

Wade Hampton Frost, who was a Professor of Epidemiology at Johns Hopkins University from 1919 to 1938, spurred the development of epidemiologic methods. His 6 publications in the American Journal of Hygiene, which later became the American Journal of Epidemiology, comprise a 1928 Cutter lecture on a theory of epidemics, a survey-based study of tonsillectomy and immunity to Corynebacterium diphtheriae (1931), 2 papers from a longitudinal study of the incidence of minor respiratory diseases (1933 and 1935), an attack rate ratio analysis of the decline of diphtheria in Baltimore (1936), and a 1936 lecture on the age, time, and cohort analysis of tuberculosis mortality. These 6 American Journal of Hygiene /American Journal of Epidemiology papers attest that Frost's personal evolution mirrored that of the emerging “early” epidemiology: The scope of epidemiology extended beyond the study of epidemics of acute infectious diseases, and rigorous comparative study designs and their associated quantitative methods came to light. PMID:24022889

Neither hereditary periodic fever nor periodic fever, aphthae, pharingitis, adenitis: Undifferentiated periodic fever in a tertiary pediatric center

PubMed Central

De Pauli, Silvia; Lega, Sara; Pastore, Serena; Grasso, Domenico Leonardo; Bianco, Anna Monica Rosaria; Severini, Giovanni Maria; Tommasini, Alberto; Taddio, Andrea

2018-01-01

AIM To describe the frequency and clinical characteristics of patients with undifferentiated periodic fever (UPF) and to investigate whether a clinical classification of UPF based on the PRINTO-Eurofever score can help predicting the response to treatment and the outcome at follow-up. METHODS Clinical and therapeutic information of patients with recurrent fever who presented at a single pediatric rheumatology center from January 2006 through April 2016 were retrospectively collected. Patients with a clinical suspicion of hereditary periodic fever (HPF) syndrome and patients with clinical picture of periodic fever, aphthae, pharingitis, adenitis (PFAPA) who were refractory to tonsillectomy underwent molecular analysis of five HPF-related genes: MEFV (NM_000243.2), MVK (NM_000431.3), TNFRSF1A (NM_001065.3), NLRP3 (NM_001079821.2), NLRP12 (NM_001277126.1). All patients who had a negative genetic result were defined as UPF and further investigated. PRINTO-Eurofever score for clinical diagnosis of HPF was calculated in all cases. RESULTS Of the 221 patients evaluated for periodic fever, twelve subjects with a clinical picture of PFAPA who were refractory to tonsillectomy and 22 subjects with a clinical suspicion of HPF underwent genetic analysis. Twenty-three patients (10.4%) resulted negative and were classified as UPF. The median age at presentation of patients with UPF was 9.5 mo (IQR 4-24). Patients with UPF had a higher frequency of aphthae (52.2% vs 0%, P = 0.0026) and musculoskeletal pain (65.2% vs 18.2%, P = 0.0255) than patients with genetic confirmed HPF. Also, patients with UPF had a higher frequency of aphthous stomatitis (52.2% vs 10.7%, P < 0.0001), musculoskeletal pain (65.2% vs 8,0%, P < 0.0001), and abdominal pain (52.2% vs 4.8%, P < 0.0001) and a lower frequency of pharyngitis (56.6% vs 81.3%, P = 0.0127) compared with typical PFAPA in the same cohort. Twenty-one of 23 patients with UPF (91.3%) received steroids, being effective in 16; 13 (56.2%) were given colchicine, which was effective in 6. Symptoms resolution occurred in 2 patients with UPF at last follow-up. Classification according to the PRINTO-Eurofever score did not correlate with treatment response and prognosis. CONCLUSION UPF is not a rare diagnosis among patients with periodic fever. Clinical presentation place UPF half way on a clinical spectrum between PFAPA and HPF. The PRINTO-Eurofever score is not useful to predict clinical outcome and treatment response in these patients. PMID:29456932

[2000 year history of tonsillectomy. Images from the history of otorhinolaryngology, highlighted by instruments from the collection of the German Medical History Museum in Ingolstadt].

PubMed

Feldmann, H

1997-12-01

The etymology of the anatomical terms and their use in history are elucidated: "Tonsil" (from Latin tonsa = the oar) in use since Celsus (about 40 AD). The Greek terms of that time, "antiádes", "paristhmia", were not adopted in later medical terminology. "Amygdala" (Greek/Latin = the almond) was introduced by Vesalius in 1543. Vesalius was also the first to depict the tonsils in a specimen of the whole human body; Duverney (1761) gives the first exact depiction of the pharyngeal region. Special anatomical and histological studies of the tonsils were carried out in the 19 century. Cornelius Celsus in Rome (about 40 AD) described the blunt removal of the tonsils by use of the finger. This method was favoured anew by numerous laryngologists at the beginning of the 20th century when it had been realised that a gentle enucleation of the entire tonsil including its capsule was advisable against cutting off a slice, but before long this procedure was discarded again for hygienic reasons. Precursors of special instruments for tonsillectomy were instruments designed for shortening the uvula: uvulotomy. Paré (1564) and Scultetus (1655) devised instruments that permitted placing a thread shaped like a snare around the uvula and cutting it off by strangulation. Hildanus (1646), Scultetus (1655) and Heister (1763) presented an instrument of the guillotine-type for uvulotomy. This instrument was modified by P. S. Physick (USA 1828) and used for tonsillotomy. It became the prototype for a number of similar instruments which were to follow: W. M. F. Fahnestock (USA 1832). M. Mackenzie (London 1880), G. Sluder (USA 1911). Besides these guillotines snares were also perfected and used for tonsillotomy, e.g. by W. Brünings (1908). The concentration on tonsillotomy aimed at performing the operation as quickly as possible, especially in children, as it was not yet possible to sustain general anaesthesia for a longer period of time while doing surgery in the pharynx. The operation of the tonsils, that had been started by general surgeons, at the end of the 19th century became the domain of the otolaryngologists because they had the superior technique of illumination. Important steps of progress were later on mouth-gags combined with tongue-depressors, and placing the head in a suspended and reclined position. This position had already been advocated by Killian in 1920, but it could only be introduced after improved techniques of general anaesthesia were available. These stages of historical development are described and illustrated with many details.

"Loss of breath" as a cause of postoperative hypoxia and bradycardia in children submitted to tonsillectomy.

PubMed

Moro, Eduardo Toshiyuki; Goulart, Alexandre Palmeira

2015-01-01

the "shortness of breath" or "breathing interruption" crisis can be considered a cause of hypoxia in childhood. It is characterized by the presence of a triggering factor followed by weeping and apnea in expiration accompanied by cyanosis or pallor. The sequence of events may include bradycardia, loss of consciousness, abnormal postural tone and even asystole. A review of the literature revealed only two reports of postoperative apnea caused by "shortness of breath". this article describes the case of a child with a history of "shortness of breath" undiagnosed before the adenotonsillectomy, but that represented the cause of episodes of hypoxemia and bradycardia in the postoperative period. the "shortness of breath" crisis should be considered as a possible cause of perioperative hypoxia in children, especially when there is a history suggestive of this problem. As some events may be accompanied by bradycardia, loss of consciousness, abnormal postural tone and even asystole, observation in a hospital setting should be considered. Copyright © 2013 Sociedade Brasileira de Anestesiologia. Published by Elsevier Editora Ltda. All rights reserved.

Oral sensory nerve damage: Causes and consequences.

PubMed

Snyder, Derek J; Bartoshuk, Linda M

2016-06-01

Oral sensations (i.e., taste, oral somatosensation, retronasal olfaction) are integrated into a composite sense of flavor, which guides dietary choices with long-term health impact. The nerves carrying this input are vulnerable to peripheral damage from multiple sources (e.g., otitis media, tonsillectomy, head injury), and this regional damage can boost sensations elsewhere in the mouth because of central interactions among nerve targets. Mutual inhibition governs this compensatory process, but individual differences lead to variation in whole-mouth outcomes: some individuals are unaffected, others experience severe loss, and some encounter sensory increases that may (if experienced early in life) elevate sweet-fat palatability and body mass. Phantom taste, touch, or pain sensations (e.g., burning mouth syndrome) may also occur, particularly in those expressing the most taste buds. To identify and treat these conditions effectively, emerging clinical tests measure regional vs. whole-mouth sensation, stimulated vs. phantom cues, and oral anatomy. Scaling methods allowing valid group comparisons have strongly aided these efforts. Overall, advances in measuring oral sensory function in health and disease show promise for understanding the varied clinical consequences of nerve damage.

Oral Sensory Nerve Damage: Causes and Consequences

PubMed Central

Snyder, Derek J.; Bartoshuk, Linda M.

2016-01-01

Oral sensations (i.e., taste, oral somatosensation, retronasal olfaction) are integrated into a composite sense of flavor, which guides dietary choices with long-term health impact. The nerves carrying this input are vulnerable to peripheral damage from multiple sources (e.g., otitis media, tonsillectomy, head injury), and this regional damage can boost sensations elsewhere in the mouth because of central interactions among nerve targets. Mutual inhibition governs this compensatory process, but individual differences lead to variation in whole-mouth outcomes: some individuals are unaffected, others experience severe loss, and some encounter sensory increases that may (if experienced early in life) elevate sweet-fat palatability and body mass. Phantom taste, touch, or pain sensations (e.g., burning mouth syndrome) may also occur, particularly in those expressing the most taste buds. To identify and treat these conditions effectively, emerging clinical tests measure regional vs. whole-mouth sensation, stimulated vs. phantom cues, and oral anatomy. Scaling methods allowing valid group comparisons have strongly aided these efforts. Overall, advances in measuring oral sensory function in health and disease show promise for understanding the varied clinical consequences of nerve damage. PMID:27511471

Treatment of PANDAS and PANS: a systematic review.

PubMed

Sigra, Sofia; Hesselmark, Eva; Bejerot, Susanne

2018-03-01

Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) are a subtype of acute-onset obsessive-compulsive disorder (OCD) thought to be caused by an autoimmune response to group A streptococcal infection. Based on this proposed pathophysiology, alternative treatments for acute-onset OCD have been introduced, including antibiotics and immunomodulatory interventions. However, the literature on treatment of PANDAS is diverse, and clinical consensus regarding optimal treatment strategy is lacking. We conducted a systematic review of articles in PubMed, Cochrane Library, and Scopus that addressed treatment for PANDAS and related disorders. Twelve research studies involving the following treatments met inclusion criteria: penicillin, azithromycin, intravenous immunoglobulin, plasma exchange, tonsillectomy, cognitive behavior therapy, NSAID and corticosteroids. In addition, 65 case reports in which patients received immunomodulatory treatments, antibiotics, and/or psychotropics were identified. We determined that rigorously conducted research regarding treatments for PANDAS is scarce, and published studies have a high risk of bias. Further research is needed in which promising treatment strategies for PANDAS and other variants of OCD with proposed autoimmune etiology are rigorously investigated. Copyright © 2018 The Authors. Published by Elsevier Ltd.. All rights reserved.

Clinical applications of plasma based electrosurgical systems

NASA Astrophysics Data System (ADS)

Woloszko, Jean; Endler, Ashley; Ryan, Thomas P.; Stalder, Kenneth R.

2013-02-01

Over the past 18 years, several electrosurgical systems generating a low temperature plasma in an aqueous conductive solution have been commercialized for various clinical applications and have been used in over 10 million patients to date. The most popular utilizations are in arthroscopic surgery, otorhinolaryngology surgery, spine and neurosurgery, urology and wound care. These devices can be configured to bring saline to the tip and to have concomitant aspiration to remove by-products and excess fluid. By tuning the electrode geometry, waveform and fluid dynamic at the tip of the devices, tissue resection and thermal effects can be adjusted individually. This allows one to design products that can operate as precise tissue dissectors for treatment of articular cartilage or debridement of chronic wounds, as well as global tissue debulking devices providing sufficient concomitant hemostasis for applications like tonsillectomies. Effects of these plasma based electrosurgical devices on cellular biology, healing response and nociceptive receptors has also been studied in various models. This talk will include a review of the clinical applications, with product descriptions, results and introductory review of some of the research on the biological effects of these devices.

Obstructive sleep apnea, seizures, and childhood apraxia of speech.

PubMed

Caspari, Susan S; Strand, Edythe A; Kotagal, Suresh; Bergqvist, Christina

2008-06-01

Associations between obstructive sleep apnea and motor speech disorders in adults have been suggested, though little has been written about possible effects of sleep apnea on speech acquisition in children with motor speech disorders. This report details the medical and speech history of a nonverbal child with seizures and severe apraxia of speech. For 6 years, he made no functional gains in speech production, despite intensive speech therapy. After tonsillectomy for obstructive sleep apnea at age 6 years, he experienced a reduction in seizures and rapid growth in speech production. The findings support a relationship between obstructive sleep apnea and childhood apraxia of speech. The rather late diagnosis and treatment of obstructive sleep apnea, especially in light of what was such a life-altering outcome (gaining functional speech), has significant implications. Most speech sounds develop during ages 2-5 years, which is also the peak time of occurrence of adenotonsillar hypertrophy and childhood obstructive sleep apnea. Hence it is important to establish definitive diagnoses, and to consider early and more aggressive treatments for obstructive sleep apnea, in children with motor speech disorders.

["Loss of breath" as a cause of postoperative hypoxia and bradycardia in children submitted to tonsillectomy].

PubMed

Moro, Eduardo Toshiyuki; Goulart, Alexandre Palmeira

2015-01-01

The "shortness of breath" or "breathing interruption" crisis can be considered a cause of hypoxia in childhood. It is characterized by the presence of a triggering factor followed by weeping and apnea in expiration accompanied by cyanosis or pallor. The sequence of events may include bradycardia, loss of consciousness, abnormal postural toneand even asystole. A review of the literature revealed only two reports of postoperative apneacaused by "shortness of breath". This article describes the case of a child with a history of "shortness of breath" undiagnosed before the adenotonsillectomy, but that represented the cause of episodes of hypoxemia and bradycardia in the postoperative period. the "shortness of breath" crisis should be considered as a possible cause of perioperative hypoxia in children, especially when there is a history suggestive of this problem. As some events may be accompanied by bradycardia, loss of consciousness, abnormal postural tone and even asystole, observation in a hospital setting should be considered. Copyright © 2013 Sociedade Brasileira de Anestesiologia. Publicado por Elsevier Editora Ltda. All rights reserved.

Anaesthesia for the paediatric outpatient.

PubMed

Jöhr, Martin; Berger, Thomas M

2015-12-01

The aim of this review was to discuss recent developments in paediatric anaesthesia, which are particularly relevant to the practitioner involved in paediatric outpatient anaesthesia. The use of a pharmacological premedication is still a matter of debate. Several publications are focussing on nasal dexmedetomidine; however, its exact place has not yet been defined. Both inhalational and intravenous anaesthesia techniques still have their advocates; for diagnostic imaging, however, propofol is emerging as the agent of choice. The disappearance of codeine has left a breach for an oral opioid and has probably worsened postoperative analgesia following tonsillectomy. In recent years, a large body of evidence for the prevention of postoperative agitation has appeared. Alpha-2-agonists as well as the transition to propofol play an important role. There is now some consensus that for reasons of practicability prophylactic antiemetics should be administered to all and not only to selected high-risk patients. Perfect organization of the whole process is a prerequisite for successful paediatric outpatient anaesthesia. In addition, the skilled practitioner is able to provide a smooth anaesthetic, minimizing complications, and, finally, he has a clear concept for avoiding postoperative pain, agitation and vomiting.

Pharmacokinetics and analgesic effectiveness of intravenous parecoxib for tonsillectomy ± adenoidectomy.

PubMed

Tan, Lena; Taylor, Elsa; Hannam, Jacqueline A; Salkeld, Lesley; Salman, Sam; Anderson, Brian J

2016-12-01

Few pharmacokinetic (PK) and pharmacodynamic (PD) data exist for COX-2 selective inhibitors in children. We wished to characterize the PKPD of parecoxib and its active metabolite, valdecoxib, in this population. Children (n = 59) were randomized to parecoxib 0.25 mg·kg -1 , 1 mg·kg -1 , and 2 mg·kg -1 during tonsillectomy ± adenoidectomy. Samples (4-6 per child) were obtained from indwelling cannula over 6 h. A second group of inpatient children (n = 15) given 1 mg·kg -1 contributed PK data from 6 to 24 h. Pain scores and rescue medication for the first group were recorded postoperatively for up to 24 h. PK data were pooled with those (10 samples/24 h) from a published study of children (n = 38) who underwent surgery. A three-compartment parent and one-compartment metabolite model with first-order elimination was used to describe data using nonlinear mixed effects models. An E MAX model described the relationship between dose and rescue morphine equivalents during recovery. Parecoxib PK parameter estimates were CL PARECOXIB 19.1 L·h -1 ·70 kg -1 , V1 PARECOXIB 4.2 L·70 kg -1 , Q2 PARECOXIB 6.29 L·h -1 ·70 kg -1 , V2 PARECOXIB 130 L·70 kg -1 , Q3 PARECOXIB 6.02 L·h -1 ·70 kg -1 , and V3 PARECOXIB 2.03 L·70 kg -1 . We assumed all parecoxib was metabolized to valdecoxib with CL VALDECOXIB 9.53 L·h -1 ·70 kg -1 and V VALDECOXIB 51 L·70 kg -1 . There was no maturation of clearance over the age span studied. There were no differences in pain scores between groups on waking, discharge, 12 h, or 24 h. There were no differences in analgesia consumption over 24 h between groups for tramadol, fentanyl, and morphine rescue use. Fentanyl and morphine consumption, expressed as morphine equivalents (0.13 mg·kg -1 ) in the 0.25 mg·kg -1 group, was greater than that observed in the 1 or 2 mg·kg -1 groups (0.095 mg·kg -1 ) in PACU. Parecoxib 0.9 mg·kg -1 in a 2-year-old, 0.75 mg·kg -1 in a 7-year-old, and 0.65 mg·kg -1 in a 12-year-old child achieves dose equivalence of 40 mg in a standard 70 kg person. Clearance maturation may occur in infants younger than the current cohort. Parecoxib doses above 1 mg·kg -1 add no additional analgesia. © 2016 John Wiley & Sons Ltd.

Branchial cleft cyst: An unusual site for the cervical metastasis of nasopharyngeal carcinoma.

PubMed

Liao, Yu-Chang; Adel, Mohamad; Lee, Li-Yu; Chang, Kai-Ping

2018-04-01

Cancers found in the resected branchial cleft cyst are rare clinically but usually impose substantive diagnostic and treatment challenges for clinicians. A 31-year-old man presented with a lateral neck mass that was suspected to be an inflammatory branchial cleft cyst. After excision, the pathologic specimen revealed a benign cystic appearance with a focus of undifferentiated carcinoma. Serologic tests for Epstein-Barr virus were negative. A positron emission tomography scan and upper aerodigestive tract endoscopies were negative for any other suspicious lesion. The patient underwent random biopsies of the nasopharynx, tongue base, and hypopharynx and bil tonsillectomy. Pathologic examination of the nasopharyngeal biopsies showed the presence of undifferentiated carcinoma. The cancerous part of the branchial cleft cyst and this nasopharyngeal specimen were positive for the latent membrane protein-1 and EBV-encoded RNAs of Epstein-Barr virus (EBV) and confirmed our diagnosis. This is the first report of a NPC metastasizing to a branchial cleft cyst. Molecular diagnostic techniques facilitate the definite diagnosis that enabled us to refine treatment plans and offered the patient a favorable outcome. Copyright © 2017 Elsevier B.V. All rights reserved.

Hemophilia Care in the Pediatric Age

PubMed Central

Bertamino, Marta; Riccardi, Francesca; Banov, Laura; Svahn, Johanna; Molinari, Angelo Claudio

2017-01-01

Hemophilia is the most common of the severe bleeding disorders and if not properly managed since early infancy can lead to chronic disease and lifelong disabilities. However, it enjoys the most efficacious and safe treatment among the most prevalent monogenic disorders. Hemophilia should be considered in the neonatal period in the case of unusual bleeding or in the case of positive family history. Later, hemophilia should be suspected mainly in males because of abnormal bruising/bleeding or unusual bleeding following invasive procedures—for example, tonsillectomy or circumcision. Prophylactic treatment that is started early with clotting-factor concentrates has been shown to prevent hemophilic arthropathy and is, therefore, the gold standard of care for hemophilia A and B in most countries with adequate resources. Central venous access catheters and arterovenous fistulas play an important role in the management of hemophilia children requiring repeated and/or urgent administration of coagulation factor concentrates. During childhood and adolescence, personalized treatment strategies that suit the patient and his lifestyle are essential to ensure optimal outcomes. Physical activity is important and can contribute to better coordination, endurance, flexibility and strength. The present article focuses also on questions frequently posed to pediatric hematologists like vaccinations, day-care/school access and dental care. PMID:28534860

The effect of obstructive sleep apnea syndrome on growth and development in nonobese children: a parallel study of twins.

PubMed

Zhang, Xiao Man; Shi, Jun; Meng, Guo Zhen; Chen, Hong Sai; Zhang, Li Na; Wang, Zhao Yan; Wu, Hao

2015-03-01

To explore the effects of obstructive sleep apnea syndrome (OSAS) on children's growth by the study of identical twins. Seventeen cases of nonobese children with OSAS were included in this study. The control group was their identical twin sibling, who had no signs of OSAS. Data including height, weight, and serum insulin-like growth factor 1 levels were analyzed before tonsillectomy and adenoidectomy (T&A) and at 3, 6, and 12 months after surgery. The mean apnea hyponea index was 3.9 times/hour in patients with OSAS and became normal after surgery. Minimum oxygen saturation gradually increased after T&A. The height and weight of the OSAS group before T&A was lower than the control group. During the follow-up period, height and weight increased but were lower than the control group. Serum insulin-like growth factor 1 levels in the OSAS group before T&A were lower than the control group. The level was significantly increased 3 months after T&A. OSAS impairs growth and development. Significant growth recovery occurs after T&A, and early surgical intervention is an important factor for improvement in growth. Copyright © 2015. Published by Elsevier Inc.

Pediatric epstein-barr virus carriers with or without tonsillar enlargement may substantially contribute to spreading of the virus.

PubMed

Hug, Martina; Dorner, Marcus; Fröhlich, Franziska Zucol; Gysin, Claudine; Neuhaus, Diego; Nadal, David; Berger, Christoph

2010-10-15

Human-to-human transmission of the persistent infection establishing Epstein-Barr virus (EBV) occurs via saliva. Tonsils act as important portal of entry and exit of EBV. The contagiousness of pediatric EBV carriers and the role played by tonsillar enlargement (TE) are not known. We compared EBV shedding in mouthwash samples from pediatric EBV carriers with or without TE to that in mouthwash samples from pediatric patients with infectious mononucleosis (IM), the symptomatic form of primary infection if delayed after the age of 5 years. EBV DNA was quantified by polymerase chain reaction, and contagiousness was assessed using the cord lymphocyte transformation assay. EBV carriers with TE shed EBV DNA at an almost similar frequency (although in lower amounts) as pediatric patients with acute IM but more frequently (P <.001) and in higher amounts (P = .038) than EBV carriers without TE. EBV DNA levels in mouthwash samples from EBV carriers with TE mirrored levels in tonsils and gradually declined after tonsillectomy. Almost half of the mouthwash samples from pediatric EBV carriers contained infectious EBV. Pediatric EBV carriers--in particular, those with TE-may considerably contribute to the spreading of EBV in industrialized countries.

The University of Pennsylvania curriculum for training otorhinolaryngology residents in transoral robotic surgery.

PubMed

Sperry, Steven M; O'Malley, Bert W; Weinstein, Gregory S

2014-01-01

To define a curriculum for the development of robotic surgical skills in otorhinolaryngology residency training. A systematic review of the current literature on robotic surgery training was performed. Based on prior reports in other specialties, a curriculum for otorhinolaryngology residents was created that progresses through several modules, including didactics, inanimate skills laboratory, and operative experience. The curriculum for residents in otorhinolaryngology was designed as follows: didactics include an overview of the robotic device and instruments, a tutorial in basic controls and function, and a room setup and positioning. The anatomy and steps of transoral procedures are taught through books, videos, operative observations, and cadaver dissections. Skills are developed with a virtual reality robotic simulator and robotics labs. The operative experience progresses from case observation to bedside assistant to console surgeon. The role of the console surgeon progresses in a stepwise fashion, and the procedures of radical tonsillectomy, supraglottic partial laryngectomy, and base of tongue resection have been organized as a series of steps. A structured curriculum for training residents in transoral robotic surgery was developed. This training is important for otorhinolaryngology residents to acquire the knowledge and skills to perform robotic surgery safely. © 2015 S. Karger AG, Basel.

Tonsillotomy: facts and fiction.

PubMed

Windfuhr, J P; Savva, K; Dahm, J D; Werner, J A

2015-04-01

In contrast to total or extracapsular tonsillectomy (TE), subtotal/intracapsular/partial tonsillectomy (SIPT) or tonsillotomy (TT) is associated with significant less postoperative morbidity. It has been stated that patients older than 8 years of age or with a history of tonsillitis should be excluded from SIPT/TT. Some health insurance companies mandate utilization of particular surgical instruments. Finally, it has been stated that the remaining tonsillar tissue may become a subject of recurrent tonsillitis or tonsillar regrowth, in both cases requiring revision surgery in terms of TE. This literature review was undertaken to clarify what has been validated in the literature concerning indications, surgical techniques, complications and outcome of SIPT/TT as reported since 1960. A Medline review was undertaken and all papers included that were published in English or German language until September 30, 2013. Exclusion criteria were: publication date 1960 and earlier, other languages, no relation to tonsil surgery, papers not available to the authors, uncommon surgical techniques, national surveys or studies without patients. The quality of the papers was classified according to "The Oxford 2011 Levels of Evidence". The surgical techniques were classified according to Windfuhr and Werner and extended to interstitial tonsil therapy. Other issues were: study period, hemorrhage, dehydration, intake of analgesics, return to normal diet, surgical instruments, operation time, number of surgeons involved, number of patients, age, indications, follow-up, rate of tonsillar regrowth, tonsillitis and secondary TE. A total of 379 different publications were retrieved, but only 86 studies found eligible for further analysis. There were 10,499 patients in the study groups and 10,448 patients in the control groups. Utilization of the microdebrider largely prevailed, followed by Coblation, CO2-LASER, surgical scissor, Radiofrequency, Interstitial ThermoTherapy with various instruments, Diode-LASER, and other instruments. Instruments were not specified for 1,815 patients. Data for operation time, intraoperative bleeding, return to normal diet, analgesic intake were in favor for SIPT/TT and ablation procedures. Regrowth and tonsillitis occurred in rates of <6 % on average. Secondary surgery became necessary in only every third patient of this subgroup. Studies of variable quality impede comparison of all aspects in the papers. At least every second study did not address issues like operation time, intraoperative bleeding, return to normal diet, analgesic intake, rates of tonsillar regrowth, postsurgical tonsillitis and secondary TE. There are insufficient data to show that a single surgical instrument is superior. A history of tonsillitis and an age >8 years are definitely not commonly accepted as contraindication for SIPT, TT or ablation procedures. There is a strong evidence that pain is less after SIPT, TT and tonsil ablation resulting in an earlier return to normal diet and activity. Large, well-designed randomized controlled trials with an adequate follow-up are necessary to determine whether the procedure is capable to replace TE to resolve upper airway obstruction resulting from tonsillar hypertrophy as well as recurrent episodes of tonsillitis in children and adults.

Tonsillectomy or adenotonsillectomy versus non-surgical management for obstructive sleep-disordered breathing in children.

