Complications of adenotonsillectomy: a case report of meningitis due to dual infection with nontypeable Haemophilus influenzae and Streptococcus pneumoniae, and a prospective study of the rate of postoperative bacteremia

CASE REPORT

Bacterial meningitis is a rare complication of adenotonsillectomy. We present a case of meningitis due to nontypeable Haemophilus influenzae and Streptococcus pneumoniae after adenotonsillectomy. Pulsed-field gel electrophoresis patterns indicated that the oral cavity was the source of H. influenzae and S. pneumoniae isolated from the cerebrospinal fluid. BLOOD CULTURE STUDY: As bacteremia is thought to be one of the etiologies of meningitis, we prospectively investigated the rate of bacteremia as a complication of adenotonsillectomy. Of the 46 patients included in the study, mean age of five years old, 11 (24%) had positive blood cultures during the operation. H. influenzae was the commonest organism grown (seven cultures), three of seven produced beta-lactamase, followed by S. pneumoniae (one culture), H. parainfluenzae (one culture), Peptostreptococcus micros (one culture), and Veillonella spp. (one culture). The bacteria were composed of tonsil or adenoid surface cultures in eight of 11 patients (73%).

CONCLUSIONS

We present a rare case of meningitis complicating a adenotonsillectomy procedure, in a three years old boy. Meningitis is a rare complication of adenotonsillectomy, but bacteremia which may lead to meningitis occurs frequently, as the results.

Bilateral orbital preseptal cellulitis after combined adenotonsillectomy and strabismus surgery--case report and pathogenetic hypothesis

The first case of bilateral orbital preseptal cellulitis complicating combined adenotonsillectomy and strabismus surgery is reported. The issues of antimicrobial prophylaxis are discussed. The authors speculate about the possible routes of surgical site infection. Transient bacteraemia secondary to adenotonsillectomy may be theoretically a source of distant surgical site infection to the orbit, raising the issue of distant surgical site contamination during multidisciplinary surgery. Combined adenotonsillectomy and eye surgery might benefit from prophylactic systemic antibiotic administration.

[Clinical study of post-operative pain following coblation tonsillectomy and/or adenoidectomy in children with sleep-disordered breathing]

OBJECTIVE

To explore the characteristics of post-operative pain following coblation tonsillectomy and/or adenoidectomy in children with sleep-disordered breathing (SDB) and explore the correlation between the first day post-operative pain scores and age and operating time.

METHOD

1) A total of 113 SDB children scheduled to undergo coblation tonsillectomy and/or adenoidectomy were recruited. 113 children were divided into two groups according to the method of operation, children who underwent coblation tonsillectomy and adenoidectomy were enrolled in study group one and children who underwent coblation adenoidectomy only were in study group two. Be sides, children of study group one with a history of chronic tonsillitis were in chronic tonsillitis group, children without a history of chronic tonsillitis were in non-chronic tonsillitis group. 2) The parents scored pain in their children on a VAS (anchored by "no pain" at 0 and "worst pain" at 10) in the morning, before using any analgesics and having breakfast, over the first 3 and the seventh post-operative days. 3) Post-operative pain scores were compared between both the study group one and two and chronic tonsillitis group and non-chronic tonsillitis group. Futhermore, the correlation between the first day post-operative pain scores and age and operating time were also analysed.

RESULT

1) The difference of post-operative pain scores over the first 3 and the seventh post-operative days were significant between the study group one and group two (P<0.05). 2) Non-chronic tonsillitis group were significantly less painful than chronic tonsillitis group on day 1, day 2 and day 7 (z=-2.004, -2.059, -2.334, P<0.05). But there was no significant difference in pain levels on day 3 (P>0.05). 3) The first day post-operative pain scores was correlated with age (r=0.273, P<0.01) and operating time (r=0.423, P<0.01).

CONCLUSION

The first day post-operative pain scores was correlated with age and operating time. Children with a history of chronic tonsillitis were more painful than children without the history.

African American ethnicity as a risk factor for respiratory complications following adenotonsillectomy

OBJECTIVE

To evaluate whether African American ethnicity is a risk factor for major respiratory complications following adenotonsillectomy (T&A).

DESIGN

Retrospective cohort study.

SETTING

A Canadian tertiary care center. PATIENTS Children aged 0 to 18 years who underwent T&A at our institution from 2002 to 2006 with planned or unplanned postoperative admissions.

MAIN OUTCOME MEASURES

We evaluated the association between ethnicity and our main outcome measure, major perioperative respiratory complications of T&A. Parental report of ethnicity was available for 23% of our cohort. At our institution, African American children undergo a routine preoperative sickle cell test (TestSC). Data on TestSC were included for all children. We established that having a TestSC was an accurate proxy for African American ethnicity (sensitivity, 96%; specificity, 93%; positive predictive value, 77%; negative predictive value, 99%).

RESULTS

Seventy-four of 594 children experienced major respiratory complications (12.5%). Compared with children who did not have major respiratory complications, those who did had a TestSC (P = .01), were 2 years or younger (P < .001) and had lower weight-for-age z scores (P = .04), moderate to severe obstructive sleep apnea (P = .003), and comorbidities (P < .001). When controlling for these variables in a multivariate analysis, children of African American ethnicity (TestSC used as a proxy) were at higher risk of having major perioperative respiratory complications (adjusted odds ratio, 1.82 [95% CI 1.05-3.14]) (P = .003).

CONCLUSIONS

Children of African American ethnicity (TestSC used as a proxy) are nearly twice as likely to experience major respiratory complications related to T&A. Ethnicity may be an additional independent risk factor for clinicians to consider when planning for T&A.

Postadenoidectomy hemorrhage: a two