PubMed

Venekamp, Roderick P; Hearne, Benjamin J; Chandrasekharan, Deepak; Blackshaw, Helen; Lim, Jerome; Schilder, Anne G M

2015-10-14

Obstructive sleep-disordered breathing (oSDB) is a condition that encompasses breathing problems when asleep, due to an obstruction of the upper airways, ranging in severity from simple snoring to obstructive sleep apnoea syndrome (OSAS). It affects both children and adults. In children, hypertrophy of the tonsils and adenoid tissue is thought to be the commonest cause of oSDB. As such, tonsillectomy - with or without adenoidectomy - is considered an appropriate first-line treatment for most cases of paediatric oSDB. To assess the benefits and harms of tonsillectomy with or without adenoidectomy compared with non-surgical management of children with oSDB. We searched the Cochrane Register of Studies Online, PubMed, EMBASE, CINAHL, Web of Science, Clinicaltrials.gov, ICTRP and additional sources for published and unpublished trials. The date of the search was 5 March 2015. Randomised controlled trials comparing the effectiveness and safety of (adeno)tonsillectomy with non-surgical management in children with oSDB aged 2 to 16 years. We used the standard methodological procedures expected by The Cochrane Collaboration. Three trials (562 children) met our inclusion criteria. Two were at moderate to high risk of bias and one at low risk of bias. We did not pool the results because of substantial clinical heterogeneity. They evaluated three different groups of children: those diagnosed with mild to moderate OSAS by polysomnography (PSG) (453 children aged five to nine years; low risk of bias; CHAT trial), those with a clinical diagnosis of oSDB but with negative PSG recordings (29 children aged two to 14 years; moderate to high risk of bias; Goldstein) and children with Down syndrome or mucopolysaccharidosis (MPS) diagnosed with mild to moderate OSAS by PSG (80 children aged six to 12 years; moderate to high risk of bias; Sudarsan). Moreover, the trials included two different comparisons: adenotonsillectomy versus no surgery (CHAT trial and Goldstein) or versus continuous positive airway pressure (CPAP) (Sudarsan). Disease-specific quality of life and/or symptom score (using a validated instrument): first primary outcomeIn the largest trial with lowest risk of bias (CHAT trial), at seven months, mean scores for those instruments measuring disease-specific quality of life and/or symptoms were lower (that is, better quality of life or fewer symptoms) in children receiving adenotonsillectomy than in those managed by watchful waiting:- OSA-18 questionnaire (scale 18 to 126): 31.8 versus 49.5 (mean difference (MD) -17.7, 95% confidence interval (CI) -21.2 to -14.2);- PSQ-SRBD questionnaire (scale 0 to 1): 0.2 versus 0.5 (MD -0.3, 95% CI -0.31 to -0.26);- Modified Epworth Sleepiness Scale (scale 0 to 24): 5.1 versus 7.1 (MD -2.0, 95% CI -2.9 to -1.1).No data on this primary outcome were reported in the Goldstein trial.In the Sudarsan trial, the mean OSA-18 score at 12 months did not significantly differ between the adenotonsillectomy and CPAP groups. The mean modified Epworth Sleepiness Scale scores did not differ at six months, but were lower in the surgery group at 12 months: 5.5 versus 7.9 (MD -2.4, 95% CI -3.1 to -1.7). Adverse events: second primary outcomeIn the CHAT trial, 15 children experienced a serious adverse event: 6/194 (3%) in the adenotonsillectomy group and 9/203 (4%) in the control group (RD -1%, 95% CI -5% to 2%).No major complications were reported in the Goldstein trial.In the Sudarsan trial, 2/37 (5%) developed a secondary haemorrhage after adenotonsillectomy, while 1/36 (3%) developed a rash on the nasal dorsum secondary to the CPAP mask (RD -3%, 95% CI -6% to 12%). Secondary outcomesIn the CHAT trial, at seven months, mean scores for generic caregiver-rated quality of life were higher in children receiving adenotonsillectomy than in those managed by watchful waiting. No data on this outcome were reported by Sudarsan and Goldstein.In the CHAT trial, at seven months, more children in the surgery group had normalisation of respiratory events during sleep as measured by PSG than those allocated to watchful waiting: 153/194 (79%) versus 93/203 (46%) (RD 33%, 95% CI 24% to 42%). In the Goldstein trial, at six months, PSG recordings were similar between groups and in the Sudarsan trial resolution of OSAS (Apnoea/Hypopnoea Index score below 1) did not significantly differ between the adenotonsillectomy and CPAP groups.In the CHAT trial, at seven months, neurocognitive performance and attention and executive function had not improved with surgery: scores were similar in both groups. In the CHAT trial, at seven months, mean scores for caregiver-reported ratings of behaviour were lower (that is, better behaviour) in children receiving adenotonsillectomy than in those managed by watchful waiting, however, teacher-reported ratings of behaviour did not significantly differ.No data on these outcomes were reported by Goldstein and Sudarsan. In otherwise healthy children, without a syndrome, of older age (five to nine years), and diagnosed with mild to moderate OSAS by PSG, there is moderate quality evidence that adenotonsillectomy provides benefit in terms of quality of life, symptoms and behaviour as rated by caregivers and high quality evidence that this procedure is beneficial in terms of PSG parameters. At the same time, high quality evidence indicates no benefit in terms of objective measures of attention and neurocognitive performance compared with watchful waiting. Furthermore, PSG recordings of almost half of the children managed non-surgically had normalised by seven months, indicating that physicians and parents should carefully weigh the benefits and risks of adenotonsillectomy against watchful waiting in these children. This is a condition that may recover spontaneously over time.For non-syndromic children classified as having oSDB on purely clinical grounds but with negative PSG recordings, the evidence on the effects of adenotonsillectomy is of very low quality and is inconclusive.Low-quality evidence suggests that adenotonsillectomy and CPAP may be equally effective in children with Down syndrome or MPS diagnosed with mild to moderate OSAS by PSG.We are unable to present data on the benefits of adenotonsillectomy in children with oSDB aged under five, despite this being a population in whom this procedure is often performed for this purpose.

The role of drug-induced sleep endoscopy in surgical planning for obstructive sleep apnea syndrome.

PubMed

Aktas, Ozturk; Erdur, Omer; Cirik, Ahmet Adnan; Kayhan, Fatma Tulin

2015-08-01

This study investigated the role of drug-induced sleep endoscopy (DISE) in the surgical treatment planning of patients with obstructive sleep apnea syndrome (OSAS). This study was conducted using patients diagnosed with OSAS between January 2007 and March 2009, who were scheduled for surgical treatment. DISE was performed using propofol in patients considered to have upper respiratory tract obstruction as indicated by Muller's maneuver. After completing the sleep endoscopy, the patient was intubated and surgery was performed (tonsillectomy and uvulopalatopharyngoplasty). A successful operation was defined as a decrease in the respiratory disturbance index to below 5 or a decrease of ≥50 % following the operation. The study included 20 patients (4 female and 16 male) aged 19-57 years. No statistically significant correlation between modified Mallampati class and operation success or between the polysomnographic stage of disease and operation success was identified. A significantly high operation success rate was found in the group with obstruction of the upper airway according to DISE (p < 0.05), whereas a significantly low operation success rate was found in the group with obstruction of the lower airway according to DISE (p < 0.01). DISE may be used to identify the localization of obstruction for diagnostic purposes, and it can be helpful in selecting the treatment method.

[A Case of Cystic Cervical Lymph Node Metastasis of HPV-positive Tonsil Cancer, Being Discriminated as the Branchiogenic Carcinoma].

PubMed

Kambara, Rumi; Tamai, Masamitsu; Horii, Arata

2016-02-01

In recent years, human papillomavirus (HPV)-positive oropharyngeal carcinomas have been increasing. The first manifestation of these tumors is frequently as cystic metastasis to cervical lymph nodes that may precede recognition of the primary tumor, so, they often result in misdiagnosis as branchial cleft cysts. We report a case of cystic cervical lymph node metastasis of HPV-positive tonsil cancer. The patient was a 70-years-old man who noticed a mass on his left neck. The tumor was large and soft, and it was diagnosed as benign in fine-needle aspiration cytology. We diagnosed the tumor as a branchial cleft cyst and undertook surgery. The histopathological diagnosis was squamous cell carcinoma arising from a branchiogenic cyst. However, because it did not satisfy the diagnostic criteria, we diagnosed the tumor as an unknown primary tumor. One year later, left tonsil cancer was suspected based on PET-CT imaging and a left tonsillectomy was undertaken, whereafter tonsil cancer was found. In p16 immunostaining, it was positive in both cystic mass and tonsil. The cervical mass was cystic lymph node metastasis of HPV-positive tonsil cancer. It is important to investigate the oropharynx, when we found cystic cervical mass, because HPV-positive oropharyngeal carcinoma frequently results in cystic neck metastasis.

Electroacupuncture-Assisted Craniotomy on an Awake Patient.

PubMed

Sidhu, Amritpal; Murgahayah, Trushna; Narayanan, Vairavan; Chandran, Hari; Waran, Vicknes

2017-01-01

Although acupuncture has existed for over 2000 years, its application as an anesthetic aid began in the 1950s in China. The first surgical procedure performed under acupuncture anesthesia was a tonsillectomy. Soon thereafter, major and minor surgical procedures took place with electroacupuncture alone providing the anesthesia. The procedures performed were diverse, ranging from cardiothoracic surgery to dental extractions. Usage of acupuncture anesthesia, specifically in neurosurgery, has been well documented in hospitals across China, especially in Beijing, dating back to the 1970s. We present a case of a 65-year-old man who presented with right-sided body weakness. He had a past medical history of uncontrolled diabetes mellitus, hypertension, and obstructive sleep apnea requiring use of a nasal continuous positive airway pressure device during sleep. We performed a computed tomography brain scan, which revealed a left-sided acute on chronic subdural hemorrhage. Due to his multiple comorbidities, we decided to perform the surgical procedure under electroacupuncture anesthesia. The aim of this case report is to describe a craniotomy performed under electroacupuncture on an elderly patient with multiple comorbidities who was awake during the procedure and in whom this procedure, if it had been performed under general anesthesia, would have carried high risk. Copyright © 2016 Medical Association of Pharmacopuncture Institute. Published by Elsevier B.V. All rights reserved.

Observations on a set of Greco-Roman eye, ear, nose, and throat surgical instruments.

PubMed

Dedo, Herbert H

2017-02-01

The tools described in this article are verified to be Greco-Roman medical and surgical instruments for the eye, ear, nose, and throat. They include three myrtle leaf-shaped scalpels, three ear spoons, a "Q-tip," a forceps, a needle, and two arrow-pointed scalpels. One of the arrow-pointed scalpels is nearly identical to a Juerger keratome, suggesting that in Roman times, cataracts were extracted, not just "couched" into the posterior chamber. The description presented here goes beyond traditional archeological claims, because as a head and neck surgeon, I evaluated these instruments from a surgeon's point of view. For example, nonsurgeon medical historians have claimed the myrtle leaf-shaped items were used as handles or for blunt dissection, which I feel is mistaken. Review of the literature reveals the Greco-Roman surgeons were doing tonsillectomies, tracheotomies, and cataract extractions, and recognized that swimming in dirty water could cause ear infection. However, it is clear that with poor or no anesthesia, the pain from blunt dissection would have been intolerable, and unnecessary tissue planes would have been opened increasing wound infection risks. Therefore, there would have been no need for the myrtle leaf-shaped blade if it were just a handle. Laryngoscope, 2016 127:354-358, 2017. © 2016 The American Laryngological, Rhinological and Otological Society, Inc.

A Multicentre Audit of Single-Use Surgical Instruments (SUSI) for Tonsillectomy and Adenoidectomy

PubMed Central

O'Flynn, P; Silva, S; Kothari, P; Persaud, R

2007-01-01

INTRODUCTION Prions are resistant to conventional sterilisation procedures and, therefore, could be transmitted iatrogenically through re-usable adenoid and tonsil surgical instruments. Using disposable instruments would avoid the risk of transmission. We present the results of a complete audit loop using BBraun single-use surgical instruments (SUSI). PATIENTS AND METHODS This was a prospective multicentre audit. Surgeons were asked to fill in a standardised questionnaire recording details including postoperative complications, and evaluation of each piece of equipment compared with their own experience of conventional re-usable instruments. In the first cycle, constructive criticisms of the instruments were noted and the manufacturers modified the instruments accordingly. A second cycle of audit was subsequently undertaken. RESULTS A total of 86 patients were audited in the first cycle and 97 in the second cycle. Postoperative haemorrhage rate for both cycles was well within acceptable range. In the first audit cycle, surgeons generally found the Draffin rods, Boyle-Davis gag and bipolar diathermy forceps of poor quality and difficult to use. These were redesigned and, on repeat evaluation during the second audit cycle, were found to be just as good, if not better, than the re-usable instruments. CONCLUSIONS This study suggests that SUSI may be just as good as re-usable instruments. Furthermore, they may be more cost effective. PMID:18201478

Prevalence of microorganisms and immunoglobulins in children with tonsillar hypertrophy and adenoiditis.

PubMed

Miramontes, Henrique Prestes; Fagundes, Djalma José; Jurgielewicz, Julia Coelho Lima E; Miramontes Neto, Haroldo Prestes; Oliveira, Renan Gianotto de; Oliveira, Gustavo Gianotto de; Souza, Maria Rosa Machado de

2014-07-01

 Benign idiopathic tonsillar hypertrophy (HBI) may affect a child's quality of life and sleep. Several studies have sought to relate the clinical features of HBI with the infectious and/or immunologic changes that occur.  To increase the knowledge of the etiology of HBI.  From 2012 to 2013 we conducted a retrospective observational study of 101 children with HBI who underwent tonsillectomies at Ambulatory ENT General Hospital of the East Zone of São Paulo City, a region with a poor socioeconomic population. Preoperative serologic results were available to confirm mononucleosis, cytomegalovirus, anti-streptolysin O (ASLO) and immunoglobulins. The mean patient age was 5.8 years (55% male, 45% female). Using the Mann-Whitney U test, we identified significant gender differences in the parameters of immunoglobulins (Ig) M (IgM), IgA, and IgE. Forty-seven percent of the patients had increased ASLO levels, and 37% had increased IgE levels.  An evaluation of a patient's serologic parameters and laboratory results may be relevant to the etiology and prevention of HBI. Based on the results obtained from the study sample, the identification of etiologic agents and causative factors remain a public health challenge that affects the quality of life of children.

[Organic and functional limitations due to milking phenomenon: a clinical case report].

PubMed

Gómez-Henry, Juan Carlos; Rodríguez-Pérez, Francisco Antonio

2014-01-01

The incidence of milking phenomenon is between 0.6 and 4 % in angiographic series; however, autopsy studies raise the incidence of myocardial bridges up to 85 %. This malformation goes unnoticed in most cases but can have a big impact on personal and professional level. The objective was to present an example of milking phenomenon with disability and professional consequences. Male, 44 years old, bricklayer and farmhand laborer. He referred tonsillectomy and osteoarthritis and being a smoker of 10 cigarettes per day, drinking 2-3 cups of coffee daily and 2-3 glasses of wine at the weekends. The primary care physician referred him to cardiologist with suspicion of arrhythmia. The cardiology service report mentioned electrocardiogram at sinusal rhythm, 90 beats per minute and incomplete right bundle-branch block. At ergonomics test, in the first stage of Bruce protocol, the patient's development of hypertensive crisis suggested a milking phenomenon. Finally, the diagnosis was established by angiographic studies with left common branch, circumflex coronary artery, right coronary artery and anterior descendent artery, without evidence of pathology but it was seen systolic compression on the medial segment. The case was concluded by the disability assessment team, recognizing a total permanent disability with limitations for activities requiring moderate physical efforts. The milking phenomenon diagnosis that could be related with ischemic heart disease is by angiography. Finally, the patient ended with total permanent disability.

Methodological Quality of National Guidelines for Pediatric Inpatient Conditions

PubMed Central

Hester, Gabrielle; Nelson, Katherine; Mahant, Sanjay; Eresuma, Emily; Keren, Ron; Srivastava, Rajendu

2014-01-01

Background Guidelines help inform standardization of care for quality improvement (QI). The Pediatric Research in Inpatient Settings (PRIS) network published a prioritization list of inpatient conditions with high prevalence, cost, and variation in resource utilization across children’s hospitals. The methodological quality of guidelines for priority conditions is unknown. Objective To rate the methodological quality of national guidelines for 20 priority pediatric inpatient conditions. Design We searched sources including PubMed for national guidelines published 2002–2012. Guidelines specific to one organism, test or treatment, or institution were excluded. Guidelines were rated by two raters using a validated tool (AGREE II) with an overall rating on a 7-point scale (7–highest). Inter-rater reliability was measured with a weighted kappa coefficient. Results 17 guidelines met inclusion criteria for 13 conditions, 7 conditions yielded no relevant national guidelines. The highest methodological quality guidelines were for asthma, tonsillectomy, and bronchiolitis (mean overall rating 7, 6.5 and 6.5 respectively); the lowest were for sickle cell disease (2 guidelines) and dental caries (mean overall rating 4, 3.5, and 3 respectively). The overall weighted kappa was 0.83 (95% confidence interval 0.78–0.87). Conclusions We identified a group of moderate to high methodological quality national guidelines for priority pediatric inpatient conditions. Hospitals should consider these guidelines to inform QI initiatives. PMID:24677729

DNA damage in children with obstructive adenotonsillar hypertrophy.

PubMed

Yoruk, Ozgur; Alp, Hakan; Yuksel, Sancak; Bakan, Ebubekir

2014-11-01

The objective of this prospective, controlled study was to evaluate oxidative DNA damage in children with obstructive adenotonsillar hypertrophy. This study included 30 patients with obstructive adenotonsillar hypertrophy (male/female ratio, 3:2; age range, 3-9 y) scheduled to undergo tonsillectomy and adenoidectomy and 25 control subjects of similar age and sex with no adenotonsillar disease or airway obstruction. Urine and blood samples were obtained from each child for 8-hydroxy 2-deoxyguanosine (8-OhdG) and malondialdehyde (MDA) concentrations. There were significant differences in leukocyte (3.28 [0.69/10] vs 0.70 [0.15/10] dG) and urine 8-OhdG (8.22 [2.27/10] vs 5.26 [1.3/10] dG) levels in patients with obstructive adenotonsillar hypertrophy and healthy subjects (P < 0.001 for both). Plasma (2.98 [1.31] vs 1.14 [0.64] μM) and urine (1.77 [0.84] vs 0.56 [0.32] μM) MDA levels were also different (P < 0.001 for both). There were positive correlations between 8-OhdG in leukocyte DNA and plasma MDA (r = 0.648, P < 0.001) and between levels of urine 8-OhdG excretion and urine MDA (r = 0.588, P < 0.001). The DNA damage in children with adenotonsillar hypertrophy should be kept in mind, but further studies must be done with larger patient groups.

The role of the actinomyces in obstructive tonsillar hypertrophy and recurrent tonsillitis in pediatric population.

PubMed

Kutluhan, Ahmet; Salvız, Mehti; Yalçıner, Gökhan; Kandemir, Olcay; Yeşil, Cemile

2011-03-01

To determine the prevalence of tonsillar Actinomyces in subjects with recurrent tonsillitis and those with obstructive tonsillar hypertrophy, and to determine the association between the presence of Actinomyces and tonsillar volume, and crypt abscess. A prospective designed cross-sectional study consisted of 90 children subjects who underwent tonsillectomy or adenotonsillectomy for recurrent tonsillitis and obstructive tonsillar hypertrophy. The subjects of recurrent tonsillitis (Group A) and obstructive tonsillar hypertrophy (Group B) were compared to the presence of Actinomyces. The relationship between the presence of Actinomyces and the presence of crypt abscess, and tonsillar volume were also compared. Actinomyces was found to be significantly more prominent in obstructive tonsillar hypertrophy group (61.5%) compared to recurrent tonsillitis group (26.6%) (p<0.001). Additionally, the mean tonsillar volume was significantly higher in tonsils with Actinomyces than those without (p<0.001). The histopathological study revealed that there was no significant inflammatory response to the existence of Actinomyces. According to the presented study, Actinomyces was seen more prominent in subjects with obstructive tonsillar hypertrophy compared those with recurrent tonsillitis. Furthermore Actinomyces had a pathological influence on tonsil size. This study showed there was a significant relation between Actinomyces and enlargement of tonsillar tissue. However, how causes tonsillar hypertrophy is not understood yet in tonsillar disease. Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.

Risk of transmission of sporadic Creutzfeldt-Jakob disease by surgical procedures: systematic reviews and quality of evidence.

PubMed

López, Fernando J García; Ruiz-Tovar, María; Almazán-Isla, Javier; Alcalde-Cabero, Enrique; Calero, Miguel; de Pedro-Cuesta, Jesús

2017-10-01

Sporadic Creutzfeldt-Jakob disease (sCJD) is potentially transmissible to humans. This study aimed to summarise and rate the quality of the evidence of the association between surgery and sCJD. Firstly, we conducted systematic reviews and meta-analyses of case-control studies with major surgical procedures as exposures under study. To assess quality of evidence, we used the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach. Secondly, we conducted a systematic review of sCJD case reports after sharing neurosurgical instruments. Thirteen case-control studies met the inclusion criteria for the systematic review of case-control studies. sCJD was positively associated with heart surgery, heart and vascular surgery and eye surgery, negatively associated with tonsillectomy and appendectomy, and not associated with neurosurgery or unspecified major surgery. The overall quality of evidence was rated as very low. A single case-control study with a low risk of bias found a strong association between surgery conducted more than 20 years before disease onset and sCJD. Seven cases were described as potentially transmitted by reused neurosurgical instruments. The association between surgery and sCJD remains uncertain. Measures currently recommended for preventing sCJD transmission should be strongly maintained. Future studies should focus on the potential association between sCJD and surgery undergone a long time previously.

Impaired sexual maturation associated with sleep apnea syndrome during puberty: a case study.

PubMed

Mosko, S S; Lewis, E; Sassin, J F

1980-01-01

A 20-year-old hypogonadal man was discovered to have had obstructive sleep apnea syndrome--secondary to hypertrophied tonsils, adenoids, and uvula--spanning the years of puberty. All-night polysomnographic recordings and 24 hr measurements of plasma luteinizing hormone (LH) concentrations (sampling at 20 min intervals) were performed before and after combined tonsillectomy, adenoidectomy, and uvulectomy. Two weeks preoperatively, nocturnal sleep was markedly disturbed by 407 apneic episodes, and the patient was found to be hypogonadotropic. Daytime LH concentrations were in the low-normal range for an adult male, and concentrations fell dramatically during nocturnal sleep. This contrasts with both the sleep-related elevation of LH normally seen in puberty and the adult pattern, where no difference is observed in mean concentrations during waking and sleep. Two week and 6 month postoperative evaluations revealed complete alleviation of the sleep apnea syndrome and normalization of the 24 hr pattern of plasma LH, although LH values remained in the low-normal range. Plasma testosterone concentrations were in the low to low-normal range both pre- and postoperatively. No evidence of continued sexual development, beyond that achieved preoperatively, was observed 20 months after surgery, despite continued relief from apnea. These data suggest that sleep apnea during puberty may impair sexual development by preventing the sleep-related elevation in LH secretion normally observed during a critical period spanning puberty.

Patient-perceived benefit of sialendoscopy as measured by the Glasgow Benefit Inventory.

PubMed

Meier, Bue A; Holst, René; Schousboe, Lars P

2015-08-01

Evaluate the patient-perceived effect of sialendoscopy on patients with obstructive symptoms from the salivary glands. Retrospectively identified cohort used for a prospective study of all consecutive patients at the Department of Otorhinolaryngology at Vejle Hospital, Vejle, Denmark, March 2009 to December 2013. By chart review we recorded the patient's age, gender, date of the sialendoscopy, type of gland, sialolithiasis, successful extraction of sialolithiasis, stenosis of salivary ducts, dilation, type of saliva, and surgeon. The follow-up was done by applying the Glasgow Benefit Inventory questionnaire by letter and telephone. There were 130 sialendoscopies performed on 116 patients. Of these, 24 patients were excluded due to subsequent surgery. Thus, 92 patients were eligible, of whom 80 responded, giving an 87% response rate. The Glasgow Benefit Inventory score had a predicted overall mean of 13.4 (95% confidence interval: 9.9 to 17.2). Significant positive outcomes by multiple regression were the presence of stones (P = 0.015) and examination of the parotid gland (P = 0.041). Overall, there is a significant patient-perceived benefit from sialendoscopy, which is comparable to the benefit from tonsillectomy. The benefit is significantly higher if stones are found than not and for examination of the parotid gland as compared to the submandibular gland. 4 © 2015 The American Laryngological, Rhinological and Otological Society, Inc.

[A study of the pathogenesis of tonsillar focal infection--transplantation of human tonsillar lymphocytes and human skin into SCID mice].

PubMed

Yamamoto, Y; Kuki, K; Hayashi, Y; Yamanaka, N

2000-07-01

Pustulosis palmaris et plantaris (PPP) has been considered as one of the typical tonsillar focal infections, based on the marked clinical improvement of the skin lesions after tonsillectomy. In early-stage of PPP, it has been reported that lymphocytes, predominantly CD4-positive cells, infiltrate the palmar and plantar skin. However, the origin and mechanism of infiltration by these lymphocytes is not clear and there are very few reports on whether tonsillar cells react directly with the skin, possibly due to the difficulty of establishing adequate animal models. In this study, we established an experimental animal model of mice with severe combined immunodeficiency (SCID) and observed the reactions of the tonsillar lymphocytes (TL) or peripheral blood lymphocytes (PBL) of patients with PPP to their own plantar skin by transplanting the lymphocytes and skin of the patient into the mice. The results revealed that TL infiltrated the skin to a significantly greater extent than PBL. Most of these lymphocytes were T lymphocytes, and no B lymphocytes were detected in the transplanted skin. Strong expression of LFA-1 and ICAM-1 was observed in the skin after the TL transplantation. These results suggest that TL have a strong affinity for the skin in PPP, and that the adhesion molecules may play an important role in the infiltration by lymphocytes of the skin.

Otolaryngologic manifestations of Noonan syndrome.

PubMed

Geelan-Hansen, Katie; Anne, Samantha

2015-09-01

Noonan syndrome is an autosomal dominant disorder with associated anomalies that include short stature, congenital heart defects, developmental delay, and characteristic facial features among other abnormalities. Articulation deficiency and language delay are often present and require speech therapy. Otitis media and hearing loss have been reported to be common in these patients. We performed a retrospective chart review of pediatric patients who were diagnosed with Noonan syndrome at our tertiary care center from January 1979 through December 2009. We found 19 such patients. Of these, 8 had received single-specialty care at our hospital; it is not known if they had received otolaryngologic care from an outside provider. These 8 patients were not included in our study. The remaining 11 patients-6 boys and 5 girls, aged 1 to 19 years (mean: 9.2)-had all received multidisciplinary care at our institution; 9 of them had received care from an otolaryngologist at our center. Of this group, 7 had history of feeding difficulty, 6 had experienced speech delay that required speech therapy, 6 had undergone placement of a pressure equalization tube, 4 had undergone adenoidectomy with or without tonsillectomy, and 1 had been treated with endoscopic sinus surgery. Although this study is limited by our small number of patients, our results suggest that early otolaryngologist involvement must be considered in the care of children with Noonan syndrome because many have evidence of eustachian tube dysfunction, hearing loss, and speech delay.

Association between allergic and nonallergic rhinitis and obstructive sleep apnea.

PubMed

Zheng, Ming; Wang, Xiangdong; Zhang, Luo

2018-02-01

Allergic rhinitis and nonallergic rhinitis (NAR) are common disorders, which have been considered as potential risk factors for obstructive sleep apnea (OSA). This review summarizes the proposed underlying pathophysiological mechanisms to provide a better understanding of the relationship between these conditions. In adults, allergic rhinitis and NAR may be considered as symptoms potentiating, rather than risk potentiating factors in the pathophysiology of OSA, whereas in children, these are considered to be independent predictors for sleep-disordered breathing (SDB) and failure of adeno-tonsillectomy, the recommended first-line therapy for children with OSA. Current advances suggest IL-6 may be important in regulating the sleep-wake cycle, and serum soluble IL-6 receptor (sIL-6R) levels may reflect the severity of OSA. Elevated Th17/Treg ratio correlates positively with apnea-hypopnea index of OSA patients, and Th17 and Treg imbalances caused by allergic rhinitis and OSA, respectively, may possibly promote each other, leading to further imbalance. Moreover, obesity is a strong risk factor for OSA, and leptin plays an important role in ventilatory function and upper airway obstruction. The variant trigeminocardiac reflex and nasotrigeminal reflex may also be involved in the association between rhinitis and OSA. Allergic rhinitis/NAR and OSA are closely associated, and each condition can be detrimental to the other. Thus, clinicians should pay attention to the potential presence of allergic rhinitis/NAR in OSA patients and vice versa.

The correlation between tonsil size and academic performance is not a direct one, but the results of various factors.

PubMed

Kargoshaie, A A; Najafi, M; Akhlaghi, M; Khazraie, H R; Hekmatdoost, A

2009-10-01

Chronic upper airway obstruction most often occurs when both tonsils and adenoid are enlarged but may occur when either is enlarged. Obstructive sleep syndrome in young children has been reported to be associated with an adverse effect on learning and academic performance. The aim of this study was to evaluate the effect of relative size of the tonsil on academic performance in 4th grade school children. In 320 children, physical examination to determine the size of tonsils was performed by the otorhinolaryngologist. A questionnaire was developed to assess sleep patterns and problems, and socio-demographic data for the student participants. Furthermore, their school performance was assessed using their grade in mathematics, science, reading, spelling, and handwriting. No association between tonsil size and academic performance was found. Snoring frequency, body mass index and body weight showed a positive relation with tonsil size. There was no association between tonsil size and sleepiness during the day, sleeping habits, hyperactivity, enuresis, history of tonsillectomy in children and parental cigarette smoking and education. In conclusion, this study did not show any significant relationship between tonsil size and academic performance in 4th grade students. Further studies are recommended with a larger sample size, cognitive exams for evaluation of attention, and follow-up of the students until high school, when the discrepancy of the students' academic performance is more obvious.

Dexmedetomidine as a Rapid Bolus for Treatment and Prophylactic Prevention of Emergence Agitation in Anesthetized Children.

PubMed

Hauber, John A; Davis, Peter J; Bendel, Laima P; Martyn, Slava V; McCarthy, Denise L; Evans, Minh-Chau; Cladis, Franklyn P; Cunningham, Sarah; Lang, Robert Scott; Campbell, Neal F; Tuchman, Jay B; Young, Michael C

2015-11-01

Administration of dexmedetomidine (DEX) in the pediatric population for its sedative, analgesic, and anxiolytic properties has been widely reported, despite there being no label indication approved by the U.S. Food and Drug Administration for pediatric patients. Infusions of DEX, rather than bolus administration, are recommended to attenuate the hemodynamic response caused by the α2-adrenoreceptor agonist. In this prospective, double-blind, randomized study, we examined the effect of rapid IV bolus injection of DEX on emergence agitation and the hemodynamic response in a large sample of children undergoing tonsillectomy with or without adenoidectomy, with or without myringotomy, and/or tympanostomy tube insertion. Four hundred patients, aged 4 to 10 years, undergoing tonsillectomy with or without adenoidectomy, with or without myringotomy, and/or tympanostomy tube insertion, were randomized at a 1:1 ratio into 1 of the 2 treatment groups in a double-blinded fashion. After a standardized anesthetic regimen and approximately 5 minutes before the end of surgery, patients in group DEX were administered a rapid IV bolus of 4 μg·mL DEX at a dose of 0.5 μg·kg, whereas patients in group saline received a rapid IV bolus of equivalent volume saline. Baseline measurements of heart rate, systolic blood pressure, diastolic blood pressure, respiratory rate, and blood oxygen saturation were collected immediately before study drug administration and every minute thereafter for 5 minutes. In the postanesthesia care unit, vital signs were measured, emergence agitation (EA) was assessed using the Pediatric Anesthesia Emergence Delirium scale, and postoperative opioid use and complications were recorded. The incidence of EA in group DEX was significantly lower than that in group saline, regardless of whether EA was defined as a Pediatric Anesthesia Emergence Delirium score >10 (36% vs 66%, respectively; P < 0.0001; relative risk [95% confidence interval] = 0.527 [0.421-0.660]; number needed to treat = 3.33) or >12 (30% vs 61%, respectively; P < 0.0001; relative risk [95% confidence interval] = 0.560 [0.458-0.684]; number needed to treat = 3.23). Both groups exhibited similar baseline vital signs before study drug injection (all P ≥ 0.602). After injection, group DEX experienced a significant decrease in heart rate for all time points in comparison with group saline (all P < 0.0001). A significant, biphasic blood pressure response was observed in group DEX, specifically, a transient increase in systolic blood pressure at 1 minute after injection (P < 0.0001) and a subsequent decrease below baseline for 3, 4, and 5 minutes (all P < 0.0001). No patients required treatment for bradycardia, hypertension, or hypotension. A significantly smaller percentage of patients in group DEX received postoperative, supplemental opioid medication compared with group saline (48% vs 73%, respectively; P < 0.0001). Group DEX appeared to experience fewer adverse events than group saline as well (9% vs 17%, respectively; P = 0.025). Rapid IV bolus administration of DEX in children improved their recovery profile by reducing the incidence of EA. A statistically significant change in hemodynamics was observed, but no patients required any intervention for hemodynamic changes. Furthermore, DEX reduced the incidence of postoperative opioid administration, and a trend of fewer adverse events was observed in group DEX.

Diagnosis and treatment of streptococcal pharyngitis.

PubMed

Choby, Beth A

2009-03-01

Common signs and symptoms of streptococcal pharyngitis include sore throat, temperature greater than 100.4 degrees F (38 degrees C), tonsillar exudates, and cervical adenopathy. Cough, coryza, and diarrhea are more common with viral pharyngitis. Available diagnostic tests include throat culture and rapid antigen detection testing. Throat culture is considered the diagnostic standard, although the sensitivity and specificity of rapid antigen detection testing have improved significantly. The modified Centor score can be used to help physicians decide which patients need no testing, throat culture/rapid antigen detection testing, or empiric antibiotic therapy. Penicillin (10 days of oral therapy or one injection of intramuscular benzathine penicillin) is the treatment of choice because of cost, narrow spectrum of activity, and effectiveness. Amoxicillin is equally effective and more palatable. Erythromycin and first-generation cephalosporins are options in patients with penicillin allergy. Increased group A beta-hemolytic streptococcus (GABHS) treatment failure with penicillin has been reported. Although current guidelines recommend first-generation cephalosporins for persons with penicillin allergy, some advocate the use of cephalosporins in all nonallergic patients because of better GABHS eradication and effectiveness against chronic GABHS carriage. Chronic GABHS colonization is common despite appropriate use of antibiotic therapy. Chronic carriers are at low risk of transmitting disease or developing invasive GABHS infections, and there is generally no need to treat carriers. Whether tonsillectomy or adenoidectomy decreases the incidence of GABHS pharyngitis is poorly understood. At this time, the benefits are too small to outweigh the associated costs and surgical risks.

Fiberoptic nasopharyngolaryngoscopy for airway monitoring after obstructive sleep apnea surgery.

PubMed

Li, K K; Riley, R W; Powell, N B; Zonato, A

2000-12-01

This study evaluated the upper airway characteristics in the early postoperative period after reconstructive surgery for obstructive sleep apnea (OSA). During a 24-month period, the upper airway of patients who underwent uvulopalatopharyngoplasty (UPPP) with genioglossus advancement (GA) or hyoid myotomy (HM) or maxillomandibular advancement (MMA) were evaluated with fiberoptic nasopharyngolaryngoscopy (NPG) preoperatively and 24 to 72 hours postoperatively. NPG was performed on 271 patients. One hundred seventy-three patients had UPPP with GA or HM, and the remainder had MMA. All of the patients who underwent UPPP with GA or HM were found to have varying degrees of soft tissue edema involving the soft palate and the tongue base. The patients who underwent tonsillectomies and UPPP with GA or HM had greater soft palate/pharyngeal wall edema. In contrast, patients who underwent MMA had minimal edema involving the soft palate and the base of tongue, but diffuse lateral pharyngeal wall edema throughout the upper airway was identified. Eighteen of the MMA patients had ecchymosis and edema involving the pyriform sinus and aryepiglottic fold; 4 of these patients also had a hypopharyngeal hematoma involving the pyriform sinus, aryepiglottic fold, arytenoid, and false vocal cord, which partially obstructed the airway. These 4 patients were closely monitored for 1 to 2 additional days, and all were discharged without problems. None of the patients in the study had postoperative airway obstruction. NPG may be useful in postoperative airway monitoring and assist in discharge planning after upper airway reconstruction in the OSA patients.

Sleep surgery and medical malpractice.

PubMed

Tolisano, Anthony M; Bager, Jennifer M

2014-06-01

To describe and analyze the causes and outcomes of lawsuits pertaining to sleep surgery to mitigate future litigation and improve physician education. A retrospective review of a publicly available database containing jury verdicts and settlements. The LexisNexis MEGA Jury Verdicts and Settlements database was reviewed for all lawsuits including settlements and trial verdicts related to sleep surgery. Data including type of surgery performed, plaintiff allegation, nature of injury, outcomes, and indemnities were collected and analyzed. Fifty-one cases met the inclusion criteria. Of these, 30 were decided by a jury, nine were settled out of court, and 10 were resolved by other means. Overall, 57% of known outcomes favored the defendant. The most common surgery performed was tonsillectomy (57%), followed by uvulopalatopharyngoplasty (45%), adenoidectomy (31%), and septoplasty (31%). No difference was found between outcomes when comparing the most common injuries cited, including wrongful death (P = .572), airway compromise (P = .376), and drug reaction (P = .443). If failure to recognize a complication (P = .034) or delay in diagnosis (P = .026) was a component of the legal allegations, the outcome significantly favored the plaintiff. The median settlement ($545,000) and plaintiff award ($1.45 million) were not significantly different (P = .13). The majority of outcomes favored the defendant. Type of injury did not predict outcome. Failure to recognize complications and delay in diagnosis strongly predicted a verdict in favor of the plaintiff. 2c. © 2014 The American Laryngological, Rhinological and Otological Society, Inc.

Assessment of adenosine deaminase (ADA) activity and oxidative stress in patients with chronic tonsillitis.

PubMed

Garca, Mehmet Fatih; Demir, Halit; Turan, Mahfuz; Bozan, Nazım; Kozan, Ahmet; Belli, Şeyda Bayel; Arslan, Ayşe; Cankaya, Hakan

2014-06-01

To emphasize the effectiveness of adenosine deaminase (ADA) enzyme, which has important roles in the differentiation of lymphoid cells, and oxidative stress in patients with chronic tonsillitis. Serum and tissue samples were obtained from 25 patients who underwent tonsillectomy due to recurrent episodes of acute tonsillitis. In the control group, which also had 25 subjects, only serum samples were taken as obtaining tissue samples would not have been ethically appropriate. ADA enzyme activity, catalase (CAT), carbonic anhydrase (CA), nitric oxide (NO) and malondialdehyde (MDA) were measured in the serum and tissue samples of patients and control group subjects. The serum values of both groups were compared. In addition, the tissue and serum values of patients were compared. Serum ADA activity and the oxidant enzymes MDA and NO values of the patient group were significantly higher than those of the control group (p < 0.001), the antioxidant enzymes CA and CAT values of the patient group were significantly lower than those of the control group (p < 0.001). In addition, while CA, CAT and NO enzyme levels were found to be significantly higher in the tonsil tissue of the patient group when compared to serum levels (p < 0.05), there was no difference between tissue and serum MDA and ADA activity (p > 0.05). Elevated ADA activity may be effective in the pathogenesis of chronic tonsillitis both by impairing tissue structure and contributing to SOR formation.

Otolaryngology Service Usage in Children With Cleft Palate.

PubMed

Whittemore, Kenneth R; Dargie, Jenna M; Dornan, Briana K; Boudreau, Brian

2018-05-01

To determine the usage of otolaryngology services by children with cleft palate at a pediatric tertiary care facility. Retrospective case series. Specialty clinic at a pediatric tertiary care hospital. Children born between January 1, 1999, and December 31, 2002, with the diagnosis of cleft palate or cleft lip and palate. A total of 41 female and 48 male patients were included. Total number of otolaryngology clinic visits and total number of otolaryngologic surgeries (tympanostomy tube placements and other otologic or upper airway procedures). In the first 5 years of life, these children utilized an average of 8.2 otolaryngology clinic visits (SD = 5.0; range: 1-22) and underwent 3.3 tympanostomy tube surgeries (SD = 2.0; range: 0-10). Seventy-three had their first tube placed at the time of palate repair, and 4 at the time of lip repair. Fifty-one (57.3%) required other otologic or upper airway procedures, including tonsillectomy and/or adenoidectomy (27 children), removal of tympanostomy tubes (24 children), tympanomastoidectomy (3 children), and tympanoplasty (14 children). Of the children who underwent other procedures, they underwent a mean of 1.67 (SD = 0.84; range: 1-4) surgeries. Children with cleft palate are at increased risk for eustachian tube dysfunction, frequently utilize otolaryngology care, and typically receive multiple sets of tympanostomy tubes. This study found that children with cleft palate receive on average of approximately 3 sets of tympanostomy tubes, and the majority required another otologic or upper airway surgery.

Fatal infectious mononucleosis with evidence suggestive of the development of B cell lymphoma.

PubMed

Hiroshima, Kenzo; Iyoda, Akira; Isobe, Kouichi; Ishii, Genichiro; Toyozaki, Tetsuya; Shibuya, Kiyoshi; Shimamura, Fumihiko; Haga, Yukiko; Okimoto, Yuri; Horie, Hiroshi; Harigaya, Kenichi; Ohwada, Hidemi

2003-09-01

A 4-year-old girl presented to a local hospital in August 1999 with fever and cervical lymphadenopathy. A diagnosis of Epstein-Barr virus (EBV) infection was made and the patient was treated with corticosteroids. One month later she developed dyspnea secondary to tonsilar swelling, and underwent tonsillectomy and adenoidectomy. Her dyspnea increased, however, and by mid September she required mechanical ventilation. Six weeks later, she was transferred to Chiba Children's Hospital (Chiba, Japan). Despite vigorous treatment, she died within four weeks of admission. At autopsy, microscopic examination revealed numerous histiocytes with frequent hemophagocytosis in her lungs, liver, spleen, thymus, and lymph nodes. The tentative diagnosis was EBV-associated hemophagocytic syndrome (EBVAHS). A proliferation of atypical lymphocytes was observed in the lymph nodes, the majority of which stained positive with CD79a antibody. A whitish nodule, 8 mm in diameter, was noted in her right ovary. It consisted of a proliferation of pleomorphic lymphoid cells expressing CD79a antigen. In situ hybridization detected EBV RNA within CD79a antigen-positive cells in the lungs, spleen, thymus, bone marrow, lymph nodes, and the right ovary. Polymerase chain reaction analysis of DNA from the ovarian nodule demonstrated a monoclonal rearrangement of the immunoglobulin heavy chain gene indicating that it consisted of a clone of B lymphocytes. We suggest that EBVAHS develops into polyclonal and monoclonal lymphoproliferative disorder in a short period, and that EBVAHS is a preneoplastic condition that may result in B cell lymphoma.

Operative time and cost of resident surgical experience: effect of instituting an otolaryngology residency program.

PubMed

Pollei, Taylor R; Barrs, David M; Hinni, Michael L; Bansberg, Stephen F; Walter, Logan C

2013-06-01

Describe the procedure length difference between surgeries performed by an attending surgeon alone compared with the resident surgeon supervised by the same attending surgeon. Case series with chart review. Tertiary care center and residency program. Six common otolaryngologic procedures performed between August 1994 and May 2012 were divided into 2 cohorts: attending surgeon alone or resident surgeon. This division coincided with our July 2006 initiation of an otolaryngology-head and neck surgery residency program. Operative duration was compared between cohorts with confounding factors controlled. In addition, the direct result of increased surgical length on operating room cost was calculated and applied to departmental and published resident case log report data. Five of the 6 procedures evaluated showed a statistically significant increase in surgery length with resident involvement. Operative time increased 6.8 minutes for a cricopharyngeal myotomy (P = .0097), 11.3 minutes for a tonsillectomy (P < .0001), 27.4 minutes for a parotidectomy (P = .028), 38.3 minutes for a septoplasty (P < .0001), and 51 minutes for tympanomastoidectomy (P < .0021). Thyroidectomy showed no operative time difference. Cost of increased surgical time was calculated per surgery and ranged from $286 (cricopharyngeal myotomy) to $2142 (mastoidectomy). When applied to reported national case log averages for graduating residents, this resulted in a significant increase of direct training-related costs. Resident participation in the operating room results in increased surgical length and additional system cost. Although residency is a necessary part of surgical training, associated costs need to be acknowledged.

Eagle syndrome surgical treatment with piezosurgery.

PubMed

Bertossi, Dario; Albanese, Massimo; Chiarini, Luigi; Corega, Claudia; Mortellaro, Carmen; Nocini, Pierfrancesco

2014-05-01

Eagle syndrome (ES) is an uncommon complication of styloid process elongation with stylohyoideal complex symptomatic calcification. It is an uncommon condition (4% of the population) that is symptomatic in only 4% of the cases. Eagle syndrome is usually an acquired condition that can be related to tonsillectomy or to a neck trauma. A type of ES is the styloid-carotid syndrome, a consequence of the irritation of pericarotid sympathetic fibers and compression on the carotid artery. Clinical manifestations are found most frequently after head turning and neck compression. Although conservative treatment (analgesics, anticonvulsants, antidepressants, local infiltration with steroids, or anesthetic agents) have been used, surgical treatment is often the only effective treatment in symptomatic cases. We present the case of a 55-year-old patient, successfully treated under endotracheal anesthesia. The cranial portion of the calcified styloid process was shortened through an external approach, using a piezoelectric cutting device (Piezosurgery Medical II; Mectron Medical Technology, Carasco, Italy) with MT1-10 insert, pump level 4, vibration level 7. No major postoperative complications such as nerve damage, hematoma, or wound dehiscence occurred. After 6 months, the patient was completely recovered. Two years after the surgery, the patient did not refer any symptoms related to ES. The transcervical surgical approach in patients with ES seems to be safe and effective, despite the remarkable risk for transient marginal mandibular nerve palsy. This risk can be decreased by the use of the piezoelectric device for its distinctive characteristics--such as precision, selective cut action, and bloodless cut.

Parents' experiences of managing their child's postoperative pain at home: an exploratory qualitative study.

PubMed

Longard, Julie; Twycross, Alison; Williams, Anna M; Hong, Paul; Chorney, Jill

2016-09-01

To understand parents' experiences of managing their child's postoperative pain at home. Recent changes in children's health care services often shift the responsibility of managing children's postoperative pain to parents. Although pain management is important for good postoperative outcomes, it can be a challenging task for families, and children's pain is often under-managed. This qualitative study used semi-structured interviews to explore parents' experiences of managing their child's postoperative pain at home. Participants were parents of 10 typically developing 5- and 6-year olds, who underwent (adeno)tonsillectomy, and experienced no complications leading to hospitalisation in the postoperative period. One-on-one interviews were conducted with parents within three months of their child's surgery. Interviews were transcribed verbatim and content analysis was used to identify themes in parents' experiences. All children experienced some postoperative pain. Parents' experiences of managing their child's pain were impacted by balancing the pros and cons of administering analgesic medications, managing the emotional and psychological effects of their child's pain, as well as parents' information needs. Most parents' information needs were met yet they still struggled to manage their child's pain. These findings provide insight into some of the barriers that make this process challenging for many families, and what health care centres can do to help support parents manage their child's postoperative pain at home. The results of this study may aid in the design of interventions that will support parents when managing their child's postoperative pain at home and thus improve children's experiences. © 2016 John Wiley & Sons Ltd.

Asymptomatic cardiopulmonary changes caused by adenoid hypertrophy.

PubMed

Abdel-Aziz, Mosaad

2011-07-01

Adenoid hypertrophy is the most common cause of pediatric upper airway obstruction, and it can lead to cardiopulmonary complications such as pulmonary hypertension, cor pulmonale, and even heart failure. The aim of this study was to detect the asymptomatic cardiopulmonary changes that could happen in children with adenoid hypertrophy.Eighty children with adenoid hypertrophy were included in this study. Chest x-ray was used to assess the cardiothoracic ratio, whereas echocardiography was used for measuring the pulmonary arterial pressures, right ventricular diastolic filling parameters, and right ventricular end-diastolic diameters. All patients underwent adenoidectomy with or without tonsillectomy, and they were subjected again to echocardiographic assessment 6 months after the operation. No patient showed an increase in the cardiothoracic ratio on x-ray. Preoperative echocardiography showed an increase in pulmonary artery pressure (22.7 [SD, 3.8] mm Hg), a decrease in right ventricular diastolic filling parameters (E/A = 1.03 [SD, 0.17]), and an increase in right ventricular end-diastolic diameters (1.89 [SD, 0.19] cm). Postoperatively, pulmonary artery pressure decreased to 17.2 [SD, 2.1] mm Hg, right ventricular diastolic filling (E/A) increased to 1.25 [SD, 0.11], and right ventricular end-diastolic diameters decreased to 1.68 [SD, 0.12] cm. The comparison between preoperative and postoperative results for each individual parameter was statistically significant. Clinically asymptomatic cardiopulmonary changes due to adenoid hypertrophy are not rare. Early diagnosis and treatment of upper airway obstruction can prevent these serious complications. Echocardiographic examination should be recommended for these patients as a part of preoperative preparation to avoid anesthetic complications.

Snoring during early childhood and academic performance at ages thirteen to fourteen years.

PubMed

Gozal, D; Pope, D W

2001-06-01

Obstructive sleep apnea syndrome in young children is associated with an adverse effect on learning. However, the long-term impact of sleep-disordered breathing (SDB) during early childhood on learning remains unknown. Questionnaires were mailed to seventh and eighth graders attending public schools whose class ranking was either in the top 25% (high performance [HP]) or bottom 25% of their class (low performance [LP]), and who were matched for age, gender, race, school, and street of residence. Snoring frequency and loudness at 2 to 6 years of age, tonsillectomy and adenoidectomy (T&A) for snoring or recurrent infection, school grades, and parental smoking and snoring were assessed. The questionnaire response rate was 82.8%. Because of ongoing ring, 13 responders were excluded, such that 1588 questionnaires could be analyzed (797 in LP and 791 in HP group). Frequent and loud snoring during early childhood was reported in 103 LP children (12.9%) compared with 40 HP children (5.1%; odds ratio: 2.79; confidence interval: 1.88-4.15). Furthermore, 24 LP and 7 HP children underwent T&A for snoring (odds ratio: 3.40; confidence interval: 1.47-7.84), while 21 LP and 19 HP children required surgery for recurrent tonsillitis. Children with lower academic performance in middle school are more likely to have snored during early childhood and to require T&A for snoring compared with better performing schoolmates. These findings support the concept that SDB-associated neurocognitive morbidity may be only partially reversible or that a "learning debt" may develop with SDB during early childhood and hamper subsequent school performance.

Selected medical conditions and risk of pancreatic cancer.

PubMed

Olson, Sara H

2012-01-01

We review the current evidence for associations of several medical conditions with risk of pancreatic cancer, including allergies, pancreatitis, gall bladder disease, cholecystectomy, ulcers, gastrectomy, appendectomy, and tonsillectomy. There are consistent findings of reduced risk associated with presence of self-reported allergies, particularly hay fever but not asthma; data on other allergies are limited and inconclusive. Several studies provide evidence that patients with pancreatic cancer are more likely than comparison groups to report pancreatitis. Those studies that investigated the time between onset of pancreatitis and diagnosis of pancreatic cancer found that risk estimates declined with longer periods of time; however, increased risks were noted for long-term pancreatitis, indicating that this condition is both a risk factor and a sign of early disease. Increased risk was reported in association with cholelithiasis, but the few studies that considered time before diagnosis of cancer did not find increased risk for cholelithiasis diagnosed in the more distant past. There is weak evidence that cholecystectomy 2 or more years before cancer diagnosis is related to risk, but this is based on only a few studies. There is no consistent association between ulcers and risk, while gastrectomy may increase risk. Overall, study of these conditions, particularly those that are rare, presents methodologic challenges. Time between diagnoses is likely to be important but is not considered in most studies. Lack of adequate control in several studies for risk factors such as smoking and heavy alcohol use also makes it difficult to draw firm conclusions about these results. Copyright © 2011 Wiley Periodicals, Inc.

Remission and incidence of obstructive sleep apnea from middle childhood to late adolescence.

PubMed

Spilsbury, James C; Storfer-Isser, Amy; Rosen, Carol L; Redline, Susan

2015-01-01

To study the incidence, remission, and prediction of obstructive sleep apnea (OSA) from middle childhood to late adolescence. Longitudinal analysis. The Cleveland Children's Sleep and Health Study, an ethnically mixed, urban, community-based cohort, followed 8 y. There were 490 participants with overnight polysomnography data available at ages 8-11 and 16-19 y. Baseline participant characteristics and health history were ascertained from parent report and US census data. OSA was defined as an obstructive apnea- hypopnea index ≥ 5 or an obstructive apnea index ≥ 1. OSA prevalence was approximately 4% at each examination, but OSA largely did not persist from middle childhood to late adolescence. Habitual snoring and obesity predicted OSA in cross-sectional analyses at each time point. Residence in a disadvantaged neighborhood, African-American race, and premature birth also predicted OSA in middle childhood, whereas male sex, high body mass index, and history of tonsillectomy or adenoidectomy were risk factors among adolescents. Obesity, but not habitual snoring, in middle childhood predicted adolescent OSA. Because OSA in middle childhood usually remitted by adolescence and most adolescent cases were incident cases, criteria other than concern alone over OSA persistence or incidence should be used when making treatment decisions for pediatric OSA. Moreover, OSA's distinct risk factors at each time point underscore the need for alternative risk-factor assessments across pediatric ages. The greater importance of middle childhood obesity compared to snoring in predicting adolescent OSA provides support for screening, preventing, and treating obesity in childhood. © 2014 Associated Professional Sleep Societies, LLC.

Informed Consent in Pediatric Otolaryngology: What Risks and Benefits Do Parents Recall?

PubMed

Pianosi, Kiersten; Gorodzinsky, Ayala Y; Chorney, Jill MacLaren; Corsten, Gerard; Johnson, Liane B; Hong, Paul

2016-08-01

To evaluate parental recall of surgical risks and benefits in pediatric otolaryngology and to assess for factors that may influence recall. Prospective cohort study. Academic pediatric otolaryngology clinic. Eighty-four parents of children <6 years of age who underwent consultation for adeno/tonsillectomy and/or tympanostomy tube insertion were prospectively enrolled. Consultation visits were video recorded and the benefits and risks of surgery documented. Two weeks following the consultation, parents were contacted for assessment of recall of information discussed during the consultation. Overall, parents recalled only one-third of the risks of surgery mentioned by the surgeons. Parents were significantly more likely to recall the benefits of surgery as opposed to the risks (P < .001). Nine parents (10.7%) reported that no benefits were discussed during the consultation, and 10 (11.9%) reported no mention of any risks. Inconsistencies were present in which risks and benefits were mentioned by the providers. Parents who decided to proceed with surgery (58.3%) were significantly less likely to recall the surgical risks than those who did not (P < .001). The specific surgeon involved, the number of caregivers present, parental education level, and prior surgical history did not influence recall. Parental recall of benefits and risks associated with common pediatric otolaryngology procedures was poor. This information is important because a low rate of recall may influence parents' perspectives of the procedure and could alter their decision-making processes or expectations. Methods to improve parental recall should be further studied. © American Academy of Otolaryngology—Head and Neck Surgery Foundation 2016.

New clinical staging for pharyngeal surgery in obstructive sleep apnea patients.

PubMed

Vidigal, Tatiana Aguiar; Haddad, Fernanda Louise Martinho; Cabral, Rafael Ferreira Pacheco; Oliveira, Maria Claudia Soares; Cavalcante, Ricardo Rodrigues; Bittencourt, Lia Rita Azeredo; Tufik, Sergio; Gregório, Luis Carlos

2014-01-01

The success of pharyngeal surgery in the treatment of obstructive sleep apnea syndrome depends on the appropriate selection of patients. To propose a new staging for indication of pharyngeal surgery in obstructive sleep apnea syndrome. A total of 54 patients undergoing extended tonsillectomy were retrospectively included, divided into six stages. Stage I: patients with palatine tonsils grade 3/4 and modified Mallampati index 1/2; stage II: palatine tonsils 3/4 and modified Mallampati index 3/4; stage III: palatine tonsils 1/2 and modified Mallampati index 1/2; stage IV: palatine tonsils 1/2 and modified Mallampati index 3/4; stage V: body mass index ≥40 kg/m(2) with palatine tonsils 3/4 and modified Mallampati index 1, 2, 3, or 4. Stage VI: body mass index ≥40 with palatine tonsils 1/2 and modified Mallampati index 1, 2, 3, or 4. The surgical success rates were 88.9%, 75.0%, 35.7%, 38.5%, and 100.0% in stages I-V. The presence of hypertrophic palatine tonsils was the anatomical factor in common in the most successful stages (I, II, and V), regardless of body mass index. Although the modified Mallampati index classes 3 and 4 reduced the success rate of surgery in patients with hypertrophic tonsils (stage II), the presence of modified Mallampati index classes 1 and 2 did not favor surgical success in patients with normal tonsils (stage III). Copyright © 2014 Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico-Facial. Published by Elsevier Editora Ltda. All rights reserved.

Bacteriological evaluation of tonsillar microbial flora according to age and tonsillar size in recurrent tonsillitis.

PubMed

Develioglu, Omer Necati; Ipek, Havva Duru; Bahar, Hrisi; Can, Gunay; Kulekci, Mehmet; Aygun, Gokhan

2014-06-01

Although numerous studies based on the bacteriology of the tonsil have been carried out, none of them analyzed the variation of tonsillar flora with respect to both age and tonsillar size. The purpose of this study was to isolate the facultative and obligate anaerobes both from the surface and the core of tonsils in recurrent tonsillitis as well as to analyze the variation of isolated bacterial strains according to age and tonsillar size. A prospective study was performed on 111 patients who underwent tonsillectomy. We analyzed the differences between the bacterial pathogens in recurrent tonsillitis and semi-growth estimates with regard to age and tonsillar grade. Among 111 cases, 604 bacterial strains of 21 different from the tonsil superficial and core were isolated. The most common facultative anaerobic species isolated from the surface and core were Coagulase-negative staphylococci, Alpha-hemolytic streptococci and Diphtheroid bacilli in all subgroups except patients below 8 years old. The most commonly obligate anaerobic species isolated from the core were Propionibacterium acnes, Prevotella melaninogenica and Peptostreptococcus anaerobius. We found no significant difference in the cultured bacteria with respect to age and tonsillar size. The study subgroups did not differ in the occurrence of semiquantitative growth estimates of 3-4+. Our study demonstrates that there is polymicrobial aerobic and anaerobic flora in tonsils with regardless of patient's age and tonsillar size. This polymicrobial spectrum of bacteria may contribute to recurrence and to the failure of conservative treatment of these cases and therefore leads to surgical therapy.

Long-term changes in neurocognition and behavior following treatment of sleep disordered breathing in school-aged children.

PubMed

Biggs, Sarah N; Vlahandonis, Anna; Anderson, Vicki; Bourke, Robert; Nixon, Gillian M; Davey, Margot J; Horne, Rosemary S C

2014-01-01

Sleep disordered breathing (SDB) in children is associated with detrimental neurocognitive and behavioral consequences. The long term impact of treatment on these outcomes is unknown. This study examined the long-term effect of treatment of SDB on neurocognition, academic ability, and behavior in a cohort of school-aged children. Four-year longitudinal study. Children originally diagnosed with SDB and healthy non-snoring controls underwent repeat polysomnography and age-standardized neurocognitive and behavioral assessment 4y following initial testing. Melbourne Children's Sleep Centre, Melbourne, Australia. Children 12-16 years of age, originally assessed at 7-12 years, were categorized into Treated (N = 12), Untreated (N = 26), and Control (N = 18) groups. Adenotonsillectomy, Tonsillectomy, Nasal Steroids. Decision to treat was independent of this study. Changes in sleep and respiratory parameters over time were assessed. A decrease in obstructive apnea hypopnea index (OAHI) from Time 1 to Time 2 was seen in 63% and 100% of the Untreated and Treated groups, respectively. The predictive relationship between change in OAHI and standardized neurocognitive, academic, and behavioral scores over time was examined. Improvements in OAHI were predictive of improvements in Performance IQ, but not Verbal IQ or academic measures. Initial group differences in behavioral assessment on the Child Behavior Checklist did not change over time. Children with SDB at baseline continued to exhibit significantly poorer behavior than Controls at follow-up, irrespective of treatment. After four years, improvements in SDB are concomitant with improvements in some areas of neurocognition, but not academic ability or behavior in school-aged children.

Otorhinolaryngological patient injuries in Finland.

PubMed

Lehtivuori, Tuuli; Palonen, Reima; Mussalo-Rauhamaa, Helena; Holi, Tarja; Henriksson, Markus; Aaltonen, Leena-Maija

2013-10-01

Otorhinolaryngology (ORL) is considered a specialty associated with few serious patient injuries. Research data that support this belief are, however, scarce. We analyzed claims associated with ORL to determine the number of Finnish cases and the possible common denominators. Register study of ORL cases in the Patient Insurance Centre (PIC), the Regional State Administrative Agencies (RSAA), and the National Supervisory Authority for Welfare and Care (Valvira) during the years 2004 to 2008. These three agencies are the main actors in the field of patient injury in Finland. We analyzed compensated ORL patient injury cases from the PIC and cases associated with the ORL specialty for Valvira and RSAA from 2004 to 2008 and surveyed patient treatment files, statements from specialists, and compensation decisions. Injuries were usually associated with operations; three patients who experienced injuries during these procedures died. Common ORL operations such as tonsillectomy, septoplasty, and paranasal sinus surgery were most often associated with compensated injuries. Serious injuries were few, with a total of 110 out of 422 (26.1%) claims compensated by the PIC. Of the 110 compensated cases, 30 (27.3%) were related to tumor surgery. The most usual compensated case had iatrogenic nerve injury affecting the facial or trigeminal nerves. Of the compensated cases, 79 (71.8%) were treated by specialists, 15 (13.6%) by residents, and the rest by other medical professionals. Patient injuries in ORL are seldom severe and are strongly associated with surgery. A typical compensated injury was one that occurred in a central hospital during working hours. N/A. Copyright © 2013 The American Laryngological, Rhinological, and Otological Society, Inc.

A comprehensive comparison between pediatric and adult patients with periodic fever, aphthous stomatitis, pharyngitis, and cervical adenopathy (PFAPA) syndrome.

PubMed

Rigante, Donato; Vitale, Antonio; Natale, Marco Francesco; Lopalco, Giuseppe; Andreozzi, Laura; Frediani, Bruno; D'Errico, Francesca; Iannone, Florenzo; Cantarini, Luca

2017-02-01

Periodic fever, aphthous stomatitis, pharyngitis, and cervical adenopathy (PFAPA) syndrome is a mysterious disorder characterized by periodically recurrent fevers, oropharyngeal inflammation, and adenitis, which mainly affects children, though in very recent times, it has been also recognized in adulthood. We enrolled 115 unrelated pediatric and adult patients with history of periodic fevers who fulfilled the current diagnostic criteria for PFAPA syndrome in three Italian referral centers and highlighted differences between children and adults. Eighty-five children and 30 adults were evaluated: the frequency of flares was significantly higher in pediatric cases, while febrile attack duration was significantly longer in adults. Clockwork periodicity of fever and recurrent pharyngitis were more frequently observed in childhood, but no differences were identified for aphthosis and cervical adenopathy. Conversely, joint symptoms, myalgia, headache, fatigue, ocular signs, and rashes were more common in adults. The simultaneous occurrence of two or three cardinal PFAPA signs did not show any statistical difference between the groups, while the occurrence of only one cardinal manifestation was more frequent in adults. Corticosteroids were effective in 98.82 % of children and 88.2 % of adults. Tonsillectomy was rarely performed, resulting effective in only two patients. Our data illustrate the clinical overlap between pediatric and adult cases of PFAPA syndrome. Adults are characterized by a wider repertoire of inflammatory signs, suggesting that onset in adulthood might leave the disease misdiagnosed. Clinicians, not only pediatricians, should take into account this clinical entity in every patient of whatever age suffering from recurrent fevers of unknown origin.

Comparison in anesthetic effects of propofol among patients with different ABO blood groups.

PubMed

Du, Yiri; Shi, Haixia; Yu, Jianshe

2017-05-01

Our study was aimed to investigate anesthetic effects of propofol in patients with different blood groups.A total of 72 participants were enrolled from patients arranged for surgeries of cholecystectomy, tonsillectomy, and spinal operation. Each blood group (A, B, AB, and O) contained 18 participants. Mean arterial pressure (MAP), heart rate (HR), and bispectral index (BIS) were assayed with Philips monitor. These indexes were observed before propofol anesthesia (T0), and then were recorded when concentration of propofol was 1 μg/mL (T1), 2 μg/mL (T2), 3 μg/mL (T3), and 4 μg/mL (T4). The differences in MAP, HR, and BIS at T0 among groups were compared with the χ test. Multiple comparisons were adopted to calculate the differences in MAP, HR, and BIS between groups at T1, T2, T3, and T4.No significant differences in age, sex, and weight of all groups were found (P > .05). Before propofol anesthesia (T0), all the participants exhibited no differences in MAP, HR, and BIS (P > .05). Subsequently, we found obvious differences in ΔMAP, ΔHR, and ΔBIS between groups. The patients in the B blood group showed highest ΔMAP and ΔHR at each time point (P < .05 for both). As for ΔBIS, patients in A blood group exhibited highest value at T3 and T4 (P < .05).The blood group remarkably affects the anesthetic effects of propofol.

A study of the course of the internal carotid artery in the parapharyngeal space and its clinical importance.

PubMed

Ozgur, Zuhal; Celik, Servet; Govsa, Figen; Aktug, Hüseyin; Ozgur, Tomris

2007-12-01

The differences in the course and shape of the internal carotid artery (ICA) in the parapharyngeal space were investigated to determine the possible risks for serious hemorrhage during tonsillectomy, drainage of peritonsillar abscess, soft palate injuries, adenoidectomy and velopharyngeoplasty. The course of the ICA was studied in the parapharyngeal spaces of 50 adult cadavers. From each specimen, circumferential sections were obtained and they stained with hematoxylin-eosin and Verhoeff's elastic staining. The cervical course of the ICA showed no curvature in 70 cases; but in 25 cases it had a medial curve, and five cases showed kinking out of a total 100 dissected carotid sheaths. In two cases, kinking of the ICA was related to the pharyngeal wall. The histological examination of all kinking specimens demonstrated depletion and decreasing muscle tissue in tunica media and an increase was observed in vasa vasorum numbers in the tunica adventitia of ICA. The dissections and integrity losses were seen in tunica media and tunica adventitia. The vessel wall of histological structure change were detected in kinking specimens and lays the groundwork for the vessel wall to get easily harmed or torn either directly or indirectly by decreasing the elasticity and soundness of the wall. The transposition of the ICA artery in submucous position becomes important for otorhinolaryngologists when its aberrant course causes a widening in the retropharyngeal or parapharyngeal tissues and an impression on the pharyngeal wall. Curving and kinking of the ICA can constitute a risk factor for acute hemorrhage in routine surgical procedures, which are performed by inexperienced surgeons.

Guidelines for the management and treatment of periodic fever syndromes: periodic fever, aphthous stomatitis, pharyngitis and adenitis syndrome.

PubMed

Terreri, Maria Teresa R A; Bernardo, Wanderley Marques; Len, Claudio Arnaldo; da Silva, Clovis Artur Almeida; de Magalhães, Cristina Medeiros Ribeiro; Sacchetti, Silvana B; Ferriani, Virgínia Paes Leme; Piotto, Daniela Gerent Petry; Cavalcanti, André de Souza; de Moraes, Ana Júlia Pantoja; Sztajnbok, Flavio Roberto; de Oliveira, Sheila Knupp Feitosa; Campos, Lucia Maria Arruda; Bandeira, Marcia; Santos, Flávia Patricia Sena Teixeira; Magalhães, Claudia Saad

2016-01-01

To establish guidelines based on scientific evidence for the management of periodic fever, aphthous stomatitis, pharyngitis and adenitis (PFAPA) syndrome. The Guideline was prepared from 5 clinical questions that were structured through PICO (Patient, Intervention or indicator, Comparison and Outcome), to search in key primary scientific information databases. After defining the potential studies to support the recommendations, these were graduated considering their strength of evidence and grade of recommendation. 806 articles were retrieved and evaluated by title and abstract; from these, 32 articles were selected to support the recommendations. 1. PFAPA is a diagnosis of exclusion established on clinical grounds, and one must suspect of this problem in children with recurrent and periodic febrile episodes of unknown origin, or with recurrent tonsillitis interspersed with asymptomatic periods, especially in children in good general condition and with preservation of weight and height development. 2. Laboratory findings are nonspecific. Additional tests do not reveal pathognomonic changes. 3. The evidence supporting an indication for surgical treatment (tonsillectomy with or without adenoidectomy), is based on two non-blinded randomized clinical trials with small numbers of patients. 4. The use of prednisone at the onset of fever in patients with PFAPA proved to be an effective strategy. There is still need for more qualified evidence to support its use in patients with PFAPA. 5. Despite promising results obtained in studies with IL-1β inhibitors, such studies are limited to a few case reports. Copyright © 2015 Elsevier Editora Ltda. All rights reserved.

[Asymmetric negative pressure pulmonary edema after acute upper airway obstruction: case report].

PubMed

Peixoto, Aldo José

2002-06-01

Negative pressure pulmonary edema after acute upper airway obstruction is a well-described event, though infrequently diagnosed and reported. This report aimed at presenting a case of upper airway obstruction negative pressure pulmonary edema following acute upper airway obstruction characterized by pulmonary edema asymmetry, being more prominent in the right lung. A 4-year-old boy, 17 kg, phisical status ASA I submitted to combined tonsillectomy, adenoidectomy and turbinate cauterization under general anesthesia with sevoflurane/nitrous oxide/O2. Surgery duration was 90 minutes without complications. During anesthetic recovery and spontaneously breathing, patient reacted to tracheal tube, which was removed. Following, ventilatory efforts resulted in chest wall retraction without apparent air movement, being impossible to ventilate him with facial mask. Symptoms evolved to severe hypoxemia (50% SpO2) requiring reintubation. At this point, it was observed that the lung was stiffer and there were bilateral rales characterizing pulmonary edema. A chest X-ray showed diffuse bilateral infiltrates, right upper lobe atelectasis and marked pulmonary edema asymmetry (right greater than left). Patient was mechanically ventilated with PEEP for 20 hours when he was extubated. There was a progressive pulmonary edema improvement and patient was discharged 48 hours later. Negative pressure pulmonary edema (NPPE) is a rare event with high morbidity risk. It is often not diagnosed and requires from the anesthesiologist an updated knowledge and adequate management. It is usually bilateral, rarely unilateral, and exceptionally asymmetric as in this case. Most cases are treated by mechanical ventilation with PEEP or CPAP without any other therapy. The prognosis is favorable, with most cases recovering within the first 24 hours.

Drug-induced sedation endoscopy in children <2 years with obstructive sleep apnea syndrome: upper airway findings and treatment outcomes.

PubMed

Boudewyns, A; Van de Heyning, P; Verhulst, S

2017-05-01

Few data are available about the pattern of upper airway (UA) obstruction in children <2 years with obstructive sleep apnea syndrome (OSAS). Also, the role of adenoidectomy versus adenotonsillectomy (AT) is poorly defined in this age group. We performed drug-induced sedation endoscopy (DISE) in young OSAS children to investigate the pattern of UA obstruction and the value of DISE in therapeutic decision making. Retrospective analysis of ≤2-year-old children undergoing DISE-directed UA surgery. OSAS severity and the treatment outcomes were documented by polysomnography. Data are available for 28 patients, age 1.5 years (1.3-1.8), BMI-z score 0.5 (-0.7 to 1.3) with severe OSAS, obstructive apnea/hypopnea index (oAHI) 13.8/hr (7.5-28.3). All but 3 had (>50%) obstruction at the level of the adenoids, and all but 5 had (>50%) tonsillar obstruction. DISE-directed treatment consisted of adenoidectomy (n = 4), tonsillectomy (n = 1), and AT (n = 23). There was a significant improvement in respiratory parameters. Twenty children (71.4%) had a postoperative oAHI <2/hr. None had palatal or tongue base obstruction. Five children had a circumferential UA narrowing (hypotonia), 2 of them had residual OSAS. DISE showed a collapse of the epiglottis in 6 and late-onset laryngomalacia in 4. These findings did not affect surgical outcome. Adenotonsillar hypertrophy is the major cause of UA obstruction, and DISE-directed UA surgery was curative in 71,4% of children ≤2 years. We suggest that DISE may be helpful in surgical decision making. Circumferential UA narrowing may result in less favorable surgical outcomes.

Microbiology of peritonsillar abscess in the South Estonian population

PubMed Central

Vaikjärv, Risto; Kasenõmm, Priit; Jaanimäe, Liis; Kivisild, Ave; Rööp, Tiiu; Sepp, Epp; Mändar, Reet

2016-01-01

Objective The first aim of this study was to compare the microbiota of different locations (pus, tonsillar fossa, blood) in peritonsillar abscess (PTA) patients in order to optimize the sampling scheme. The second aim was to estimate the occurrence of tonsillitis episodes and macroscopic oropharyngeal signs characteristic of recurrent tonsillitis in PTA patients. Methods The study group consisted of 22 consecutive patients with PTA undergoing bilateral tonsillectomy. The PTA was punctured; pus and tonsillar fossa biopsy samples and the peripheral blood cultures were collected. The index of tonsillitis was calculated by multiplying the number of tonsillitis episodes per year by the morbidity period in years. Macroscopic oropharyngeal signs were evaluated and they were as follows: tonsillar sclerosis, obstruction of the tonsillar crypts, scar tissue on tonsils, cryptic debris, and lymphatic tissue aggregates. Results The cultures of the pus were positive in 16 out of 22 patients and the cultures of the tonsillar fossa samples were positive in all cases. In total, 62 different organisms were found from tonsillar fossa, pus, and blood samples, which belonged to 5 different phyla and 18 different families. In the tonsillar fossa, the most frequent bacteria found were Streptococcus spp. In pus samples, the most frequently found bacteria were Streptococcus spp. and bacteria from the Streptococcus milleri group. Conclusion PTA patients had mixed anaerobic and aerobic microbiota both in the tissue of the tonsillar fossa and the pus of the peritonsillar space. We demonstrated that the tonsillar fossa specimen is a better material for microbiological analyses, because it reveals more bacteria per culture. PTA patients usually have a low number of tonsillitis episodes in their previous history, but a relatively high number of macroscopic oropharyngeal signs, indicating the sclerotic process in palatal tonsils. PMID:27113570

Characterization of the expanded T cell population in infectious mononucleosis: apoptosis, expression of apoptosis-related genes, and Epstein–Barr virus (EBV) status

PubMed Central

Verbeke, C S; Wenthe, U; Bergler, W F; Zentgraf, H

2000-01-01

Infectious mononucleosis (IM), a manifestation of primary infection with EBV, is characterized by a massive expansion of the T cell population. In this study we examined this expanded T cell population regarding its EBV status, its proliferative and apoptotic activity, and its expression of apoptosis-related genes. Whereas previous studies were performed on ex vivo cultures or on peripheral blood, our investigations included in vivo analysis of IM tonsillectomy specimens (14 cases) by in situ hybridization for viral RNA (EBERs) combined with immunohistochemistry (IHC; CD3, CD45RO, CD20, CD79a, Ki-67, Bcl-2, Bax, Fas, FasL) and the TUNEL method. Of the EBER+ cells 50–70% showed expression of the B cell markers CD20/CD79a. The remainder of the EBER+ cells expressed neither B nor T cell antigens. No co-expression of EBERs and T cell antigens was detected in any of the specimens. In accordance with a high rate of apoptosis (up to 2·37%) within the expanded T cell population, Bcl-2 expression was drastically reduced and FasL expression remarkably increased. The levels of Bax and Fas expression showed no or moderate up-regulation. In conclusion, the massive expansion of IM T cells is not caused by EBV infection of these cells but merely represents an intense immune reaction. Through altered expression of Bcl-2/Bax and Fas/FasL, the activated T cells are subject to enhanced apoptosis while residing within the lymphoid tissue, which eventually allows the efficient silencing of this potentially damaging T cell response. PMID:10792379

Comprehensive microbiome analysis of tonsillar crypts in IgA nephropathy.

PubMed

Watanabe, Hirofumi; Goto, Shin; Mori, Hiroshi; Higashi, Koichi; Hosomichi, Kazuyoshi; Aizawa, Naotaka; Takahashi, Nao; Tsuchida, Masafumi; Suzuki, Yusuke; Yamada, Takuji; Horii, Arata; Inoue, Ituro; Kurokawa, Ken; Narita, Ichiei

2017-12-01

Immunoglobulin A nephropathy (IgAN) is the most prevalent primary chronic glomerular disease, in which the mucosal immune response elicited particularly in the tonsils or intestine has been estimated to be involved in the development of the disease. To explore the relationship between IgAN and bacterial flora in the tonsils, we conducted a comprehensive microbiome analysis. We enrolled 48 IgAN patients, 21 recurrent tonsillitis (RT) patients without urine abnormalities and 30 children with tonsillar hyperplasia (TH) who had undergone tonsillectomy previously. Genomic DNA from tonsillar crypts of each patient was extracted, and V4 regions of the 16S ribosomal RNA gene were amplified and analysed using a high-throughput multiplexed sequencing approach. Differences in genus composition among the three study groups were statistically analysed by permutational multivariate analysis of variance and visualized by principal component analysis (PCA). Substantial diversity in bacterial composition was detected in each sample. Prevotella spp., Fusobacterium spp., Sphingomonas spp. and Treponema spp. were predominant in IgAN patients. The percentage of abundance of Prevotella spp., Haemophilus spp., Porphyromonas spp. and Treponema spp. in IgAN patients was significantly different from that in TH patients. However, there was no significant difference in the percentage of abundance of any bacterial genus between IgAN and RT patients. PCA did not distinguish IgAN from RT, although it discriminated TH. No significant differences in microbiome composition among the groups of IgAN patients according to clinicopathological parameters were observed. Similar patterns of bacteria are present in tonsillar crypts of both IgAN and RT patients, suggesting that the host response to these bacteria might be important in the development of IgAN. © The Author 2016. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved.

Causes and costs for ED visits after pediatric adenotonsillectomy.

PubMed

Curtis, Jonathan L; Harvey, D Brandon; Willie, Scott; Narasimhan, Evan; Andrews, Seth; Henrichsen, Jake; Van Buren, Nicholas C; Srivastava, Rajendu; Meier, Jeremy D

2015-04-01

(1) Review the reasons, timing, and costs for children presenting to the emergency department (ED) after adenotonsillectomy (T&A). Case series with chart review. Tertiary care children's hospital. A standardized activity-based hospital accounting system was used to identify 437 children from an academic pediatric otolaryngology practice presenting to the ED after T&A from 2009 to 2012. The reason for presentation, timing after surgery, and facility costs were recorded. The study cohort represented 13.3% of the 3198 patients who underwent T&A during that time period. Overall, 133 (4.2%) presented for dehydration, 106 (3.3%) presented for post-tonsillectomy hemorrhage, 65 (2.0%) for poorly controlled pain, 42 (1.3%) for fever, 29 (1.0%) for vomiting/nausea/GI discomfort, 22 (0.7%) for respiratory complications, and 12 (0.4%) for miscellaneous reasons related to the operation; 28 (0.8%) were unrelated to the T&A and excluded. Mean postoperative day at the time of ED presentation was 4.4 (95% CI, 4.1-4.7). The mean cost per patient presenting to the ED was $1420 (95% CI, $1104-$1737), the most costly subgroups being those presenting with respiratory complications ($2855; 95% CI, $1434-$4277), hemorrhage ($1502; 95% CI, $1216-$1787), and dehydration ($1372; 95% CI, $995-$1750). The least costly subgroup was acute postoperative pain ($781; 95% CI, $282-$1200). A significant portion of children present to the ED after T&A for poorly controlled pain, dehydration, or fever. The costs from these visits are significant. Accounting for these costs in the global care for pediatric T&A could assist in calculating appropriate reimbursement for bundled payments in this climate of health care reform. © American Academy of Otolaryngology—Head and Neck Surgery Foundation 2015.

[Effectiveness of pidotimod in combination with bacterial lysates in the treatment of the pfapa (periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis) syndrome].

PubMed

Buongiorno, A; Pierossi, N

2015-06-01

PFAPA (periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis) syndrome is the most common autoinflammatory syndrome in pediatrics, accepted as an hyperimmune condition. Pidotimod is a molecule with immunomodulatory activity on both innate and adaptive immune responses; it also has the capacity to modulate the function of the respiratory epithelial cells through the activation of a NK-KB pathway which would involve the host-virus interaction. Moreover, the proven beneficial effect of Pidotimod in enhancing the immune response during vaccination, and its benefits in the prevention of respiratory tract infections, should be noted. A joint combination of Pidotimod and bacterial lysates was used to treat 37 children with a clinical diagnosis of PFAPA; within the end of the first year of therapy, the healing rate of PFAPA symptoms was 67.5% (25 children), with a 10.8% (4 cases) still in complete remission within the end of the second year of follow-up. It is important to highlight that 29 children (78.3%) had benefitted from this therapy, in terms of healing, with a marked decrease in the incidence of fever from a total of 360 to 106 episodes, and episodes of periodic fever occurring almost 4 times less frequently. The use of Pidotimod determined a significant reduction of surgical tonsillectomy's treatment. This approach had a strong impact on the children's quality of life; a significant decrement in the use of antipyretic drugs, as well as a lower rate of antibiotic prescription, were also noted. It also had a dramatic impact on families' lives, because the treatment lowers the number of absences of family members from work or school/kindergarten.

Human beta defensin-1 is involved in the susceptibility to adeno-tonsillar hypertrophy.

PubMed

Zupin, Luisa; Celsi, Fulvio; Bresciani, Martina; Orzan, Eva; Grasso, Domenico Leonardo; Crovella, Sergio

2018-04-01

Innate immunity molecules are known to play a pivotal role in the homeostasis of the oral mucosa, permitting the presence of commensal microflora and, at the same time, providing a first line of defense against pathogens attempting to invade the oral cavity. Tonsils represent the local immune tissue in oral cavity, being able to provide a non-specific response to pathogens; however, in the presence of microbes or foreign materials present in the mouth tonsils could became infected and develop chronic inflammation, thus leading to hypertrophy. The etiology of the disease is multifactorial depending upon environmental and host factors, the latter including molecules of mucosal innate immunity. Ninety-five children with adeno-tonsillar hypertrophy subjected to adeno-tonsillectomy were recruited at the pediatric otorhinolaryngology service of the Institute for Maternal and Child Health IRCCS Burlo Garofolo, Trieste (Italy). The specimen discarded from the surgery were used for genomic DNA extraction and genotyping, for mRNA extraction and gene expression analysis, finally the samples were cut and used to prepare slides to perform immunohistochemistry. Functional polymorphisms within DEFB1 gene, encoding the human beta defensin-1 (hBD-1), were analyzed finding association between DEFB1 rare haplotypes and susceptibility to adeno-tonsillar hypertrophy. DEFB1 mRNA expression was detected in the tonsils and the hBD-1 protein was localized at the epithelia of tonsils mainly in the proximity of the basal lamina. Our findings lead us to hypothesize an involvement of hBD-1 mediated innate immunity in the modulation of the susceptibility towards adeno-tonsillar hypertrophy development. Copyright © 2018 Elsevier B.V. All rights reserved.

Proteomic Profiling of Serial Prediagnostic Serum Samples for Early Detection of Colon Cancer in the U.S. Military.

PubMed

Shao, Stephanie; Neely, Benjamin A; Kao, Tzu-Cheg; Eckhaus, Janet; Bourgeois, Jolie; Brooks, Jasmin; Jones, Elizabeth E; Drake, Richard R; Zhu, Kangmin

2017-05-01

Background: Serum proteomic biomarkers offer a promising approach for early detection of cancer. In this study, we aimed to identify proteomic profiles that could distinguish colon cancer cases from controls using serial prediagnostic serum samples. Methods: This was a nested case-control study of active duty military members. Cases consisted of 264 patients diagnosed with colon cancer between 2001 and 2009. Controls were matched to cases on age, gender, race, serum sample count, and collection date. We identified peaks that discriminated cases from controls using random forest data analysis with a 2/3 training and 1/3 validation dataset. We then included epidemiologic data to see whether further improvement of model performance was obtainable. Proteins that corresponded to discriminatory peaks were identified. Results: Peaks with m/z values of 3,119.32, 2,886.67, 2,939.23, and 5,078.81 were found to discriminate cases from controls with a sensitivity of 69% and a specificity of 67% in the year before diagnosis. When smoking status was included, sensitivity increased to 76% while histories of other cancer and tonsillectomy raised specificity to 76%. Peaks at 2,886.67 and 3,119.32 m/z were identified as histone acetyltransferases while 2,939.24 m/z was a transporting ATPase subunit. Conclusions: Proteomic profiles in the year before cancer diagnosis have the potential to discriminate colon cancer patients from controls, and the addition of epidemiologic information may increase the sensitivity and specificity of discrimination. Impact: Our findings indicate the potential value of using serum prediagnostic proteomic biomarkers in combination with epidemiologic data for early detection of colon cancer. Cancer Epidemiol Biomarkers Prev; 26(5); 711-8. ©2016 AACR . ©2016 American Association for Cancer Research.

Studying Life Effects & Effectiveness of Palatopharyngoplasty (SLEEP) Study: Subjective Outcomes of Isolated Uvulopalatopharyngoplasty

PubMed Central

Weaver, Edward M.; Woodson, B. Tucker; Yueh, Bevan; Smith, Timothy; Stewart, Michael G.; Hannley, Maureen; Schulz, Kristine; Patel, Milesh M.; Witsell, David

2018-01-01

OBJECTIVE To test the hypothesis that uvulopalatopharyngoplasty (UPPP) improves sleep apnea-related quality of life (measured on the Functional Outcomes of Sleep Questionnaire [FOSQ]) at three-month follow-up. Secondary objectives were to test: 1) the stability of the outcomes at six months, 2) the effect on global sleep apnea quality of life change, and 3) the effect on sleep apnea symptoms. STUDY DESIGN Multicenter, prospective, longitudinal case series. SETTING Diverse university- and community-based otolaryngology practices. SUBJECTS AND METHODS The cohort included 68 patients from 17 practices, with a mean±standard deviation age of 44±12 years and mean apnea-hypopnea index 35±32 events/hour. All patients underwent UPPP, defined as an open procedure modifying the shape and size of the palate, pharynx, and uvula, with or without tonsillectomy. Baseline data were collected on-site before surgery, and outcome data were collected by mail three and six months after surgery, with follow-up rates of 51% and 50%, respectively. RESULTS FOSQ scores improved from 14.3±3.4 (scale 5–20, normal ≥17.9) at baseline to 17.2±2.7 at three months (mean improvement 2.9, 95% confidence interval [1.8, 4.0], p<0.001) and 17.5±2.5 at six months (mean improvement 3.1, 95% confidence interval [2.0, 4.2], p<0.001). All quality of life and symptom measures improved significantly at three and six months (all p<0.05). CONCLUSION This prospective, multicenter, university- and community-based study provides evidence that UPPP significantly improves disease-specific quality of life and sleep apnea symptoms in patients with sleep apnea. Validity may be limited by significant loss to follow-up and absence of an unoperated control group. PMID:21493246

Movement Distribution: A New Measure of Sleep Fragmentation in Children with Upper Airway Obstruction

PubMed Central

Coussens, Scott; Baumert, Mathias; Kohler, Mark; Martin, James; Kennedy, Declan; Lushington, Kurt; Saint, David; Pamula, Yvonne

2014-01-01

Study Objectives: To develop a measure of sleep fragmentation in children with upper airway obstruction based on survival curve analysis of sleep continuity. Design: Prospective repeated measures. Setting: Hospital sleep laboratory. Participants: 92 children aged 3.0 to 12.9 years undergoing 2 overnight polysomnographic (PSG) sleep studies, 6 months apart. Subjects were divided into 3 groups based on their obstructive apnea and hypopnea index (OAHI) and other upper airway obstruction (UAO) symptoms: primary snorers (PS; n = 24, OAHI < 1), those with obstructive sleep apnea syndrome (OSAS; n = 20, OAHI ≥ 1) and non-snoring controls (C; n = 48, OAHI < 1). Interventions: Subjects in the PS and OSAS groups underwent tonsillectomy and adenoidectomy between PSG assessments. Measurements and Results: Post hoc measures of movement and contiguous sleep epochs were exported and analyzed using Kaplan-Meier estimates of survival to generate survival curves for the 3 groups. Statistically significant differences were found between these group curves for sleep continuity (P < 0.05) when using movement events as the sleep fragmenting event, but not if stage 1 NREM sleep or awakenings were used. Conclusion: Using conventional indices of sleep fragmentation in survival curve analysis of sleep continuity does not provide a useful measure of sleep fragmentation in children with upper airway obstruction. However, when sleep continuity is defined as the time between gross body movements, a potentially useful clinical measure is produced. Citation: Coussens S, Baumert M, Kohler M, Martin J, Kennedy D, Lushington K, Saint D, Pamula Y. Movement distribution: a new measure of sleep fragmentation in children with upper airway obstruction. SLEEP 2014;37(12):2025-2034. PMID:25325486

Cervical lymph node metastases of squamous cell carcinoma of unknown origin: the diagnostic value of FDG PET/CT and clinical outcome.

PubMed

Dale, Einar; Moan, Jon M; Osnes, Terje A; Bogsrud, Trond V

2017-02-01

FDG PET/CT is perceived as a valuable diagnostic tool in addition to the standard diagnostic workup for patients with isolated neck lymph nodes of squamous cell carcinoma of unknown primary (SCCUP). For patients with SCCUP intended for primary radiotherapy, we hypothesize that the previously reported FDG PET/CT detection rates are too high. From 2008 to 2015, 30 SCCUP patients were examined with FDG PET/CT. The objective of the FDG PET/CT examination was twofold: (1) improve the radiotherapy target definition, and (2) identify the primary cancer. Before the FDG PET/CT, the patients had been through a standard workup consisting of CT of the neck and chest, examination with flexible endoscopy with patient awake, panendoscopy and examination under general anesthesia, tonsillectomy and sometimes blind sampling biopsies, and MRI (floor of the mouth). All FDG PET/CTs were performed applying a flat table, head support and fixation mask as part of the radiotherapy treatment planning. Diagnostic CT with contrast was an integrated part of the PET/CT examination. Only 1/30 patients (cancer of the vallecula) had their primary cancer detected by FDG PET/CT. In addition, a non-biopsied patient with high uptake in the ipsilateral palatine tonsil was included, giving a detection rate of ≤7 % (95 % CI 2-21 %). In this retrospective study, we found that the FDG PET/CT detection rate of the primary for SCCUP patients is lower than previously reported. It is questionable whether FDG PET/CT is necessary for these patients when improved, advanced workup is available.

Streptococcal throat infections and exacerbation of chronic plaque psoriasis: a prospective study.

PubMed

Gudjonsson, J E; Thorarinsson, A M; Sigurgeirsson, B; Kristinsson, K G; Valdimarsson, H

2003-09-01

Guttate psoriasis has a well-known association with streptococcal throat infections but the effects of these infections in patients with chronic psoriasis remains to be evaluated in a prospective study. To determine whether streptococcal throat infections are more common in and can cause exacerbation in patients with chronic psoriasis. Two hundred and eight patients with chronic plaque psoriasis and 116 unrelated age-matched household controls were followed for 1 year. At recruitment all patients were examined, their disease severity scored and throat swabs taken. Patients and corresponding controls were then re-examined and tested for streptococcal colonization whenever they reported sore throat or exacerbation of their psoriasis during the study period. The psoriasis patients reported sore throat significantly more often than controls (61 of 208 vs. three of 116, P < 0.0001), and beta-haemolytic streptococci of Lancefield groups A, C and G (M protein-positive streptococci) were more often cultured from the patients than the controls (19 of 208 vs. one of 116, P = 0.003). A significant exacerbation of psoriasis (P = 0.004) was observed only if streptococci were isolated and the patients were assessed 4 days or later after the onset of sore throat. No difference was observed between groups A, C or G streptococci in this respect. This study confirms anecdotal and retrospective reports that streptococcal throat infections can cause exacerbation of chronic plaque psoriasis. It is concluded that psoriasis patients should be encouraged to report sore throat to their physician and that early treatment of streptococcal throat infections might be beneficial in psoriasis. A controlled trial for assessing potential benefits of tonsillectomy in patients with severe psoriasis should also be considered.

Patterns of care analysis for head & neck cancer of unknown primary site: a survey inside the German society of radiation oncology (DEGRO).

PubMed

Müller von der Grün, Jens; Bon, Dimitra; Rödel, Claus; Balermpas, Panagiotis

2018-05-14

Due to the absence of randomized trials, the optimal management for squamous cell cancer of unknown primary in the head and neck region (SCCHN CUP) remains controversial. Current strategies are based on retrospective studies, clinical experience, and institutional policies. An anonymous questionnaire with a total of 24 questions was created and distributed by the use of an online version (Google Forms®, Google, Mountain View, CA, USA) as well as a printout version as equivalent option. An email with a link to the survey and the questionnaire as attachment was sent to 361 DEGRO(German Society of Radiation Oncology)-associated departments. Frequency distributions of responses for each question were calculated. The data were also analyzed by type of practice. Representativity of the sample size for the DEGRO was also evaluated. 66 responses were received including answers from 20 (30%) university departments, 16 (24%) non-university institutions, and 30 (46%) radiation oncology practices. 95% of the participants routinely present these cases in an interdisciplinary tumor board and use intensity modulated radiotherapy (IMRT) techniques for SCCHN CUP treatment. Surgery includes neck dissection in 83% and tonsillectomy in 73% of the cases. Human papilloma virus (HPV) status is routinely determined in 82% of the departments. Statistically significant differences between universities and institutions and clinics and practices could be found with respect to positron emission tomography-computed tomography (PET-CT) utilization, indications for chemotherapy, radiotherapy volumes, and cumulative doses. Diagnostics and treatment for SCCHN CUP within the DEGRO remain heterogeneous. A prospective register trial with standard operation procedures is warranted to homogenize and possibly improve management.

Prevalence and Quantitation of Species C Adenovirus DNA in Human Mucosal Lymphocytes

PubMed Central

Garnett, C. T.; Erdman, D.; Xu, W.; Gooding, Linda R.

2002-01-01

The common species C adenoviruses (serotypes Ad1, Ad2, Ad5, and Ad6) infect more than 80% of the human population early in life. Following primary infection, the virus can establish an asymptomatic persistent infection in which infectious virions are shed in feces for several years. The probable source of persistent virus is mucosa-associated lymphoid tissue, although the molecular details of persistence or latency of adenovirus are currently unknown. In this study, a sensitive real-time PCR assay was developed to quantitate species C adenovirus DNA in human tissues removed for routine tonsillectomy or adenoidectomy. Using this assay, species C DNA was detected in Ficoll-purified lymphocytes from 33 of 42 tissue specimens tested (79%). The levels varied from fewer than 10 to greater than 2 × 106 copies of the adenovirus genome/107 cells, depending on the donor. DNA from serotypes Ad1, Ad2, and Ad5 was detected, while the rarer serotype Ad6 was not. When analyzed as a function of donor age, the highest levels of adenovirus genomes were found among the youngest donors. Antibody-coated magnetic beads were used to purify lymphocytes into subpopulations and determine whether viral DNA could be enriched within any purified subpopulations. Separation of T cells (CD4/8- expressing and/or CD3-expressing cells) enriched viral DNA in each of nine donors tested. In contrast, B-cell purification (CD19-expressing cells) invariably depleted or eliminated viral DNA. Despite the frequent finding of significant quantities of adenovirus DNA in tonsil and adenoid tissues, infectious virus was rarely present, as measured by coculture with permissive cells. These findings suggest that human mucosal T lymphocytes may harbor species C adenoviruses in a quiescent, perhaps latent form. PMID:12368303

Safety Considerations in the Use of Ketorolac for Postoperative Pain.

PubMed

Maslin, Benjamin; Lipana, Lawrence; Roth, Brandon; Kodumudi, Gopal; Vadivelu, Nalini

2017-01-01

Ketorolac use has significantly expanded for postoperative pain management since it first became available in the United States, primarily due to well established effects on patient pain scores and its ability to reduce perioperative opioid requirements. As an inhibitor of cyclooxygenase, ketorolac use has raised clinical concern including particular controversy regarding its potential effects on bone healing, postoperative kidney function and perioperative bleeding. To review the supporting data from clinical studies addressing the safety of ketorolac use for postoperative pain. This review highlights the most up-to-date research from clinical trials as well as from retrospective studies and meta-analyses regarding the effects of perioperative use of ketorolac on bone healing, kidney function and blood loss. Based on the most up-to-date literature, ketorolac in normal doses has been demonstrated to be safe with respect to bone healing. In patients with normal kidney function, numerous studies have established the safety of Ketorolac; however other studies have raised safety concerns in patients with comorbid kidney, heart and liver disease. While there is evidence that ketorolac may cause prolonged bleeding time and may be associated with increased postoperative blood loss after tonsillectomy, large scale prospective randomized controlled trials and subsequent meta-analyses have failed to establish an association of ketorolac use and perioperative blood loss. Perioperative administration of ketorolac has been demonstrated to be safe and effective in healthy patients and is particularly beneficial as an opioid-sparing agent in vulnerable patient groups. However, in certain surgical and medical contexts, proper patient selection based on the multidisciplinary collaboration between perioperative clinician specialists will optimize patient safety and pain management outcomes. Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.org.

Gender differences in inflammatory markers in children.

PubMed

Casimir, Georges J A; Mulier, Sandra; Hanssens, Laurence; Zylberberg, Kathya; Duchateau, Jean

2010-03-01

No clear explanation exists to understand how sex hormones and/or chromosomes affect the immune system. In vitro studies of human lymphoid cells also show sex differences in immune function. To evaluate these differences in frequent pediatric emergencies, we analyze the expression of inflammatory markers (C-reactive protein, erythrocyte sedimentation rate, and neutrophil count) underlying inflammatory processes in children: 482 children (241 girls and 241 boys) hospitalized for pneumonia (n = 384), pyelonephritis (n = 39), or bronchiolitis (n = 59) matched for age and sex. All patients were younger than 10 years. A control population of 97 children (50 girls and 47 boys) admitted for day surgery (tonsillectomy, circumcision, or strabismus) was included. We observed highly significant differences between girls and boys: median C-reactive protein concentration of 5.45 mg/dL (range, 0.2-36.0 mg/dL) for girls and 2.6 mg/dL (range, 0.3-37.3 mg/dL) for boys (P < 0.0001), and median erythrocyte sedimentation rate of 39.5 mm/h (range, 2-104 mm/h) for girls and 24 mm/h (range, 4-140 mm/h) for boys (P < 0.005). Neutrophil counts were also significantly different: a median of 8,796 cells/microL (range, 328-27,645 cells/microL) for girls and 6,774 cells/microL (range, 600-38,668 cells/microL) for boys (P < 0.02). The duration of fever after initiating antibiotic therapy was longer in girls than in boys, but there was no difference (Fisher exact test, P < 0.06). The present study documents a relationship between sex and both the production of inflammatory markers and neutrophil recruitment. Sex difference also showed more direct clinical relevance with associations seen between sex and both duration of fever and duration of disease (bronchiolitis P < 0.0007).

Unique histologic features of tonsils from patients with periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA) syndrome.

PubMed

Manthiram, Kalpana; Correa, Hernan; Boyd, Kelli; Roland, Joseph; Edwards, Kathryn

2018-05-01

The objective of this study is to compare the histology and immune cell composition of tonsils from patients with periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA) syndrome to those from patients with obstructive sleep apnea (OSA). Patients with PFAPA and age-matched controls with OSA who had undergone tonsillectomy at Vanderbilt Children's Hospital were recruited. After informed consent, archival paraffin-embedded, formalin-fixed tonsil tissues were obtained. Sizes of major histologic regions were measured. Cores of germinal centers, crypts, and squamous epithelium were assembled on a tissue microarray for immunohistochemical staining and digital image analysis. Features of tonsils from PFAPA and OSA patients were compared with Wilcoxon signed-rank test. Samples from 16 cases with PFAPA and 16 controls with OSA were evaluated. Tonsils from PFAPA cases had significantly smaller germinal centers (0.18 vs. 0.47 mm 2 , p = 0.001) and wider squamous epithelia (176 vs. 138 μm, p = 0.008) than those of OSA patients. The percentages of B and T lymphocytes and myeloid cells were comparable in germinal centers, crypts, and squamous epithelia from PFAPA and OSA patients. Longer time from the last febrile episode in PFAPA cases was associated with larger germinal center area (Spearman's rho = 0.61, p = 0.02). We found differences in the sizes of germinal centers and squamous epithelia in tonsils of patients with PFAPA and OSA, but the cellular compositions within these areas were comparable. Our results suggest that tonsils from patients with PFAPA change histologically over time with enlarging germinal centers following a febrile episode. Additional studies are needed to understand the pathogenesis of PFAPA.

Acoustic and perceptual aspects of vocal function in children with adenotonsillar hypertrophy--effects of surgery.

PubMed

Lundeborg, Inger; Hultcrantz, Elisabeth; Ericsson, Elisabeth; McAllister, Anita

2012-07-01

To evaluate outcome of two types of tonsil surgery (tonsillectomy [TE]+adenoidectomy or tonsillotomy [TT]+adenoidectomy) on vocal function perceptually and acoustically. Sixty-seven children, aged 50-65 months, on waiting list for tonsil surgery were randomized to TE (n=33) or TT (n=34). Fifty-seven age- and gender-matched healthy preschool children were controls. Twenty-eight of them, aged 48-59 months, served as control group before surgery, and 29, aged 60-71 months, served as control group after surgery. Before surgery and 6 months postoperatively, the children were recorded producing three sustained vowels (/ɑ/, /u/, and /i/) and 14 words. The control groups were recorded only once. Three trained speech and language pathologists performed the perceptual analysis using visual analog scale for eight voice quality parameters. Acoustic analysis from sustained vowels included average fundamental frequency, jitter percent, shimmer percent, noise-to-harmonic ratio, and the center frequencies of formants 1-3. Before surgery, the children were rated to have more hyponasality and compressed/throaty voice (P<0.05) and lower mean pitch (P<0.01) in comparison to the control group. They also had higher perturbation measures and lower frequencies of the second and third formants. After surgery, there were no differences perceptually. Perturbation measures decreased but were still higher compared with those of control group (P<0.05). Differences in formant frequencies for /i/ and /u/ remained. No differences were found between the two surgical methods. Voice quality is affected perceptually and acoustically by adenotonsillar hypertrophy. After surgery, the voice is perceptually normalized but acoustic differences remain. Outcome was equal for both surgical methods. Copyright © 2012 The Voice Foundation. Published by Mosby, Inc. All rights reserved.

Unilateral Radiotherapy for the Treatment of Tonsil Cancer

DOE Office of Scientific and Technical Information (OSTI.GOV)

Chronowski, Gregory M., E-mail: gchronowski@mdanderson.org; Garden, Adam S.; Morrison, William H.

2012-05-01

Purpose: To assess, through a retrospective review, clinical outcomes of patients with squamous cell carcinoma of the tonsil treated at the M. D. Anderson Cancer Center with unilateral radiotherapy techniques that irradiate the involved tonsil region and ipsilateral neck only. Methods and Materials: Of 901 patients with newly diagnosed squamous cell carcinoma of the tonsil treated with radiotherapy at our institution, we identified 102 that were treated using unilateral radiotherapy techniques. All patients had their primary site of disease restricted to the tonsillar fossa or anterior pillar, with <1 cm involvement of the soft palate. Patients had TX (n =more » 17 patients), T1 (n = 52), or T2 (n = 33) disease, with Nx (n = 3), N0 (n = 33), N1 (n = 23), N2a (n = 21), or N2b (n = 22) neck disease. Results: Sixty-one patients (60%) underwent diagnostic tonsillectomy before radiotherapy. Twenty-seven patients (26%) underwent excision of a cervical lymph node or neck dissection before radiotherapy. Median follow-up for surviving patients was 38 months. Locoregional control at the primary site and ipsilateral neck was 100%. Two patients experienced contralateral nodal recurrence (2%). The 5-year overall survival and disease-free survival rates were 95% and 96%, respectively. The 5-year freedom from contralateral nodal recurrence rate was 96%. Nine patients required feeding tubes during therapy. Of the 2 patients with contralateral recurrence, 1 experienced an isolated neck recurrence and was salvaged with contralateral neck dissection only and remains alive and free of disease. The other patient presented with a contralateral base of tongue tumor and involved cervical lymph node, which may have represented a second primary tumor, and died of disease. Conclusions: Unilateral radiotherapy for patients with TX-T2, N0-N2b primary tonsil carcinoma results in high rates of disease control, with low rates of contralateral nodal failure and a low incidence of acute toxicity requiring gastrostomy.« less

Evidence of the causal role of human papillomavirus type 58 in an oropharyngeal carcinoma.

PubMed

Baboci, Lorena; Boscolo-Rizzo, Paolo; Holzinger, Dana; Bertorelle, Roberta; Biasini, Lorena; Michel, Angelika; Schmitt, Markus; Spinato, Giacomo; Bussani, Rossana; Alemany, Laia; Tirelli, Giancarlo; Da Mosto, Maria Cristina; Del Mistro, Annarosa; Pawlita, Michael

2013-11-12

Persistent human papillomavirus infection (HPV) is recognized as an important etiologic factor for a subset of head and neck squamous cell carcinomas (SCC), especially those arising from the oropharynx. Whereas HPV16 accounts for the majority of HPV DNA-positive oropharyngeal SCC, infections with other mucosal high-risk HPV types are quite rare and biological data demonstrating their causal involvement are insufficient. Here we present the first case of an oropharyngeal SCC driven by HPV type 58. A 69-year-old Caucasian woman presented with an enlarged and firm left tonsil. A computed tomography scan showed a left tonsillar mass, extending to the soft palate and the glossotonsillar sulcus. The patient underwent extended radical tonsillectomy and ipsilateral selective neck dissection. Pathology confirmed an infiltrating, poorly differentiated SCC of the left tonsil with node metastasis (pT2N1). Adjuvant external beam radiation therapy (60 Grays (Gy)) was administered. After 1 year of follow-up, the patient is well with no evidence of cancer recurrence. HPV analyses of the tumor tissue by BSGP5+/6+ -PCR/MPG, targeting 51 mucosal HPV types, showed single positivity for HPV type 58. Presence of HPV58 E6*I RNA demonstrated biological activity of the virus in the tumor tissue, and presence of serum antibodies to HPV58 oncoproteins E6 and E7 indicated presence of an HPV58-driven cancer. Overexpression of cellular protein p16INK4a and reduced expression of pRb, two cellular markers for HPV-induced cell transformation, were observed. Exons 4-10 of TP53 showed no mutations or polymorphisms. The presence of HPV58 as single HPV infection in combination with a broad variety of direct and indirect markers of HPV transformation provides comprehensive evidence that this oropharyngeal SCC was driven by HPV58.

Relative bioavailability and plasma paracetamol profiles of Panadol suppositories in children.

PubMed

Coulthard, K P; Nielson, H W; Schroder, M; Covino, A; Matthews, N T; Murray, R S; Van Der Walt, J H

1998-10-01

To determine the relative bioavailability and plasma paracetamol concentration profiles following administration of a proprietary formulation of paracetamol suppositories to postoperative children. Study A-eight children undergoing minor surgery had blood samples collected following the rectal administration of either a 250 mg or 500 mg paracetamol suppository on one day and an equivalent oral dose on the following day. A mean dose of 13 mg/kg gave a mean Cmax (Tmax) of 7.7 mg/L (1.6 h) and 4.9 mg/L (2.0 h) following oral and rectal administration, respectively. The mean relative rectal bioavailability was 78% (95% confidence interval of 55-101%). Study B-20 children undergoing tonsillectomy and/or adenoidectomy were randomly assigned to receive a postoperative dose of 500 mg of paracetamol either as 2 x 250 mg liquid filled or 1 x 500 mg hard wax Panadol suppository. A mean dose of 25 mg/kg produced mean maximum plasma paracetamol concentrations of 13.2 mg/L and 14.5 mg/L at 2.1 and 1.9 h for the hard and liquid filled suppository, respectively. The absorption rate constants and areas under the curves suggested no difference in the rate or extent of absorption between the two formulations. Absorption of paracetamol following rectal administration of Panadol suppositories to postoperative children is slower and reduced as compared to oral therapy. The hard wax and liquid filled products have similar absorption characteristics. The usually quoted antipyretic therapeutic range for paracetamol is 10-20 mg/L, although 5 mg/L may be effective. A single rectal dose of 25 mg/kg will obtain this lower concentration within 1 h of administration and maintain it for up to 6 h. When given in an appropriate dose for analgesia, maximum plasma paracetamol concentrations would be available in the immediate postoperative period if the rectal dose was given 2 h before the planned end of the procedure.

NTCP Modeling of Subacute/Late Laryngeal Edema Scored by Fiberoptic Examination

DOE Office of Scientific and Technical Information (OSTI.GOV)

Rancati, Tiziana; Fiorino, Claudio, E-mail: fiorino.claudio@hsr.i; Sanguineti, Giuseppe

2009-11-01

Purpose: Finding best-fit parameters of normal tissue complication probability (NTCP) models for laryngeal edema after radiotherapy for head and neck cancer. Methods and Materials: Forty-eight patients were considered for this study who met the following criteria: (1) grossly uninvolved larynx, (2) no prior major surgery except for neck dissection and tonsillectomy, (3) at least one fiberoptic examination of the larynx within 2 years from radiotherapy, (4) minimum follow-up of 15 months. Larynx dose-volume histograms (DVHs) were corrected into a linear quadratic equivalent one at 2 Gy/fr with alpha/beta = 3 Gy. Subacute/late edema was prospectively scored at each follow-up examinationmore » according to the Radiation Therapy Oncology Group scale. G2-G3 edema within 15 months from RT was considered as our endpoint. Two NTCP models were considered: (1) the Lyman model with DVH reduced to the equivalent uniform dose (EUD; LEUD) and (2) the Logit model with DVH reduced to the EUD (LOGEUD). The parameters for the models were fit to patient data using a maximum likelihood analysis. Results: All patients had a minimum of 15 months follow-up (only 8/48 received concurrent chemotherapy): 25/48 (52.1%) experienced G2-G3 edema. Both NTCP models fit well the clinical data: with LOGEUD the relationship between EUD and NTCP can be described with TD50 = 46.7 +- 2.1 Gy, n = 1.41 +- 0.8 and a steepness parameter k = 7.2 +- 2.5 Gy. Best fit parameters for LEUD are n = 1.17 +- 0.6, m = 0.23 +- 0.07 and TD50 = 47.3 +- 2.1 Gy. Conclusions: A clear volume effect was found for edema, consistent with a parallel architecture of the larynx for this endpoint. On the basis of our findings, an EUD <30-35 Gy should drastically reduce the risk of G2-G3 edema.« less

Influence of food and lifestyle on the risk of developing inflammatory bowel disease.

PubMed

Niewiadomski, O; Studd, C; Wilson, J; Williams, J; Hair, C; Knight, R; Prewett, E; Dabkowski, P; Alexander, S; Allen, B; Dowling, D; Connell, W; Desmond, P; Bell, S

2016-06-01

The Barwon area in Australia has one of the highest incidence rates of inflammatory bowel disease (IBD) and therefore is an ideal location to study the impact of environmental exposures on the disease's development. To study these exposures prior to the development of IBD in a population-based cohort. One hundred and thirty-two incident cases (81 Crohn disease (CD) and 51 ulcerative colitis (UC)) from an IBD registry and 104 controls replied to the International Organization of Inflammatory Bowel Diseases environmental questionnaire. This included 87 questions about pre-illness exposures that included childhood illnesses, vaccinations, breastfeeding, house amenities, pets and swimming, diet and smoking. The factors associated with CD included smoking (odds ratio (OR): 1.42, confidence interval (CI): 1-2.02, P = 0.029); childhood events, including tonsillectomy (OR: 1.74, CI: 1.15-2.6, P = 0.003) and chicken pox infection (OR: 3.89, CI: 1.61-9.4, P = 0.005) and pre-diagnosis intake of frequent fast food (OR: 2.26, CI: 1.76-4.33, P = 0.003). In UC, the risk factors included smoking (OR: 1.39, CI: 1.1-1.92, P = 0.026) and pre-diagnosis intake of frequent fast food (OR: 2.91, CI: 1.54-5.58, P < 0.001), and high caffeine intake was protective (OR: 0.51, 95% CI: 0.3-0.87, P = 0.002). Other protective exposures for UC included high fruit intake (OR: 0.59, CI: 0.4-0.88, P = 0.003) and having pets as a child (OR: 0.36, CI: 0.2-0.79, P = 0.001). This first Australian population-based study of environmental risk factors confirms that smoking, childhood immunological events and dietary factors play a role in IBD development; while high caffeine intake and pet ownership offer a protective effect. © 2016 Royal Australasian College of Physicians.

Postoperative paediatric pain prevalence: A retrospective analysis in a university teaching hospital.

PubMed

Avian, Alexander; Messerer, Brigitte; Wünsch, Gerit; Weinberg, Annelie; Kiesling, Andreas Sandner; Berghold, Andrea

2016-10-01

Overall pain prevalence in paediatric patients is well documented, but relatively little attention has been paid to pain prevalence and intensity on specific postoperative days within the first week following an operation. To evaluate reported pain prevalence on the day of surgery and each day during the following week and to analyse pain trajectories. Retrospective study. Single centre university hospital. 815 postoperative children and adolescents (age≤18 years) were included (female: 36%, age 9.8±5.8). Children with ear, nose, throat (e.g. tonsillectomy), eye (e.g. strabismus repair) or dental surgery (e.g. dental extraction) were treated at other departments and therefore were not included in this study. Retrospective analysis of the overall and clinically relevant (pain score ≥4/10) postoperative pain prevalence in children and adolescents during the first week after surgery. Possible influencing factors (age, sex, body mass index, type of anaesthesia, type of surgery and duration of surgery) on pain trajectories are analysed using mixed model techniques. Overall, 36% of 815 analysed children and adolescents suffered from pain ≥4 during their entire hospital stay. Compared to the day of surgery, the number of patients with pain ≥4 was slightly higher on day 1 after surgery (21% vs. 25%, respectively). In self-reported pain intensity rating (done for patients age≥4 years) the type of surgery (p<.001) was the only significant variable influencing pain intensity. In observational pain assessment (age<4 years) pain scores increased with patient's age (p=.004). In this patient group, pain intensity ratings did not differ between types of surgery (p=.278). Type of surgery is an important predictor for self-reported pain intensity ratings in children but not for observational pain assessment in younger children. In younger children observational pain assessment ratings increase with age. Copyright © 2016 Elsevier Ltd. All rights reserved.

The effect of adenotonsillectomy on serum insulin like growth factors and the adenoid/nasopharynx ratio in pediatric patients: a blind, prospective clinical study.

PubMed

Tatlıpınar, Arzu; Atalay, Sacide; Esen, Erkan; Yılmaz, Gökalp; Köksal, Sema; Gökçeer, Tanju

2012-02-01

Obstructive adenoid and tonsillar hyperplasia may present with retardation of growth. An adenoid-nasopharynx (A/N) ratio determined by means of lateral cephalometric radiographs has long been used as a diagnostic tool in the assessment of adenoid size. This study was designed to investigate the effect of adenotonsillectomy on insulin-like growth factor-I (IGF-I) and insulin-like growth factor binding protein-3 (IGFBP-3) levels and correlation between A/N ratio and IGF-I and IGFBP-3 levels. Patients (n=48) that had been operated on our clinic with a diagnosis of adenotonsillar hypertrophy between July 2009 and January 2010 were included in the study. The routine ear-nose and throat examination was done in all patients. Blood samples were taken, and lateral cephalometric radiographs were obtained preoperatively and repeated at 6-9 months (mean 7.2 ± 1.0 mo) following tonsillectomy and adenoidectomy. The chemiluminescent enzyme-linked immunosorbent method was used to IGF-I and IGFBP-3 levels. Each cephalometric radiograph was evaluated by a blinded radiologist. The A/N ratio was calculated using the Fujioka method. When the preoperative and postoperative results were compared, a statistically significant increase in serum IGF-I and IGFBP-3 and a decreased A/N ratio were found. However, although correlation between the Δ(preoperative-postoperative difference) IGFBP-3 and ΔA/N ratio was 40%, it was not statistically significant. Additionally, no statistically significant correlation between the ΔIGF-I and ΔA/N ratio was found. The results of the present study indicate that adenotonsillectomy could result in the relief of nasopharyngeal obstruction and have a positive effect on growth in children by decreasing the A/N ratio and increasing IGF-I and IGFBP-3. There was no correlation between the ΔA/N ratio and ΔIGF-I and ΔIGFBP-3 levels. Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.

Intraindividual comparison of 1,470 nm diode laser versus carbon dioxide laser for tonsillotomy: a prospective, randomized, double blind, controlled feasibility trial.

PubMed

Havel, Miriam; Sroka, Ronald; Englert, Elsa; Stelter, Klaus; Leunig, Andreas; Betz, Christian S

2012-09-01

The need for reduction of post-tonsillectomy hemorrhage has led to promotion of tonsillotomy techniques for tonsil tissue reduction in obstructive tonsillar hypertrophy. This trial compares ablative tissue effects using 1,470 nm diode laser and carbon dioxide laser for tonsillotomy in an intraindividual design. 21 children aged 3-13 years (mean age 6.3 years) underwent laser tonsillotomy for obstructive tonsillar hypertrophy in this double blind, prospective, randomized, clinical feasibility trial. In each of the blinded patients, tonsillotomy was performed using fiber guided 1,470 nm diode laser (contact mode, 15 W power) on the one side and carbon dioxide laser (12 W power) on the other side. An independent, blinded physician documented clinical presentation and patients' symptoms preoperatively and on Days 1, 3, 7, 14, and 21 post-operatively using standardized questionnaire including VAS for each side separately. The mean duration of operative treatment was 2.7 min using 1,470 nm laser and 4.9 min using carbon dioxide laser respectively. Intraoperative bleeding and the frequency of bipolar forceps use for intraoperative bleeding control was significantly less using 1,470 nm diode laser system. There was no difference in post-operative pain scores between the carbon dioxide laser treated and the 1,470 nm fiber guided diode laser treated side. No infections, hemorrhages or other complications occurred in the course of the 3 weeks post-operative period. A fiber-guided 1,470 nm diode laser system offers an efficient and safe method for tonsillotomy as treatment of obstructive tonsillar hypertrophy. Compared to our standard practice (carbon dioxide laser), 1,470 nm laser application provides comparable tissue ablation effects with less intraoperative bleeding and shorter operation time. Copyright © 2012 Wiley Periodicals, Inc.

Pulmonary hypertension evaluation by Doppler echocardiogram in children and adolescents with mouth breathing syndrome.

PubMed

Lima, Marcela Silva; Nader, Carolina Maria Fontes Ferreira; Franco, Letícia Paiva; Meira, Zilda Maria Alves; Capanema, Flavio Diniz; Guimarães, Roberto Eustáquio Santos; Becker, Helena Maria Gonçalves

Adenotonsillar hyperplasia (ATH) and allergic rhinitis (AR) are the most common causes of upper airway obstruction in children. Such diseases, by affecting the upper airways, can cause chronic alveolar hypoventilation, pulmonary vasoconstriction and pulmonary hypertension, which in some cases, are irreversible. This cross-sectional study aimed to evaluate the prevalence of pulmonary hypertension in two groups of mouth-breathing (MB) 2-12 years old children with ATH and isolated allergic rhinitis, through Doppler echocardiography. 54 patients with ATH and indications for adenoidectomy and/or tonsillectomy and 24 patients with persistent allergic rhinitis were selected and submitted to Doppler echocardiography. The Systolic Pulmonary Artery Pressure (SPAP) was determined by tricuspid regurgitation and the Mean Pulmonary Artery Pressure (MPAP) was calculated from the SPAP. Similar measurements were carried out in 25 nasal breathing (NB) individuals. The mean MPAP and SPAP were higher in the MB than in the NB group (17.62±2.06 [ATH] and 17.45±1.25 [AR] vs. 15.20±2.36 [NB] mmHg, p<0.005, and 25.61±3.38 [ATH] and 25.33±2.06 [AR] vs. 21.64±3.87 [NB] mmHg, p<0.005, respectively) and the mean acceleration time of pulmonary flow trace (Act) was higher in the NB than in the MB group (127.24±12.81 [RN] vs. 114.06±10.63ms [ATH] and 117.96±10.28 [AR] MS [AR]; p<0.0001). None of the MB children (ATH and AR) met the PH criteria, although individuals with both ATH and isolated AR showed significant evidence of increased pulmonary artery pressure by Doppler echocardiography in relation to NB individuals. No differences were observed between the ATH and AR groups. Copyright © 2017 Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico-Facial. Published by Elsevier Editora Ltda. All rights reserved.

Laser CO2 tonsillotomy versus argon plasma coagulation (APC) tonsillotomy: A retrospective study with 10-year follow-up.

PubMed

Papaspyrou, Giorgos; Linxweiler, Maximilian; Knöbber, Dirk; Schick, Bernhard; Al Kadah, Basel

2017-01-01

Tonsillotomy is increasingly gaining acceptance as the treatment for tonsillar hyperplasia resulting in obstructive symptoms. The aim of this study was to compare the long-term results of CO 2 laser tonsillotomy with those of argon plasma coagulation (APC) tonsillotomy. The data of 64 children, aged 2-10 years (mean 4.7 years), treated in the Department of Otolaryngology, Head and Neck Surgery, in Homburg, Germany with APC (36 patients) or CO 2 laser (28 patients) for tonsillar hyperplasia between June 2004 and December 2004 were available for analysis. Forty-five (APC: 26 patients, CO 2 : 19 patients) of the 64 patients (70.3%) could be contacted and were available for follow-up in a telephone survey conducted 10 years after surgery. The mean operation time was 17 min (range 10-25 min) in the APC group and 23 min (range 13-32 min) in the CO 2 group (p = 0.0003). No case of intra- or postoperative bleeding was documented. One minor intraoperative complication in the form of a superficial lip burn was documented in the APC group. During the minimum 10 years of follow-up, 1 patient treated with APC underwent a surgical revision because of tonsillar regrowth, whereas in the group of patients treated with CO 2 , no surgical revision was needed. Regarding the parents' assessment of their children's symptoms, 89.4% of the parents of the CO 2 laser group and 84.6% of the parents of the APC group reported that the overall long-term operation results of their children to be "very satisfying." Regarding complications, the need for secondary tonsillectomy, and parents' satisfaction, no statistically significant differences were found. Both CO 2 laser tonsillotomy and APC tonsillotomy are safe procedures leading to very satisfying results with respect to intra- and postoperative complications. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

A case-control study of Drug-Induced Sleep Endoscopy (DISE) in pediatric population: A proposal for indications.

PubMed

Collu, Maria Antonietta; Esteller, Eduard; Lipari, Fiorella; Haspert, Raul; Mulas, Demetrio; Diaz, Miguel Angel; Dwivedi, Raghav C

2018-05-01

To evaluate whether and when Drug-Induced Sleep Endoscopy (DISE) changes diagnosis and treatment plan in pediatric Obstructive Sleep Apnoea Syndrome (OSAS) with the aim to identify specific subgroups of patients for whom DISE should be especially considered. A case-control study of DISE in 150 children with OSAS. Pre-operative OSA were assessed through detailed history, Chervin questionnaire, physical examination and overnight polysomnography. The group of study was divided into three subgroups according to clinical and polysomnographyc criteria: conventional OSAS, disproportional OSAS and persistent OSAS. Endoscopic evaluation of the upper airway during DISE was scored using Chan classification. Surgical treatment was tailored individually upon the basis of sleep endoscopy findings: performance of any surgery other than tonsillectomy and adenoidectomy (T&A) was considered as a change of the treatment plan. Cases and controls were compared considering presence and absence of DISE-directed extra surgery, respectively. 150 patients with mean age (SD) 56.09 (23.94) months and mean apnoea-hypopnea index (AHI) of 5.79 (6.52) underwent DISE. The conventional subgroup represented the 58.67% of the sample (n = 88), while the disproportional one counted for the 26.67% (n = 40), and the persistent one for 14.66% (n = 22) of the population. Sleep endoscopy changed the surgical plan in 4.5% of conventional OSAS, 17.5% of disproportional OSAS and 72.7% of persistent OSAS (p < 0.005). Overall, a change of the treatment plan operated by DISE was associated with a non-conventional OSAS status (OR = 6; 95% CI = 1.6-26.4). DISE is a safe procedure in children suffering from OSAS, and, despite being unnecessary in conventional cases of OSA, DISE should be considered not only in syndromic children, as previously demonstrated, but also in the general non-syndromic pediatric population, in the case of non-conventional OSA patients, and in children with persistent OSAS. Copyright © 2018 Elsevier B.V. All rights reserved.

Ear, nose and throat day-case surgery at a district general hospital.

PubMed

Pézier, T; Stimpson, P; Kanegaonkar, R G; Bowdler, D A

2009-03-01

In 2000, The NHS Plan in the UK set a target of 75% for all surgical activity to be performed as day-cases. We aim to assess day-case turnover for ENT procedures and, in particular, day-case rates for adult and paediatric otological procedures together with re-admissions within 72 h as a proxy measure of safety. Retrospective collection of data (procedure and length of stay) from the computerised theatre system (Galaxy) and Patient Information Management System (PIMS) of all elective patients operated over one calendar year. The setting was a district general hospital ENT department in South East England. All ENT operations are performed with the exception of oncological head and neck procedures and complex skull-base surgery. Overall, 2538 elective operations were performed during the study period. A total of 1535 elective adult procedures were performed with 74% (1137 of 1535) performed as day-cases. Of 1003 paediatric operations, 73% (730 of 1003) were day-cases. Concerning otological procedures, 93.4% (311 of 333) of paediatric procedures were day-cases. For adults, we divided the procedures into major and minor, achieving day-case rates of 88% (93 of 101) and 91% (85 of 93), respectively. The overall day-case rate for otological procedures was 91% (528 of 580). Re-admission rates overall were 0.7% (11 of 1535) for adults and 0.9% (9 of 1003) for paediatric procedures. The most common procedure for re-admission was tonsillectomy accounting for 56% of all adult re-admissions and 78% of paediatric re-admissions. The were no deaths following day-case procedures. ENT surgery is well-suited to a day-case approach. UK Government targets are attainable when considering routine ENT surgery. Day-case rates for otology in excess of targets are possible even when considering major ear surgery.

Periodontal disease bacteria specific to tonsil in IgA nephropathy patients predicts the remission by the treatment.

PubMed

Nagasawa, Yasuyuki; Iio, Kenichiro; Fukuda, Shinji; Date, Yasuhiro; Iwatani, Hirotsugu; Yamamoto, Ryohei; Horii, Arata; Inohara, Hidenori; Imai, Enyu; Nakanishi, Takeshi; Ohno, Hiroshi; Rakugi, Hiromi; Isaka, Yoshitaka

2014-01-01

Immunoglobulin (Ig)A nephropathy (IgAN) is the most common form of primary glomerulonephritis in the world. Some bacteria were reported to be the candidate of the antigen or the pathogenesis of IgAN, but systematic analysis of bacterial flora in tonsil with IgAN has not been reported. Moreover, these bacteria specific to IgAN might be candidate for the indicator which can predict the remission of IgAN treated by the combination of tonsillectomy and steroid pulse. We made a comprehensive analysis of tonsil flora in 68 IgAN patients and 28 control patients using Denaturing gradient gel electrophoresis methods. We also analyzed the relationship between several bacteria specific to the IgAN and the prognosis of the IgAN. Treponema sp. were identified in 24% IgAN patients, while in 7% control patients (P = 0.062). Haemophilus segnis were detected in 53% IgAN patients, while in 25% control patients (P = 0.012). Campylobacter rectus were identified in 49% IgAN patients, while in 14% control patients (P = 0.002). Multiple Cox proportional-hazards model revealed that Treponema sp. or Campylobactor rectus are significant for the remission of proteinuria (Hazard ratio 2.35, p = 0.019). There was significant difference in remission rates between IgAN patients with Treponema sp. and those without the bacterium (p = 0.046), and in remission rates between IgAN patients with Campylobacter rectus and those without the bacterium (p = 0.037) by Kaplan-Meier analysis. Those bacteria are well known to be related with the periodontal disease. Periodontal bacteria has known to cause immune reaction and many diseases, and also might cause IgA nephropathy. This insight into IgAN might be useful for diagnosis of the IgAN patients and the decision of treatment of IgAN.

[Otorhinolaryngology in the field of demography, growing outpatient care and regionalization].

PubMed

Schmidt, C E; Schuldt, T; Kaiser, A; Letzgus, P; Liebeneiner, J; Schmidt, K; Öner, A; Mlynski, R

2017-01-01

Otorhinolaryngology (ENT) departments are strongly affected by current changes in the reimbursement schemes for inpatients. The study was designed to investigate these effects on the ENT Department in Rostock and selected comparison clinics, as well as to outline solutions. We analyzed diagnosis-related group (DRG) reports of the ENT Clinic at Rostock University Medical Center from 2013 to 2015, according to the size of the outpatient potential. Comparisons were made with other surgical departments such as maxillofacial surgery and ophthalmology in terms of average length of stay and the resulting deductibles. We also compared billing as day surgery and complete outpatient surgery for the main small surgical procedures such as tonsillectomy and septum surgery. Finally, we compared the discounts with 22 ENT departments in other maximum care hospitals. The average case mix index of an ENT department in Germany is 0.75, case load average of 2,500 patients and common length of stay 4.1 days. In a typical academic ENT department as in Rostock, health plans usually discount around 500 T€ (thousand euro), which is considerably higher than comparable departments, e.g., oral and maxillofacial surgery or ophthalmology departments. However, discounts on a DRG for inpatient surgery is still approximately 1,000 € more revenue than surgery in an outpatient setting. The benchmark analysis shows that health plans in rural areas are more likely to accept inpatient surgery with discounts for small procedures than strict billing according to outpatient reimbursement schemes. These effects can result in an insufficient cost effectiveness of ENT departments in Germany. As a consequence, substantial restructuring of the in- and outpatient treatment seems necessary, also for academic ENT departments, e.g., in the form of day surgery or ambulatory surgical centers, outpatient clinics with special contracts and specialized inpatient surgery. However, this results in greater demands on the training of young physicians and management of patient flows within the department.

[Obstructive sleep apnea syndrome in young infants].

PubMed

Rosenberg, Eran; Elkrinawi, Soliman; Goldbart, Aviv; Leiberman, Alberto; Tarasiuk, Ariel; Tal, Asher

2009-05-01

Obstructive sleep apnea syndrome (OSAS) has been reported among children aged 3-6 years. Adenotonsillar hypertrophy is the most common cause of OSAS. The upper airway obstruction results in repeated obstructive apneas and hypopneas, associated with oxygen desaturations and sleep fragmentation. OSAS in children is associated with higher respiratory morbidity as well as significant clinical consequences, mainly neurocognitive and behavioral problems, impaired growth and cardiac dysfunction. The objectives of the present study were to determine the clinical and sleep characteristics of OSAS in children younger than 2 years, and to evaluate morbidity and health care utilization of infants with OSAS. This retrospective study included 35 children younger than 2 years of age, referred for polysomnography because of suspected OSAS. The controL group included healthy children, matched by age, gender and pediatrician. A total of 33 infants were diagnosed with OSAS. Mean apnea/hypopnea index [AHI) was 18.7 +/- 18.1 events/ hour [range 1.3-90.2]. In 10 infants a pattern of intermittent hypoxemia was observed. Infants with OSAS demonstrated a higher number of primary care clinic visits (20.8 +/- 14 vs. 12.1 +/- 6.6, P < 0.02). A higher percentage of children with OSAS visited the emergency room (60.6% vs. 32.2%, P < 0.03), and was hospitalized (36.3% vs. 12.9%, P < 0.03). Duration of hospitalization was also higher in the OSAS group [23.2 +/- 14.1% vs. 3 +/- 2.1%, P < 0.05). The number of drug prescriptions was higher among the study group [25.9 +/- 21.8% vs. 13.6 +/- 10.1, P < 0.03). Thirteen patients underwent adenoidectomy with or without tonsillectomy, resulting in improvement of AHI, decreasing from 26.4 +/- 24 before to 3.6 +/- 4.5 events per hour after surgery (p < 0.01). OSAS can be found in infants younger than 2 years of age. OSAS at this young age is characterized by a higher morbidity in comparison to healthy children. Early diagnosis and treatment may prevent morbidity in young children with OSAS.

Apnea and oxygen desaturations in children treated with opioids after adenotonsillectomy for obstructive sleep apnea syndrome: a prospective pilot study.

PubMed

Khetani, Justin D; Madadi, Parvaz; Sommer, Doron D; Reddy, Desigen; Sistonen, Johanna; Ross, Colin J D; Carleton, Bruce C; Hayden, Michael R; Koren, Gideon

2012-12-01

Recent case reports have alerted the medical community of fatality in children receiving codeine after tonsillectomy and/or adenoidectomy for obstructive sleep apnea syndrome. The objective of this study was to compare the rates of oxygen desaturation before and after adenotonsillectomy in children with obstructive sleep apnea syndrome (OSAS), and to examine the relationship between cytochrome P450 2D6 (CYP2D6) genotype and respiratory events. This was a prospective observational study. Twenty-six children with OSAS (mean age 78 months, range 1.8-17 years) who underwent adenotonsillectomy were studied. CYP2D6 genotype was characterized in 21 of these children. The primary endpoints of the study were the change in the rate of desaturation and in the nadir oxygen saturation values before and in the first 24 hours after surgery as measured by pulse oximetry. Twenty-two children received codeine and four were managed with hydrocodone. There was no post-operative improvement in the mean rate of desaturation (1.84 ± 1.45/hour pre-operative vs 2.97 ± 3.3/hour post-operative; p = 0.119; 95% CI -2.56, 0.313), or the post-operative nadir of oxygen saturation (85.2 ± 5.8% pre-operative vs 84.0 ± 6.8% post-operative; p = 0.632; 95% CI -3.00, 4.84) on the night after surgery. Prior to surgery, six children had an oxygen saturation nadir <80%, while post-surgery, the number increased to eight children. Ten children improved their parameters after surgery. CYP2D6 genotype by itself did not predict the changes in desaturation or nadir. Post-operative use of opioids following OSAS may not be safe for all children. It is conceivable that if the child is among the significant proportion that experiences increased oxygen desaturations, the CNS depressing effects of codeine or hydrocodone and their respectively potent morphine or hydromorphone metabolites can further compromise respiratory drive. Larger studies are needed to investigate the potential contribution of CYP2D6 genotype.

Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS): An Evolving Concept

PubMed Central

Macerollo, Antonella; Martino, Davide

2013-01-01

Pediatric autoimmune neuropsychiatric disorders associated with streptococcus infections (PANDAS) originated from the observational work of Swedo and collaborators, who formalized their definition in 1998 in a set of operational criteria. The application of these criteria, which focuses on tics and obsessive-compulsive symptoms as core symptoms, has encountered difficulties, eventually leading to a high rate of misdiagnosis. In particular, the core feature represented by the association between newly diagnosed infections and neuropsychiatric symptom relapses in youths with this diagnosis could not be demonstrated by longitudinal studies. Exploratory studies aiming to identify clinical or cognitive features that could discriminate PANDAS from other pediatric obsessive-compulsive and tic disorders present methodological limitations, and therefore are not conclusive. Other behavioral features, in addition to obsessive-compulsive symptoms and tics, have been included in pediatric acute-onset neuropsychiatric syndromes (PANS) and childhood acute neuropsychiatric syndromes (CANS), two new concepts recently proposed in order to define a much broader clinical spectrum encompassing etiologically diverse entities. Given the uncertainties on the clinical definition of PANDAS, it is not surprising that evidence in support of a post-infectious, immune-mediated pathophysiology is also insufficient. Anti-dopamine receptor antibodies might be relevant to both Sydenham’s chorea (SC)—the prototypical post-streptococcal neuropsychiatric disorder—and some rare forms of encephalitis targeting the basal ganglia specifically, but studies exploring their association with children fulfilling Swedo’s criteria for PANDAS have been inconclusive. Moreover, we lack evidence in favor of the efficacy of antibiotic prophylaxis or tonsillectomy in patients fulfilling Swedo’s criteria for PANDAS, whereas a response to immune-mediated treatments like intravenous immunoglobulins has been documented by one study, but needs replication in larger trials. Overall, the available evidence does not convincingly support the concept that PANDAS are a well-defined, isolated clinical entity subdued by definite pathophysiological mechanisms; larger, prospective studies are necessary to reshape the nosography and disease mechanisms of post-streptococcal acute neuropsychiatric disorders other than SC. Research is also under way to shed further light on a possible relationship between streptococcal infections, other biological and psychosocial stressors, and the complex pathobiology of chronic tic disorders. PMID:24106651

Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS): An Evolving Concept.

PubMed

Macerollo, Antonella; Martino, Davide

2013-01-01

Pediatric autoimmune neuropsychiatric disorders associated with streptococcus infections (PANDAS) originated from the observational work of Swedo and collaborators, who formalized their definition in 1998 in a set of operational criteria. The application of these criteria, which focuses on tics and obsessive-compulsive symptoms as core symptoms, has encountered difficulties, eventually leading to a high rate of misdiagnosis. In particular, the core feature represented by the association between newly diagnosed infections and neuropsychiatric symptom relapses in youths with this diagnosis could not be demonstrated by longitudinal studies. Exploratory studies aiming to identify clinical or cognitive features that could discriminate PANDAS from other pediatric obsessive-compulsive and tic disorders present methodological limitations, and therefore are not conclusive. Other behavioral features, in addition to obsessive-compulsive symptoms and tics, have been included in pediatric acute-onset neuropsychiatric syndromes (PANS) and childhood acute neuropsychiatric syndromes (CANS), two new concepts recently proposed in order to define a much broader clinical spectrum encompassing etiologically diverse entities. Given the uncertainties on the clinical definition of PANDAS, it is not surprising that evidence in support of a post-infectious, immune-mediated pathophysiology is also insufficient. Anti-dopamine receptor antibodies might be relevant to both Sydenham's chorea (SC)-the prototypical post-streptococcal neuropsychiatric disorder-and some rare forms of encephalitis targeting the basal ganglia specifically, but studies exploring their association with children fulfilling Swedo's criteria for PANDAS have been inconclusive. Moreover, we lack evidence in favor of the efficacy of antibiotic prophylaxis or tonsillectomy in patients fulfilling Swedo's criteria for PANDAS, whereas a response to immune-mediated treatments like intravenous immunoglobulins has been documented by one study, but needs replication in larger trials. Overall, the available evidence does not convincingly support the concept that PANDAS are a well-defined, isolated clinical entity subdued by definite pathophysiological mechanisms; larger, prospective studies are necessary to reshape the nosography and disease mechanisms of post-streptococcal acute neuropsychiatric disorders other than SC. Research is also under way to shed further light on a possible relationship between streptococcal infections, other biological and psychosocial stressors, and the complex pathobiology of chronic tic disorders.

The influence of snoring, mouth breathing and apnoea on facial morphology in late childhood: a three-dimensional study

PubMed Central

Al Ali, Ala; Richmond, Stephen; Popat, Hashmat; Playle, Rebecca; Pickles, Timothy; Zhurov, Alexei I; Marshall, David; Rosin, Paul L; Henderson, John; Bonuck, Karen

2015-01-01

Objective To explore the relationship between the prevalence of sleep disordered breathing (SDB) and face shape morphology in a large cohort of 15-year-old children. Design Observational longitudinal cohort study Setting Avon Longitudinal Study of Parents and Children (ALSPAC), South West of England. Participants Three-dimensional surface laser scans were taken for 4784 white British children from the ALSPAC during a follow-up clinic. A total of 1724 children with sleep disordered breathing (SDB) and 1862 healthy children were identified via parents’ report of sleep disordered symptoms for their children. We excluded from the original cohort all children identified as having congenital abnormalities, diagnoses associated with poor growth and children with adenoidectomy and/or tonsillectomy. Main outcome measures Parents in the ALSPAC reported sleep disordered symptoms (snoring, mouth breathing and apnoea) for their children at 6, 18, 30, 42, 57, 69 and 81 months. Average facial shells were created for children with and without SDB in order to explore surface differences. Results Differences in facial measurements were found between the children with and without SDB throughout early childhood. The mean differences included an increase in face height in SDB children of 0.3 mm (95% CI −0.52 to −0.05); a decrease in mandibular prominence of 0.9° (95% CI −1.30 to −0.42) in SDB children; and a decrease in nose prominence and width of 0.12 mm (95% CI 0.00 to 0.24) and 0.72 mm (95% CI −0.10 to −0.25), respectively, in SDB children. The odds of children exhibiting symptoms of SDB increased significantly with respect to increased face height and mandible angle, but reduced with increased nose width and prominence. Conclusions The combination of a long face, reduced nose prominence and width, and a retrognathic mandible may be diagnostic facial features of SBD that may warrant a referral to specialists for the evaluation of other clinical symptoms of SDB. PMID:26351193

The influence of snoring, mouth breathing and apnoea on facial morphology in late childhood: a three-dimensional study.

PubMed

Al Ali, Ala; Richmond, Stephen; Popat, Hashmat; Playle, Rebecca; Pickles, Timothy; Zhurov, Alexei I; Marshall, David; Rosin, Paul L; Henderson, John; Bonuck, Karen

2015-09-08

To explore the relationship between the prevalence of sleep disordered breathing (SDB) and face shape morphology in a large cohort of 15-year-old children. Observational longitudinal cohort study Avon Longitudinal Study of Parents and Children (ALSPAC), South West of England. Three-dimensional surface laser scans were taken for 4784 white British children from the ALSPAC during a follow-up clinic. A total of 1724 children with sleep disordered breathing (SDB) and 1862 healthy children were identified via parents' report of sleep disordered symptoms for their children. We excluded from the original cohort all children identified as having congenital abnormalities, diagnoses associated with poor growth and children with adenoidectomy and/or tonsillectomy. Parents in the ALSPAC reported sleep disordered symptoms (snoring, mouth breathing and apnoea) for their children at 6, 18, 30, 42, 57, 69 and 81 months. Average facial shells were created for children with and without SDB in order to explore surface differences. Differences in facial measurements were found between the children with and without SDB throughout early childhood. The mean differences included an increase in face height in SDB children of 0.3 mm (95% CI -0.52 to -0.05); a decrease in mandibular prominence of 0.9° (95% CI -1.30 to -0.42) in SDB children; and a decrease in nose prominence and width of 0.12 mm (95% CI 0.00 to 0.24) and 0.72 mm (95% CI -0.10 to -0.25), respectively, in SDB children. The odds of children exhibiting symptoms of SDB increased significantly with respect to increased face height and mandible angle, but reduced with increased nose width and prominence. The combination of a long face, reduced nose prominence and width, and a retrognathic mandible may be diagnostic facial features of SBD that may warrant a referral to specialists for the evaluation of other clinical symptoms of SDB. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

Friedman tongue position: age distribution and relationship to sleep-disordered breathing.

PubMed

Ingram, David G; Ruiz, Amanda; Friedman, Norman R

2015-05-01

Friedman tongue position (FTP) may play an important role in the evaluation of children with sleep-related breathing disorders (SRBD), but there are no previous data on FTP distribution by age. The objective of the current study was to determine the distribution of FTP by age and examine the relationship between FTP and snoring in children. Prospective cross-sectional study of 199 children (mean age, 6.8 years; 59% male) had tongue position assessed by FTP as part of their clinical examination of the oral cavity during routine ENT visits at a tertiary care children's hospital. The FTP and snoring frequency of participants was examined across the entire age range as well as by comparing those older (middle childhood and above) and younger than 5 years of age. Tongue position did not correlate with age or snoring frequency. The proportion of children with FTP III/IV was not significantly different in children younger than five years of age compared to older than five. Habitual snoring was not associated with having a higher FTP. Among children who snored <3 times per week, those who had previously undergone tonsillectomy did have higher FTP compared to those who had not (p=0.007). BMI-%-for-age was significantly correlated with FTP (p=0.003). The percent of children having FTP class III/IV differed significantly between ethnicities (22% of whites, 26% of others, 45% of hispanics, 53% of African-Americans; p=0.011). Inter-rater reliability among pediatric otolaryngologist was excellent (kappa=0.93, p<0.001). There does not appear to be an association between FTP with age or snoring frequency in children. The excellent inter-rater reliability for FTP among pediatric ENT providers suggests the null findings are not due to rater bias. These findings may serve as an important reference for those studying the role of tongue position in pediatric SRBD and complement previous studies examining FTP among children with known OSA or snoring. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.

Presidential address: adjusting the art and the science of surgery.

PubMed

Traverso, L William

2007-10-01

Why are there so many opinions for surgical treatments? Why do surgeons not agree on the same definitions? To adjust the art and science of surgery, we should understand the reason behind this Tower of Babel and ourselves by grasping the three biological lessons of history. These lessons are instincts of man--our instincts have not changed for as long as there has been recorded history. The lessons were elucidated by Will and Ariel Durant and these are competition, selection, and reproduction. How might they be applied to improving our surgical science? First, competition has always forced individuals or small groups to strengthen themselves with cooperation. Cooperate or not survive. Cooperation increases with social development and technology. Next, we must realize that nature relishes diversity. We are all born unequal and diverse. The second biological lesson is selection; which individual among a diverse group of individuals will succeed (by improving)? Therefore, by nature, man's instincts provide diverse opinions and bias. This creates a myopic view when surgeons try to discern the truth. The results are the trendy bandwagons that divert us, like tonsillectomy. Too much diversity is bad, and a balance is required. Man's third lesson of history is reproduction. Better stated is that nature loves quantity. We naturally give priority to quantity over quality. To obtain quality rather than just quantity, we need the antidotes for competition and diversity--that would be cooperation using the Deming guidelines of leadership, profound knowledge, and technology. One example of this urge for quantity and diversity is our lack of standardized definitions. These three biological lessons can be summarized by viewing competition as an impediment for quality improvement in the complex challenges of modern healthcare. Cooperation (trust) is the antidote to the bandwagon effect of unproven treatments. Cooperation and technology can be joined to establish a successful team using the global technology of the internet ("Club Web"). To improve, we must measure real cases in a registry and generate a standard set of definitions and benchmarks. A focus group that trusts each other through the common interest of a disease or organ could succeed. Only then does comparison (and improvement) become possible.

Prevalence and Determinants of Oral Human Papillomavirus Infection in 500 Young Adults from Italy

PubMed Central

Höfler, Daniela; Menegaldo, Anna; Giorgi Rossi, Paolo; Del Mistro, Annarosa; Da Mosto, Maria Cristina; Pawlita, Michael

2017-01-01

Although the prevalence of human papillomavirus (HPV)-related oropharyngeal squamous cell carcinoma (OPSCC) is increasing in developed countries and becoming a relevant health issue, the natural history of oral HPV infection is still unclear. Estimating the infection’s prevalence in specific populations and identifying risk factors can widen our understanding of its natural history and help to delineate appropriate prevention strategies. This study sought to (i) determine oral HPV prevalence and genotype distribution in a large series of young Italian adults, (ii) validate an oral rinse sampling/storage protocol, and (iii) pinpoint factors associated with oral HPV infection. Five hundred students, nurses, and technicians (19–35 years-old) studying and working at/for the University of Padua were recruited. Each participant was provided with an oral rinse sampling kit and instructions for use. They were also asked to complete an anonymous questionnaire concerning their demographic characteristics and behaviors. The questionnaires and oral rinse containers were labeled with the same identification code number. The oral rinse samples were tested using a bead-based multiplex BSGP5+/6+-MPG genotyping assay which amplifies the L1 region of 51 mucosal HPV types. The prevalence of oral HPV infection was 4.0% (95% confidence interval (CI), 2.5%-6.1%); those of 14 high-risk HPV types and of HPV-type 16 (HPV16) infection were 2.2% (95% CI, 1.1%-3.9%) and 1.6% (95% CI, 0.6%-3.1%), respectively. HPV16 was the most frequent genotype (40.0% of oral HPV infections). No association was found between oral infection and the co-variables studied (gender, tobacco, alcohol and illegal drug use, number of sex and oral sex partners, HPV vaccination status, history of HPV and sexually transmitted infections, abnormal pap smears, recurrent tonsillitis and tonsillectomy). The oral rinse sampling protocol outlined here proved to be simple, efficient and well tolerated, and the prevalence rate can be considered reliable and thus useful to guide future research. Determinants of oral HPV infection are still unclear and further studies are certainly warranted. PMID:28103272

The predictive value of polysomnography combined with quality of life for treatment decision of children with habitual snoring related to adenotonsillar hypertrophy.

PubMed

Zhao, Guoqiang; Li, Yanru; Wang, Xiaoyi; Ding, Xiu; Wang, Chunyan; Xu, Wen; Han, Demin

2018-06-01

Both surgical treatment and non-surgical treatment are suggested by clinicians for children with habitual snoring related to adenotonsillar hypertrophy; However, how should the decision be made remains unclear. The objective of this study was to investigate potential predictors for the treatment decision, i.e., surgical treatment vs wait and see in children with habitual snoring related to adenoidal and/or tonsillar hypertrophy. Children with complaints of snoring and/or apnea associated with adenotonsillar hypertrophy who received polysomnography (PSG) monitoring at our Hospital were recruited. After at least 6 months, the subjects were followed up and grouped according to whether or not they had received adenoidectomy and/or tonsillectomy (AT) execution. The heights, weights, as well as the quality of life (assessed using the obstructive sleep apnea-18 (OSA-18) quality of life questionnaire) and baseline PSG of the subjects were recorded and compared. Two logistic regressions were performed to reveal the factors influencing decision-making on conducting AT. A total of 509 children were finally included (345 males and 164 females). Among these children, 287 eventually received AT. Significant differences in age, scores for item 1 and 5 of the OSA-18, apnea-hypopnea index, obstructive apnea index, obstructive apnea-hypopnea index (OAHI), and Lowest arterial oxygen saturation (P < 0.05) were observed between groups. By multivariate logistic regression, the factors that influenced the surgical decision were identified as follows: age < 7 years (P = 0.008: odds ratio [OR] = 1.667, 95% confidence interval [CI] 1.140-2.438), score for item 5 of OSA-18 > 4 points (P = 0.042: OR = 1.489, 95% CI 1.014-2.212) and OAHI > 1/h (P = 0.044: OR = 1.579, 95% CI 1.013-2.463). School-age children aged < 7 years, with OAHI > 1/h and mouth breathing scored > 4 points were more likely to receive AT during the disease process and thus require increased attention.

A method for assessment of standards of care of anesthesia services in departments with different levels of resources.

PubMed

Montasser, A M

1998-12-01

In developing countries the standards of anesthesia care vary greatly between hospitals. In order to identify the urgent needs of disadvantaged hospitals, we compared three index hospitals in the greater Cairo area, one of which has excellent (category I), on intermediate (category II), and one with severely restricted resources (category III). Standards of care published by the American Society of Anesthesiologists (ASA) were used to develop a spreadsheet for documenting features of pre-, intra- and post-anesthetic care in patients undergoing tonsillectomies, a procedure commonly performed in all three hospitals. The spreadsheet enabled us to document all equipment, supplies and personnel engaged from pre-anesthetic evaluation to discharge. Analysis of the data revealed that the service provided by the category I hospital approached the ASA standards. In the category II hospital the patients did not go through a pre-anesthetic evaluation; instead they were seen for the first time in the operating room. No premedication was given. Intravenous access was established with the help of a needle (rather than a catheter). Monitoring consisted occasionally of a finger on the pulse. Sterilization was accomplished by boiling. Air-conditioning was not available. No records were kept and no recovery room was available. The same deficiencies existed in the category III hospital, which did not even have oropharyngeal airways, antiarrhythmic or inotropic medications, and sterile techniques were completely ignored. Despite these stark differences in care, the patients or their parents in all three hospitals appeared satisfied with the level of care they received. Much has to be done to improve anesthesia care in less fortunate departments in developing nations. Urgent help does not mean the need for sophisticated monitors or equipment only, but the establishment of practice standards first. Applying the priciples of modern management, we need to evaluate the structure, processes and outcome of anesthetic practice in developing countries in order to reengineer the way we provide help to anesthetic departments in developing nations. In this modest study we are presenting a means to evaluate the features and processes of the anesthesia services in developing countries.

Evaluation of circulating markers of hepatic apoptosis and inflammation in obese children with and without obstructive sleep apnea.

PubMed

Alkhouri, Naim; Kheirandish-Gozal, Leila; Matloob, Ammar; Alonso-Álvarez, María Luz; Khalyfa, Abdelnaby; Terán-Santos, Joaquin; Okwu, Vera; Lopez, Rocio; Gileles-Hillel, Alex; Dweik, Raed; Gozal, David

2015-09-01

Hepatocyte apoptosis and macrophage activation contribute to the disease progression of nonalcoholic fatty liver disease (NAFLD). Obstructive sleep apnea (OSA) in obese children is associated with the severity of NAFLD. The aim of this study was to evaluate plasma levels of soluble Fas (sFas), soluble Fas ligand (sFasL), cytokeratin 18 (CK18) (markers of apoptosis), and soluble CD163 (sCD163) (marker of macrophage activation) in obese children with and without OSA. Consecutive obese children who were evaluated for OSA were recruited. The diagnosis of OSA was made using overnight polysomnography (PSG). Fasting blood samples were used to determine plasma CK18, sFas, sFasL, and sCD163 levels using specific sandwich enzyme-linked immunosorbent assay (ELISA). Fifty-eight subjects were included in the analysis with a mean age of 8.9 ± 3.2 years and a mean body mass index (BMI) z-score of 2.4 ± 0.49. Circulating sFas and sFasL levels were significantly lower in subjects with mild and severe OSA compared with those without OSA (p < 0.005 for both). In addition, sCD163 levels increased with an increasing severity of OSA (no OSA = 1.6 ± 0.25 mg/L, mild OSA = 2.3 ± 0.45, and severe OSA = 3.0 ± 0.52; p < 0.001), and they correlated with the apnea-hypopnea index (AHI) [rho (95% confidence interval, CI) of 0.71 (0.41, 1.00), p-value <0.001]. In six patients with severe OSA from whom samples were taken before and after tonsillectomy, the sCD163 level decreased significantly after treatment, and there was a trend toward an increase in sFasL. Markers of apoptosis and macrophage activation are altered in obese children with OSA, indicating increased apoptotic and inflammatory pressures. Copyright © 2015 Elsevier B.V. All rights reserved.

Ultrasensitive detection of oncogenic human papillomavirus in oropharyngeal tissue swabs.

PubMed

Isaac, Andre; Kostiuk, Morris; Zhang, Han; Lindsay, Cameron; Makki, Fawaz; O'Connell, Daniel A; Harris, Jeffrey R; Cote, David W J; Seikaly, Hadi; Biron, Vincent L

2017-01-14

The incidence of oropharyngeal squamous cell carcinoma (OPSCC) caused by oncogenic human papillomavirus (HPV) is rising worldwide. HPV-OPSCC is commonly diagnosed by RT-qPCR of HPV E6 and E7 oncoproteins or by p16 immunohistochemistry (IHC). Droplet digital PCR (ddPCR) has been recently reported as an ultra-sensitive and highly precise method of nucleic acid quantification for biomarker analysis. To validate the use of a minimally invasive assay for detection of oncogenic HPV based on oropharyngeal swabs using ddPCR. Secondary objectives were to compare the accuracy of ddPCR swabs to fresh tissue p16 IHC and RT-qPCR, and to compare the cost of ddPCR with p16 IHC. We prospectively included patients with p16 + oral cavity/oropharyngeal cancer (OC/OPSCC), and two control groups: p16 - OC/OPSCC patients, and healthy controls undergoing tonsillectomy. All underwent an oropharyngeal swab with ddPCR for quantitative detection of E6 and E7 mRNA. Surgical specimens had p16 IHC performed. Agreement between ddPCR and p16 IHC was determined for patients with p16 positive and negative OC/OPSCC as well as for healthy control patients. The sensitivity and specificity of ddPCR of oropharyngeal swabs were calculated against p16 IHC for OPSCC. 122 patients were included: 36 patients with p16 + OPSCC, 16 patients with p16 - OPSCC, 4 patients with p16 + OCSCC, 41 patients with p16 - OCSCC, and 25 healthy controls. The sensitivity and specificity of ddPCR of oropharyngeal swabs against p16 IHC were 92 and 98% respectively, using 20-50 times less RNA than that required for conventional RT-qPCR. Overall agreement between ddPCR of tissue swabs and p16 of tumor tissue was high at ĸ = 0.826 [0.662-0.989]. Oropharyngeal swabs analyzed by ddPCR is a quantitative, rapid, and effective method for minimally invasive oncogenic HPV detection. This assay represents the most sensitive and accurate mode of HPV detection in OPSCC without a tissue biopsy in the available literature.

The carriage of interleukin-1B-31*C allele plus Staphylococcus aureus and Haemophilus influenzae increases the risk of recurrent tonsillitis in a Mexican population

PubMed Central

González-Andrade, Baltazar; Santos-Lartigue, Ramiro; Flores-Treviño, Samantha; Ramirez-Ochoa, Natalie Sonia; Bocanegra-Ibarias, Paola; Huerta-Torres, Francisco J.; Mendoza-Olazarán, Soraya; Villarreal-Treviño, Licet; Camacho-Ortiz, Adrián; Villarreal-Vázquez, Hipólito

2017-01-01

The aim of the present study was to estimate the relative contribution of immunogenetic and microbiological factors in the development of recurrent tonsillitis in a Mexican population. Patients (n = 138) with recurrent tonsillitis and an indication of tonsillectomy (mean age: 6.05 years ± 3.00; median age: 5 years, female: 58; age range: 1–15 years) and 195 non-related controls older than 18 years and a medical history free of recurrent tonsillitis were included. To evaluate the microbial contribution, tonsil swab samples from both groups and extracted tonsil samples from cases were cultured. Biofilm production of isolated bacteria was measured. To assess the immunogenetic component, DNA from peripheral blood was genotyped for the TNFA-308G/A single-nucleotide polymorphism (SNP) and for the IL1B -31C/T SNP. Normal microbiota, but no pathogens or potential pathogens, were identified from all control sample cultures. The most frequent pathogenic species detected in tonsils from cases were Staphylococcus aureus (48.6%, 67/138) and Haemophilus influenzae (31.9%, 44/138), which were found more frequently in patient samples than in samples from healthy volunteers (P < 0.0001). Importantly, 41/54 (75.9%) S. aureus isolates were biofilm producers (18 weak and 23 strong), whereas 17/25 (68%) H. influenzae isolates were biofilm producers (10 weak, and 7 strong biofilm producers). Patients with at least one copy of the IL1B-31*C allele had a higher risk of recurrent tonsillitis (OR = 4.03; 95% CI = 1.27–14.27; P = 0.013). TNFA-308 G/A alleles were not preferentially distributed among the groups. When considering the presence of IL1B-31*C plus S. aureus, IL1B-31*C plus S. aureus biofilm producer, IL1B-31*C plus H. influenzae or IL1B-31*C plus H. influenzae biofilm producer, the OR tended to infinite. Thus, the presence of IL1B-31*C allele plus the presence of S. aureus and/or H. influenzae could be related to the development of tonsillitis in this particular Mexican population. PMID:28542534

Diclofenac and metabolite pharmacokinetics in children.

PubMed

van der Marel, Caroline D; Anderson, Brian J; Rømsing, Janne; Jacqz-Aigrain, Evelyne; Tibboel, Dick

2004-06-01

Data concerning metabolism of diclofenac in children are limited to intravenous and enteric coated oral formulations. There are no data examining diclofenac or its hydroxyl metabolite pharmacokinetics after rectal administration in children. Infants (n = 26) undergoing tonsillectomy were given diclofenac 2 mg.kg(-1) followed by 1 mg.kg(-1) 8 h as suppository formulation for postoperative analgesia. Serum was assayed for diclofenac, 4'-hydroxydiclofenac and 5'-hydroxydiclofenac concentrations during the procedure and 1, 2 and 4 h postoperatively. The formation clearances of diclofenac to hydroxyl metabolites were estimated using nonlinear mixed effects models. A single compartment, first order absorption and first order elimination model was used to describe diclofenac pharmacokinetics. Published data from 11 children given enteric-coated diclofenac tablets were used to assess relative bioavailability. Mean (sd) age and weight of the patients were 4.5 (1.5) years and 20.5 (4.1) kg. The formation clearance to 4'-hydroxydiclofenac (% CV) and to 5'-hydroxydiclofenac were 8.41 (8.1) and 3.41 (113) l.h(-1) respectively, standardized to a 70 kg person using allometric '1/4 power' models. Clearance by other routes contributed 33.0 (64) l.h(-1) 70 kg(-1). Elimination clearance of hydroxyl metabolites was fixed at 27.5 l.h(-1) 70 kg(-1). The volumes of distribution of parent diclofenac and its hydroxyl metabolite were 22.8 (19.0) and 45.3 (l.70) kg(-1). The suppository formulation had an absorption half-life of 0.613 (33.2) h with a lag time of 0.188 (24.9) h. Interoccasion variability of formation clearance to 4'-hydroxydiclofenac, diclofenac volume of distribution, absorption half-time and lag time for the suppository was 36%, 55%, 14% and 119%, respectively. The relative bioavailability of the suppository compared with an enteric-coated tablet was 1.26. The formation clearance of the active metabolite 4'-hydroxydiclofenac contributed 19% of total clearance (44.82 l.h(-1) 70 kg(-1)). The rectum is a suitable route for administration of diclofenac in children 2-8 year of age and was associated with a higher relative bioavailabilty than enteric-coated tablets and an earlier maximum concentration (50 vs. 108 min). This pharmacokinetic profile renders diclofenac suppository a suitable formulation for short duration surgery.

Age at Exposure to Surgery and Anesthesia in Children and Association With Mental Disorder Diagnosis.

PubMed

Ing, Caleb; Sun, Ming; Olfson, Mark; DiMaggio, Charles J; Sun, Lena S; Wall, Melanie M; Li, Guohua

2017-12-01

Animals exposed to anesthetics during specific age periods of brain development experience neurotoxicity, with neurodevelopmental changes subsequently observed during adulthood. The corresponding vulnerable age in children, however, is unknown. An observational cohort study was performed using a longitudinal dataset constructed by linking individual-level Medicaid claims from Texas and New York from 1999 to 2010. This dataset was evaluated to determine whether the timing of exposure to anesthesia ≤5 years of age for a single common procedure (pyloromyotomy, inguinal hernia, circumcision outside the perinatal period, or tonsillectomy and/or adenoidectomy) is associated with increased subsequent risk of diagnoses for any mental disorder, or specifically developmental delay (DD) such as reading and language disorders, and attention deficit hyperactivity disorder (ADHD). Exposure to anesthesia and surgery was evaluated in 11 separate age at exposure categories: ≤28 days old, >28 days and ≤6 months, >6 months and ≤1 year, and 6-month age intervals between >1 year old and ≤5 years old. For each exposed child, 5 children matched on propensity score calculated using sociodemographic and clinical covariates were selected for comparison. Cox proportional hazards models were used to measure the hazard ratio of a mental disorder diagnosis associated with exposure to surgery and anesthesia. A total of 38,493 children with a single exposure and 192,465 propensity score-matched children unexposed before 5 years of age were included in the analysis. Increased risk of mental disorder diagnosis was observed at all ages at exposure with an overall hazard ratio of 1.26 (95% confidence interval [CI], 1.22-1.30), which did not vary significantly with the timing of exposure. Analysis of DD and ADHD showed similar results, with elevated hazard ratios distributed evenly across all ages, and overall hazard ratios of 1.26 (95% CI, 1.20-1.32) for DD and 1.31 (95% CI, 1.25-1.37) for ADHD. Children who undergo minor surgery requiring anesthesia under age 5 have a small but statistically significant increased risk of mental disorder diagnoses and DD and ADHD diagnoses, but the timing of the surgical procedure does not alter the elevated risks. Based on these findings, there is little support for the concept of delaying a minor procedure to reduce long-term neurodevelopmental risks of anesthesia in children. In evaluating the influence of age at exposure, the types of procedures included may need to be considered, as some procedures are associated with specific comorbid conditions and are only performed at certain ages.

Ventilation time of the middle ear in otitis media with effusion (OME) after CO2 laser myringotomy.

PubMed

Sedlmaier, Benedikt; Jivanjee, Antonio; Gutzler, Rico; Huscher, Dörte; Jovanovic, Sergije

2002-04-01

The aim of this study was to investigate the transtympanic ventilation time, the healing course of the tympanic membrane, the early and late complications, and the recurrence rate of otitis media with effusion (OME) within 6 months after CO2 laser myringotomy with the CO2 laser otoscope Otoscan. Prospective clinical study. In this study, laser myringotomy was performed with the CO2 laser otoscope Otoscan in a patient population comprising 81 children (159 ears) with a history of otitis media with effusion (OME) associated with adenoidal and sometimes tonsillar hyperplasia. The procedure on the tympanic membrane was accordingly combined with an adenoidectomy, a CO2 laser tonsillotomy, or a tonsillectomy and therefore performed under insufflation anesthesia. In all ears, approximately 2 mm circular perforations were created in the lower anterior quadrants with a power of 12 to 15 W, a pulse duration of 180 msec, and a scanned area of 2.2 mm in diameter. None of the children showed postoperative impairment of cochleovestibular function such as sensorineural hearing loss or nystagmus. Otomicroscopic and videoendoscopic monitoring documented the closure time and healing pattern of tympanic membrane perforations. The mean closure time was found to be 16.35 days (minimum, 8 days; maximum, 34 days). As a rule, an onion-skin-like membrane of keratinized material was seen in the former myringotomy perforations at the time of closure. At the follow-up 6 months later, the condition of the tympanic membrane of 129 ears (81.1%) could be checked by otomicroscopy and videoendoscopy and the hearing ability by audiometry and tympanometry. The CO2 laser myringotomy sites appeared normal and irritation-free. Two of the tympanic membranes examined (1.6%) showed atrophic scar formation, and 1 (0.8%) had a perforation with a diameter of 0.3 mm. The perforation was seen closed in a control otoscopy 15 months postoperatively. OME recurred in 26.3% of the ears seen intraoperatively with mucous secretion (n = 38) and in 13.5% of the ears with serous secretion (n = 37; P <.05). The most important principle in treating OME is ventilation of the tympanic cavity. CO2 laser myringotomy achieves this through a self-healing perforation in which its diameter roughly determines the duration of transtympanic ventilation. Laser myringotomy competes with ventilation tube insertion in the treatment of OME. It may be a useful alternative in the surgical management of secretory otitis media.

[Gender and age differences in waiting time on hospital waiting list.].

PubMed

Thornórðardóttir, Steinunn; Halldórsson, Matthías; Guðmundsson, Sigurður

2002-09-01

The size of waiting lists has traditionally been viewed as a fairly good measure of the quality of health care services. No statistical analysis exists in Iceland of the length of waiting times and the potential variation between groups of patients. This study was conducted within the office of the Directorate of Health in Iceland. This location was convenient since standardized information on waiting lists is collected by the office three times a year. Variations in waiting times were studied based on gender on the one hand and on age on the other. Data from the largest waiting lists, those amounting to 400 or more patients, were included in the study. The most frequently awaited operations were identified and the groups of people waiting for them analyzed. The departments and prospective operations included in the study were: Dept. of General Surgery at the University Hospital (UH) (laparoscopic gastro-oesophageal antireflux operation), Opthalmology at UH (phakoemulsification with implantation of artificial lens in posterior chamber), Orthopedic Surgery at UH (primary total prosthetic replacement of hip joint using sement), The Rehabilitation Center at Reykjalundur (rehabilitation, not specified), Ear, Nose and Throat (ENT) at UH (tonsillectomy), and Reconstructive Surgery at UH (reduction mammoplasty with transposition of areola). The lists were sorted by gender and age, with the latter consisting of two categories, older and younger patients. Every attempt was made as to ensure similar sample sizes for both age groups within each department. Finally, the median waiting time was determined and a Mann-Whitney test conducted in order to test for significance. The median waiting time for males at the General Surgery Dept. was 73 weeks as compared to 60 weeks for females. This was the only department where the median waiting time was significantly longer for males than for females (p<0.05). At three of the departments the older group had a longer median waiting time than the younger group, 18 weeks compared to 14 at Opthalmology (p<0.001), 26 versus 17 weeks at Reykjalundur (p<0.025) and 33 versus 21 weeks at ENT (p<0.01). Waiting times for females was significantly longer than for males at two departments, Reykjalundur (21 vs. 17 weeks, p<0.05) and ENT (33 vs. 29 weeks, p<0.05). This study revealed age and gender differences in median waiting times at Icelandic hospitals. These differences were in many cases marked and statistically significant. Various explanations have been put forward, however, further research is needed in order to determine if it these differences are due to actual clinical needs assessments or to age or gender discrimination.

Dexmedetomidine infusion for analgesia and prevention of emergence agitation in children with obstructive sleep apnea syndrome undergoing tonsillectomy and adenoidectomy.

PubMed

Patel, Anuradha; Davidson, Melissa; Tran, Minh C J; Quraishi, Huma; Schoenberg, Catherine; Sant, Manasee; Lin, Albert; Sun, Xiuru

2010-10-01

Dexmedetomidine, a specific α(2) agonist, has an analgesic-sparing effect and reduces emergence agitation. We compared an intraoperative dexmedetomidine infusion with bolus fentanyl to reduce perioperative opioid use and decrease emergence agitation in children with obstructive sleep apnea syndrome undergoing adenotonsillectomy (T&A). One hundred twenty-two patients with obstructive sleep apnea syndrome undergoing T&A, ages 2 to 10 years, completed this prospective, randomized, U.S. Food and Drug Administration-approved study. After mask induction with sevoflurane, group D received IV dexmedetomidine 2 μg · kg(-1) over 10 minutes, followed by 0.7 μg · kg(-1) · h(-1), and group F received IV fentanyl bolus 1 μg · kg(-1). Anesthesia was maintained with sevoflurane, oxygen, and nitrous oxide. Fentanyl 0.5 to 1 μg · kg(-1) was given to subjects in both groups for an increase in heart rate or systolic blood pressure 30% above preincision values that continued for 5 minutes. Observers in the postanesthesia care unit (PACU) were blinded to treatment groups. Pain was evaluated using the objective pain score in the PACU on arrival, at 5 minutes, at 15 minutes, then every 15 minutes for 120 minutes. Emergence agitation was evaluated at the same intervals by 2 scales: the Pediatric Anesthesia Emergence Delirium scale and a 5-point scale described by Cole. Morphine (0.05 to 0.1 mg · kg(-1)) was given for pain (score >4) or severe agitation (score 4 or 5) lasting more than 5 minutes. In group D, 9.8% patients needed intraoperative rescue fentanyl in comparison with 36% in group F (P = 0.001). Mean systolic blood pressure and heart rate were significantly lower in group D (P < 0.05). Minimum alveolar concentration values were significantly different between the 2 groups (P = 0.015). The median objective pain score was 3 for group D and 5 for group F (P = 0.001). In group D, 10 (16.3%) patients required rescue morphine, in comparison with 29 (47.5%) in group F (P = 0.002). The frequency of severe emergence agitation on arrival in the PACU was 18% in group D and 45.9% in group F (P = 0.004); at 5 minutes and at 15 minutes, it was lower in group D (P = 0.028). The duration of agitation on the Cole scale was statistically lower in group D (P = 0.004). In group D, 18% of patients and 40.9% in group F had an episode of Spo(2) below 95% (P = 0.01). An intraoperative infusion of dexmedetomidine combined with inhalation anesthetics provided satisfactory intraoperative conditions for T&A without adverse hemodynamic effects. Postoperative opioid requirements were significantly reduced, and the incidence and duration of severe emergence agitation was lower with fewer patients having desaturation episodes.

Oral appliances and functional orthopaedic appliances for obstructive sleep apnoea in children.

PubMed

Carvalho, Fernando R; Lentini-Oliveira, Débora A; Prado, Lucila Bf; Prado, Gilmar F; Carvalho, Luciane Bc

2016-10-05

Apnoea is a breathing disorder marked by the absence of airflow at the nose or mouth. In children, risk factors include adenotonsillar hypertrophy, obesity, neuromuscular disorders and craniofacial anomalies. The most common treatment for obstructive sleep apnoea syndrome (OSAS) in childhood is adeno-tonsillectomy. This approach is limited by its surgical risks, mostly in children with comorbidities and, in some patients, by recurrence that can be associated with craniofacial problems. Oral appliances and functional orthopaedic appliances have been used for patients who have OSAS and craniofacial anomalies because they hold the lower jaw (mandible) forwards which potentially enlarges the upper airway and increases the upper airspace, improving the respiratory function. To assess the effects of oral appliances or functional orthopaedic appliances for obstructive sleep apnoea in children. We searched the following electronic databases: Cochrane Oral Health's Trials Register (to 7 April 2016); Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 3) in the Cochrane Library (searched 7 April 2016); MEDLINE Ovid (1946 to 7 April 2016); Embase Ovid (1980 to 7 April 2016); LILACS BIREME (from 1982 to 7 April 2016); BBO BIREME (from 1986 to 7 April 2016) and SciELO Web of Science (from 1997 to 7 April 2016). We searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform for ongoing trials on 7 April 2016. We placed no restrictions on the language or date of publication when searching the electronic databases. All randomised or quasi-randomised controlled trials comparing all types of oral and functional orthopaedic appliances with placebo or no treatment, in children 15 years old or younger. reduction of apnoea to less than one episode per hour. dental and skeletal relationship, sleep parameters improvement, cognitive and phonoaudiological function, behavioural problems, quality of life, side effects (tolerability) and economic evaluation. Two review authors screened studies and extracted data independently. Authors were contacted for additional information. We calculated risk ratios with 95% confidence intervals for all important dichotomous outcomes. We assessed the quality of the evidence of included studies using GRADEpro software. The initial search identified 686 trials. Only one trial, reporting the results from a total of 23 children and comparing an oral appliance to no treatment, was suitable for inclusion in the review. The trial assessed apnoea-hypopnoea, daytime symptoms (sleepiness, irritability, tiredness, school problems, morning headache, thirstiness in the morning, oral breathing and nasal stuffiness) and night-time symptoms (habitual snoring, restless sleep and nightmares measured by questionnaire). Results were inconsistent across outcomes measures and time points. The evidence was considered very low quality. There is insufficient evidence to support or refute the effectiveness of oral appliances and functional orthopaedic appliances for the treatment of obstructive sleep apnoea in children. Oral appliances or functional orthopaedic appliances may be considered in specified cases as an auxiliary in the treatment of children who have craniofacial anomalies which are risk factors for apnoea.

Development and Validation of a Risk Scale for Emergence Agitation After General Anesthesia in Children: A Prospective Observational Study.

PubMed

Hino, Maai; Mihara, Takahiro; Miyazaki, Saeko; Hijikata, Toshiyuki; Miwa, Takaaki; Goto, Takahisa; Ka, Koui

2017-08-01

Emergence agitation (EA) is a common complication in children after general anesthesia. The goal of this 2-phase study was (1) to develop a predictive model (EA risk scale) for the incidence of EA in children receiving sevoflurane anesthesia by performing a retrospective analysis of data from our previous study (phase 1) and (2) to determine the validity of the EA risk scale in a prospective observational cohort study (phase 2). Using data collected from 120 patients in our previous study, logistic regression analysis was used to predict the incidence of EA in phase 1. The optimal combination of the predictors was determined by a stepwise selection procedure using Akaike information criterion. The β-coefficient for the selected predictors was calculated, and scores for predictors determined. The predictive ability of the EA risk scale was assessed by a receiver operating characteristic (ROC) curve, and the area under the ROC curve (c-index) was calculated with a 95% confidence interval (CI). In phase 2, the validity of the EA risk scale was confirmed using another data set of 100 patients (who underwent minor surgery under general anesthesia). The ROC curve, the c-index, the best cutoff point, and the sensitivity and specificity at the point were calculated. In addition, we calculated the gray zone, which ranges between the two points where sensitivity and specificity, respectively, become 90%. In phase 1, the final model of the multivariable logistic regression analysis included the following 4 predictors: age (logarithm odds ratios [OR], -0.38; 95% CI, -0.81 to 0.00), Pediatric Anesthesia Behavior score (logarithm OR, 0.65; 95% CI, -0.09 to 1.40), anesthesia time (logarithm OR, 0.60; 95% CI, -0.18 to 1.19), and operative procedure (logarithm OR, 2.53; 95% CI, 1.30-3.75 for strabismus surgery and logarithm OR, 2.71; 95% CI, 0.99-4.45 for tonsillectomy). The EA risk scale included these 4 predictors and ranged from 1 to 23 points. In phase 2, the incidence of EA was 39%. The c-index of phase 1 was 0.84 (95% CI, 0.74-0.94), and the c-index of phase 2 was 0.81 (95% CI, 0.72-0.89). The best cutoff point for the EA risk scale was 11 (sensitivity = 87% and specificity = 61%). The gray zone ranged from 10 to 13 points, and included 38% of patients. We developed and validated an EA risk scale for children receiving sevoflurane anesthesia. In our validation cohort, this scale has excellent predictive performance (c-index > 0.8). The EA risk scale could be used to predict EA in children and adopt a preventive strategy for those at high risk. This score-based preventive approach should be studied prospectively to assess the safety and efficacy of such a strategy.

Comparison of Postoperative Respiratory Monitoring by Acoustic and Transthoracic Impedance Technologies in Pediatric Patients at Risk of Respiratory Depression.

PubMed

Patino, Mario; Kalin, Megan; Griffin, Allison; Minhajuddin, Abu; Ding, Lili; Williams, Timothy; Ishman, Stacey; Mahmoud, Mohamed; Kurth, C Dean; Szmuk, Peter

2017-06-01

In children, postoperative respiratory rate (RR) monitoring by transthoracic impedance (TI), capnography, and manual counting has limitations. The rainbow acoustic monitor (RAM) measures continuous RR noninvasively by a different methodology. Our primary aim was to compare the degree of agreement and accuracy of RR measurements as determined by RAM and TI to that of manual counting. Secondary aims include tolerance and analysis of alarm events. Sixty-two children (2-16 years old) were admitted after tonsillectomy or receiving postoperative patient/parental-controlled analgesia. RR was measured at regular intervals by RAM, TI, and manual count. Each TI or RAM alarm resulted in a clinical evaluation to categorize as a true or false alarm. To assess accuracy and degree of agreement of RR measured by RAM or TI compared with manual counting, a Bland-Altman analysis was utilized showing the average difference and the limits of agreement. Sensitivity and specificity of RR alarms by TI and RAM are presented. Fifty-eight posttonsillectomy children and 4 patient/parental-controlled analgesia users aged 6.5 ± 3.4 years and weighting 35.3 ± 22.7 kg (body mass index percentile 76.6 ± 30.8) were included. The average monitoring time per patient was 15.9 ± 4.8 hours. RAM was tolerated 87% of the total monitoring time. The manual RR count was significantly different from TI (P = .007) with an average difference ± SD of 1.39 ± 10.6 but were not significantly different from RAM (P = .81) with an average difference ± SD of 0.17 ± 6.8. The proportion of time when RR measurements differed by ≥4 breaths was 22% by TI and was 11% by RAM. Overall, 276 alarms were detected (mean alarms/patient = 4.5). The mean number of alarms per patient were 1.58 ± 2.49 and 2.87 ± 4.32 for RAM and TI, respectively. The mean number of false alarms was 0.18 ± 0.71 for RAM and 1.00 ± 2.78 for TI. The RAM was found to have 46.6% sensitivity (95% confidence interval [CI], 0.29-0.64), 95.9% specificity (95% CI, 0.90-1.00), 88.9% positive predictive value (95% CI, 0.73-1.00), and 72.1% negative predictive value (95% CI, 0.61-0.84), whereas the TI monitor had 68.5% sensitivity (95% CI, 0.53-0.84), 72.0% specificity (95% CI, 0.60-0.84), 59.0% positive (95% CI, 0.44-0.74), and 79.5% negative predictive value (95% CI, 0.69-0.90). In children at risk of postoperative respiratory depression, RR assessment by RAM was not different to manual counting. RAM was well tolerated, had a lower incidence of false alarms, and had better specificity and positive predictive value than TI. Rigorous evaluation of the negative predictive value is essential to determine the role of postoperative respiratory monitoring with RAM.

Comparison of 1470nm diode laser vs. C02-laserlaser for tonsillotomy and a clinical feasability trial on the use of 1940nm in ENT

NASA Astrophysics Data System (ADS)

Sroka, Ronald; Pongratz, Thomas; Havel, Miriam; Englert, Elsa; Kremser, Thomas; Betz, Christain S.; Leunig, Andreas

2013-03-01

Introduction: The need for reduction of post-tonsillectomy hemorrhage has led to promotion of tonsillotomy techniques for tonsil tissue reduction in obstructive tonsillar hypertrophy. A first study compares ablative tissue effects using 1470nm diode laser and CO2-laser for tonsillotomy in an intraindividual design. A number of different laser systems have been used for volume reduction of hyperplastic nasal turbinates. The aim of a 2nd clinical feasibility study was to show the coagulative and tissue reducing effects using a novel Tm: fiber laser system emitting at λ = 1940 nm Patients and methods: First 21 children aged 3 -13 years (mean age 6.3 years) underwent laser tonsillotomy for obstructive tonsillar hypertrophy in this double blind, prospective, randomized, clinical feasibility trial. In each case, tonsillotomy was performed using fibre guided 1470nm diode laser (contact mode, 15 W power) on the one side and CO2-laser (12 W power) on the other side. An independent physician documented clinical presentation and patients' symptoms preoperatively and on day 1, 3, 7, 14 and 21 postoperatively using standardized questionnaire including VAS (was ist das) for each side separately. The 2nd clinical feasibility trial included 11 patients suffering from hyperplastic inferior nasal turbinates, who were therapy-refractory to conservative medical treatment. The obstructive nasal cavity was treated using the 1940 nm Tm: fiber laser at < 5 W output power. The treatment was performed in non-contact mode under endoscopic control. Patients ' symptoms were documented both preoperatively and on days 1 - 3 and 28 postoperatively using a non-validated questionnaire. Additionally, an endoscopic examination was performed. Results: Mean duration of single tonsillotomy operative treatment was 2.7 min using 1470nm laser and 4.9 min using CO2 laser respectively. Intraoperative bleeding and the frequency of bipolar forceps use for intraoperative bleeding control was significantly less pronounced using the 1470nm diode laser system. There was no difference in postoperative pain scores between the CO2-laser treated and the 1470nm fibre guided diode laser treated side. No infections, hemorrhages or other complications occurred in the course of the three weeks postoperative period. In the turbinate study, none of the patients showed infections, and no hemorrhages or other complications occurred intraor postoperatively.The mean laser activation time was extremely short being 28.0 +/- 8.5 s. In conjunction with a low power setting (median, 3 W; mean +/- standard deviation, 3.3 +/- 1.1 W), a low energy of 90.2 +/- 37.8 J was applied. A significant reduction in nasal obstruction could be documented in all patients on day 28 postoperatively. Evaluation, as assessed preoperatively and 4 weeks postoperatively, showed significant subjective improvements. Conclusion: A fiber-guided 1470nm diode laser system offers an efficient and safe method for tonsillotomy as treatment of obstructive tonsillar hypertrophy. Compared to our standard practice with CO2- laser, 1470nm laser application provides comparable tissue ablation effects with less intraoperative bleeding and shorter operation time. The treatment of hyperplastic inferior turbinates using a 1940 nm Tm: fiber laser provides sufficient tissue reduction in a short operation time using low total energy. Patients described a significant improvement in nasal breathing postoperatively.

Practice parameters for the surgical modifications of the upper airway for obstructive sleep apnea in adults.

PubMed

Aurora, R Nisha; Casey, Kenneth R; Kristo, David; Auerbach, Sanford; Bista, Sabin R; Chowdhuri, Susmita; Karippot, Anoop; Lamm, Carin; Ramar, Kannan; Zak, Rochelle; Morgenthaler, Timothy I

2010-10-01

Practice parameters for the treatment of obstructive sleep apnea syndrome (OSAS) in adults by surgical modification of the upper airway were first published in 1996 by the American Academy of Sleep Medicine (formerly ASDA). The following practice parameters update the previous practice parameters. These recommendations were reviewed and approved by the Board of Directors of the American Academy of Sleep Medicine. A systematic review of the literature was performed, and the GRADE system was used to assess the quality of evidence. The findings from this evaluation are provided in the accompanying review paper, and the subsequent recommendations have been developed from this review. The following procedures have been included: tracheostomy, maxillo-mandibular advancement (MMA), laser assisted uvulopalatoplasty (LAUP), uvulopalatopharyngoplasty (UPPP), radiofrequency ablation (RFA), and palatal implants. The presence and severity of obstructive sleep apnea must be determined before initiating surgical therapy (Standard). The patient should be advised about potential surgical success rates and complications, the availability of alternative treatment options such as nasal positive airway pressure and oral appliances, and the levels of effectiveness and success rates of these alternative treatments (Standard). The desired outcomes of treatment include resolution of the clinical signs and symptoms of obstructive sleep apnea and the normalization of sleep quality, the apnea-hypopnea index, and oxyhemoglobin saturation levels (Standard). Tracheostomy has been shown to be an effective single intervention to treat obstructive sleep apnea. This operation should be considered only when other options do not exist, have failed, are refused, or when this operation is deemed necessary by clinical urgency (Option). MMA is indicated for surgical treatment of severe OSA in patients who cannot tolerate or who are unwilling to adhere to positive airway pressure therapy, or in whom oral appliances, which are more often appropriate in mild and moderate OSA patients, have been considered and found ineffective or undesirable (Option). UPPP as a sole procedure, with or without tonsillectomy, does not reliably normalize the AHI when treating moderate to severe obstructive sleep apnea syndrome. Therefore, patients with severe OSA should initially be offered positive airway pressure therapy, while those with moderate OSA should initially be offered either PAP therapy or oral appliances (Option). Use of multi-level or stepwise surgery (MLS), as a combined procedure or as stepwise multiple operations, is acceptable in patients with narrowing of multiple sites in the upper airway, particularly if they have failed UPPP as a sole treatment (Option). LAUP is not routinely recommended as a treatment for obstructive sleep apnea syndrome (Standard). RFA can be considered as a treatment in patients with mild to moderate obstructive sleep apnea who cannot tolerate or who are unwilling to adhere to positive airway pressure therapy, or in whom oral appliances have been considered and found ineffective or undesirable (Option). Palatal implants may be effective in some patients with mild obstructive sleep apnea who cannot tolerate or who are unwilling to adhere to positive airway pressure therapy, or in whom oral appliances have been considered and found ineffective or undesirable (Option). Postoperatively, after an appropriate period of healing, patients should undergo follow-up evaluation including an objective measure of the presence and severity of sleep-disordered breathing and oxygen saturation, as well as clinical assessment for residual symptoms. Additionally, patients should be followed over time to detect the recurrence of disease (Standard). While there has been significant progress made in surgical techniques for the treatment of OSA, there is a lack of rigorous data evaluating surgical modifications of the upper airway. Systematic and methodical investigations are needed to improve the quality of evidence, assess additional outcome measures, determine which populations are most likely to benefit from a particular procedure or procedures, and optimize perioperative care.

Family-centred care for hospitalised children aged 0-12 years.

PubMed

Shields, Linda; Zhou, Huaqiong; Pratt, Jan; Taylor, Marjory; Hunter, Judith; Pascoe, Elaine

2012-10-17

This is an update of the Cochrane systematic review of family-centred care published in 2007 (Shields 2007). Family-centred care (FCC) is a widely used model in paediatrics, is thought to be the best way to provide care to children in hospital and is ubiquitous as a way of delivering care. When a child is admitted, the whole family is affected. In giving care, nurses, doctors and others must consider the impact of the child's admission on all family members. However, the effectiveness of family-centred care as a model of care has not been measured systematically. To assess the effects of family-centred models of care for hospitalised children aged from birth (unlike the previous version of the review, this update excludes premature neonates) to 12 years, when compared to standard models of care, on child, family and health service outcomes. In the original review, we searched up until 2004. For this update, we searched: the Cochrane Central Register of Controlled Trials (CENTRAL,The Cochrane Library, Issue 12 2011); MEDLINE (Ovid SP); EMBASE (Ovid SP); PsycINFO (Ovid SP); CINAHL (EBSCO Host); and Sociological Abstracts (CSA). We did not search three that were included in the original review: Social Work Abstracts, the Australian Medical Index and ERIC. We searched EMBASE in this update only and searched from 2004 onwards. There was no limitation by language. We performed literature searches in May and June 2009 and updated them again in December 2011. We searched for randomised controlled trials (RCTs) including cluster randomised trials in which family-centred care models are compared with standard models of care for hospitalised children (0 to 12 years, but excluding premature neonates). Studies had to meet criteria for family-centredness. In order to assess the degree of family-centredness, we used a modified rating scale based on a validated instrument, (same instrument used in the initial review), however, we decreased the family-centredness score for inclusion from 80% to 50% in this update. We also changed several other selection criteria in this update: eligible study designs are now limited to randomised controlled trials (RCTs) only; single interventions not reflecting a FCC model of care have been excluded; and the selection criterion whereby studies with inadequate or unclear blinding of outcome assessment were excluded from the review has been removed. Two review authors undertook searches, and four authors independently assessed studies against the review criteria, while two were assigned to extract data. We contacted study authors for additional information. Six studies found since 2004 were originally viewed as possible inclusions, but when the family-centred score assessment was tested, only one met the minimum score of family-centredness and was included in this review. This was an unpublished RCT involving 288 children post-tonsillectomy in a care-by-parent unit (CBPU) compared with standard inpatient care.The study used a range of behavioural, economic and physical measures. It showed that children in the CBPU were significantly less likely to receive inadequate care compared with standard inpatient admission, and there were no significant differences for their behavioural outcomes or other physical outcomes. Parents were significantly more satisfied with CBPU care than standard care, assessed both before discharge and at 7 days after discharge. Costs were lower for CPBU care compared with standard inpatient care. No other outcomes were reported. The study was rated as being at low to unclear risk of bias. This update of a review has found limited, moderate-quality evidence that suggests some benefit of a family-centred care intervention for children's clinical care, parental satisfaction, and costs, but this is based on a small dataset and needs confirmation in larger RCTs. There is no evidence of harms. Overall, there continues to be little high-quality quantitative research available about the effects of family-centred care. Further rigorous research on the use of family-centred care as a model for care delivery to children and families in hospitals is needed. This research should implement well-developed family-centred care interventions, ideally in randomised trials. It should investigate diverse participant groups and clinical settings, and should assess a wide range of outcomes for children, parents, staff and health services.

Practice Parameters for the Surgical Modifications of the Upper Airway for Obstructive Sleep Apnea in Adults

PubMed Central

Aurora, R. Nisha; Casey, Kenneth R.; Kristo, David; Auerbach, Sanford; Bista, Sabin R.; Chowdhuri, Susmita; Karippot, Anoop; Lamm, Carin; Ramar, Kannan; Zak, Rochelle; Morgenthaler, Timothy I.

2010-01-01

Background: Practice parameters for the treatment of obstructive sleep apnea syndrome (OSAS) in adults by surgical modification of the upper airway were first published in 1996 by the American Academy of Sleep Medicine (formerly ASDA). The following practice parameters update the previous practice parameters. These recommendations were reviewed and approved by the Board of Directors of the American Academy of Sleep Medicine. Methods: A systematic review of the literature was performed, and the GRADE system was used to assess the quality of evidence. The findings from this evaluation are provided in the accompanying review paper, and the subsequent recommendations have been developed from this review. The following procedures have been included: tracheostomy, maxillo-mandibular advancement (MMA), laser assisted uvulopalatoplasty (LAUP), uvulopalatopharyngoplasty (UPPP),radiofrequency ablation (RFA), and palatal implants. Recommendations: The presence and severity of obstructive sleep apnea must be determined before initiating surgical therapy (Standard). The patient should be advised about potential surgical success rates and complications, the availability of alternative treatment options such as nasal positive airway pressure and oral appliances, and the levels of effectiveness and success rates of these alternative treatments (Standard). The desired outcomes of treatment include resolution of the clinical signs and symptoms of obstructive sleep apnea and the normalization of sleep quality, the apnea-hypopnea index, and oxyhemoglobin saturation levels (Standard). Tracheostomy has been shown to be an effective single intervention to treat obstructive sleep apnea. This operation should be considered only when other options do not exist, have failed, are refused, or when this operation is deemed necessary by clinical urgency (Option). MMA is indicated for surgical treatment of severe OSA in patients who cannot tolerate or who are unwilling to adhere to positive airway pressure therapy, or in whom oral appliances, which are more often appropriate in mild and moderate OSA patients, have been considered and found ineffective or undesirable (Option). UPPP as a sole procedure, with or without tonsillectomy, does not reliably normalize the AHI when treating moderate to severe obstructive sleep apnea syndrome. Therefore, patients with severe OSA should initially be offered positive airway pressure therapy, while those with moderate OSA should initially be offered either PAP therapy or oral appliances (Option). Use of multi-level or stepwise surgery (MLS), as a combined procedure or as stepwise multiple operations, is acceptable in patients with narrowing of multiple sites in the upper airway, particularly if they have failed UPPP as a sole treatment (Option). LAUP is not routinely recommended as a treatment for obstructive sleep apnea syndrome (Standard). RFA can be considered as a treatment in patients with mild to moderate obstructive sleep apnea who cannot tolerate or who are unwilling to adhere to positive airway pressure therapy, or in whom oral appliances have been considered and found ineffective or undesirable (Option). Palatal implants may be effective in some patients with mild obstructive sleep apnea who cannot tolerate or who are unwilling to adhere to positive airway pressure therapy, or in whom oral appliances have been considered and found ineffective or undesirable (Option). Postoperatively, after an appropriate period of healing, patients should undergo follow-up evaluation including an objective measure of the presence and severity of sleep-disordered breathing and oxygen saturation, as well as clinical assessment for residual symptoms. Additionally, patients should be followed over time to detect the recurrence of disease (Standard). Conclusions: While there has been significant progress made in surgical techniques for the treatment of OSA, there is a lack of rigorous data evaluating surgical modifications of the upper airway. Systematic and methodical investigations are needed to improve the quality of evidence, assess additional outcome measures, determine which populations are most likely to benefit from a particular procedure or procedures, and optimize perioperative care. Citation: Aurora RN; Casey KR; Kristo D; Auerbach S; Bista SR; Chowdhuri S; Karippot A; Lamm C; Ramar K; Zak R; Morgenthaler TI. Practice parameters for the surgical modifications of the upper airway for obstructive sleep apnea in adults. SLEEP 2010;33(10):1408-1413. PMID:21061864

Chronic hip pain in a boy with mental retardation and cerebral palsy.

PubMed

Stein, Martin T; Gottsegen, David; Blasco, Peter A; Wolraich, Mark; Hennessy, Michael J

2010-04-01

Jonny is a 13 year old boy with spastic quadriparesis and severe mental retardation following Haemophilus influenza type B (HIB) meningitis at 2-months of age. Signs of meningitis started on the evening of his 2-month immunizations that included the HIB vaccine. He presented to his pediatrician with left hip pain that occurred intermittently for a few years and more frequently in the past six months. His parents initially attributed the pain to whizzing around the back yard in a motorized wheelchair. An earlier evaluation of hip pain led to bilateral femoral osteotomies for hip dysplasia. Obesity, associated with inactivity and a tendency to consume fatty foods, complicates Jonny's disabilities. His only activity is a modest amount of physical therapy at school and "floor time" for about one hour each day at home. In the office of his pediatrician, Jonny is friendly, smiling, and verbalizing a few words with his limited expressive vocabulary. He is resistant to a hip examination and grimaces with manipulation of his left hip. Spasticity of the left leg appears increased compared to previous examinations. He has nonpitting edema of his lower legs and feet, a cryptorchid left testicle, and a somewhat tender left inguinal area. Jonny lives with his mother and father in a small house on a busy street less than one-half mile from the pediatrician's office. Jonny's pediatrician often sees him in his wheelchair, accompanied by his mother or grandmother, and waves or stops to chat. He has van services to school, and there is a Hoyer lift in the home, but his parents do not own a van. Recently, Jonny's father finds it more difficult to lift him. The family has also been challenged by the mental health problems of Jonny's two older brothers, and a serious eye injury suffered by his middle brother in a motor-vehicle accident. Jonny's pediatrician has cared for him and his two brothers since birth. Although the parents continue to believe that the HIB vaccine caused his catastrophic illness, they remain with the pediatrician. In general, they are satisfied with the individualized educational plan at a local public school. When he was 6.5 years old, Jonny's school aid reported that he attempted to touch her in the genital area. The pediatrician attended the meeting to review this incident and successfully advocated for Jonny by pointing out that this was an isolated incident; it did not occur again. At 6 years old Jonny functioned in the 1.5-2.5 year old range with motor skills in the 6-12 month level according to the Bayley Scales of Infant Development and the Vineland Adaptive Behavior Scales. In the past a neurologist and a physiatrist saw Jonny, but both of these individuals moved from the community. He had prior evaluations at a children's orthopedic clinic at a small community hospital and at the local Shriner's hospital. He had a tonsillectomy and adenoidectomy at 7 years old. He is currently treated for constipation and receives dental care at a clinic for people with disabilities. His pediatrician has always respected the parents for their care and obvious love for their disabled child. However, parental resistance to addressing major issues such as obesity has frustrated his pediatrician. When the pediatrician suggested that Jonny was eligible for the state's managed care program, which would convert Medicaid coverage to a state sponsored program with more extensive services and case management, Jonny's mother repeatedly said that she would "think it over." At the current visit, the pediatrician recommended an adjustment of Jonny's wheelchair, a hip x-ray, a referral to Shriner's Hospital, and an appointment with a pediatric surgeon to address the undescended testicle and possible hernia. Jonny's mother mentioned that he had been to Shriner's Hospital for hip pain two years earlier but was told nothing could be done "because nothing was wrong with his bone." The hip x-ray was normal as well as a complete blood count and a C-reactive protein. The pediatric surgeon did not find a hernia and deferred treatment of the cryptorchid testicle. His parents contacted the wheelchair company to arrange adjustments. The pediatrician called the medical director at the Shriner's Hospital to discuss Jonny's case, but 2 months after the initial visit, the parents had not arranged for an appointment at the Shriner's Hospital. Jonny's hip pain persisted. The pediatrician now wonders how he can more effectively address Jonny's current problems and improve overall care for him and his family.

Preoperative blood transfusions for sickle cell disease

PubMed Central

Estcourt, Lise J; Fortin, Patricia M; Trivella, Marialena; Hopewell, Sally

2016-01-01

Background Sickle cell disease is one of the commonest severe monogenic disorders in the world, due to the inheritance of two abnormal haemoglobin (beta globin) genes. Sickle cell disease can cause severe pain, significant end-organ damage, pulmonary complications, and premature death. Surgical interventions are more common in people with sickle cell disease, and occur at much younger ages than in the general population. Blood transfusions are frequently used prior to surgery and several regimens are used but there is no consensus over the best method or the necessity of transfusion in specific surgical cases. This is an update of a Cochrane review first published in 2001. Objectives To determine whether there is evidence that preoperative blood transfusion in people with sickle cell disease undergoing elective or emergency surgery reduces mortality and perioperative or sickle cell-related serious adverse events. To compare the effectiveness of different transfusion regimens (aggressive or conservative) if preoperative transfusions are indicated in people with sickle cell disease. Search methods We searched for relevant trials in The Cochrane Library, MEDLINE (from 1946), Embase (from 1974), the Transfusion Evidence Library (from 1980), and ongoing trial databases; all searches current to 23 March 2016. We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register: 18 January 2016. Selection criteria All randomised controlled trials and quasi-randomised controlled trials comparing preoperative blood transfusion regimens to different regimens or no transfusion in people with sickle cell disease undergoing elective or emergency surgery. There was no restriction by outcomes examined, language or publication status. Data collection and analysis Two authors independently assessed trial eligibility and the risk of bias and extracted data. Main results Three trials with 990 participants were eligible for inclusion in the review. There were no ongoing trials identified. These trials were conducted between 1988 and 2011. The majority of people included had haemoglobin (Hb) SS SCD. The majority of surgical procedures were considered low or intermediate risk for developing sickle cell-related complications. Aggressive versus simple red blood cell transfusions One trial (551 participants) compared an aggressive transfusion regimen (decreasing sickle haemoglobin to less than 30%) to a simple transfusion regimen (increasing haemoglobin to 100 g/l). This trial re-randomised participants and therefore quantitative analysis was only possible on two subsets of data: participants undergoing cholecystectomy (230 participants); and participants undergoing tonsillectomy or adenoidectomy surgeries (107 participants). Data were not combined as we do not know if any participant received both surgeries. Overall, the quality of the evidence was very low across different outcomes according to GRADE methodology. This was due to the trial being at high risk of bias primarily due to lack of blinding, indirectness and the outcome estimates being imprecise. Cholecystectomy subgroup results are reported in the abstract. Results for both subgroups were similar. There was no difference in all-cause mortality between people receiving aggressive transfusions and those receiving conservative transfusions. No deaths occurred in either subgroup. There were no differences between the aggressive transfusion group and conservative transfusion group in the number of people developing: an acute chest syndrome, risk ratio 0.84 (95% confidence interval 0.38 to 1.84) (one trial, 230 participants, very low quality evidence);vaso-occlusive crisis, risk ratio 0.30 (95% confidence interval 0.09 to 1.04) (one trial, 230 participants, very low quality evidence);serious infection, risk ratio 1.75 (95% confidence interval 0.59 to 5.18) (one trial, 230 participants, very low quality evidence);any perioperative complications, risk ratio 0.75 (95% confidence interval 0.36 to 1.55) (one trial, 230 participants, very low quality evidence);a transfusion-related complication, risk ratio 1.85 (95% confidence interval 0.89 to 3.88) (one trial, 230 participants, very low quality evidence). Preoperative transfusion versus no preoperative transfusion Two trials (434 participants) compared a preoperative transfusion plus standard care to a group receiving standard care. Overall, the quality of the evidence was low to very low across different outcomes according to GRADE methodology. This was due to the trials being at high risk of bias due to lack of blinding, and outcome estimates being imprecise. One trial was stopped early because more people in the no transfusion arm developed an acute chest syndrome. There was no difference in all-cause mortality between people receiving preoperative transfusions and those receiving no preoperative transfusions (two trials, 434 participants, no deaths occurred). There was significant heterogeneity between the two trials in the number of people developing an acute chest syndrome, a meta-analysis was therefore not performed. One trial showed a reduced number of people developing acute chest syndrome between people receiving preoperative transfusions and those receiving no preoperative transfusions, risk ratio 0.11 (95% confidence interval 0.01 to 0.80) (65 participants), whereas the other trial did not, risk ratio 4.81 (95% confidence interval 0.23 to 99.61) (369 participants). There were no differences between the preoperative transfusion groups and the groups without preoperative transfusion in the number of people developing: a vaso-occlusive crisis, Peto odds ratio 1.91 (95% confidence interval 0.61 to 6.04) (two trials, 434 participants, very low quality evidence).a serious infection, Peto odds ratio 1.29 (95% confidence interval 0.29 to 5.71) (two trials, 434 participants, very low quality evidence);any perioperative complications, risk ratio 0.24 (95% confidence interval 0.03 to 2.05) (one trial, 65 participants, low quality evidence). There was an increase in the number of people developing circulatory overload in those receiving preoperative transfusions compared to those not receiving preoperative transfusions in one of the two trials, and no events were seen in the other trial (no meta-analysis performed). Authors’ conclusions There is insufficient evidence from randomised trials to determine whether conservative preoperative blood transfusion is as effective as aggressive preoperative blood transfusion in preventing sickle-related or surgery-related complications in people with HbSS disease. There is very low quality evidence that preoperative blood transfusion may prevent development of acute chest syndrome. Due to lack of evidence this review cannot comment on management for people with HbSC or HbSβ+ disease or for those with high baseline haemoglobin concentrations. PMID:27049331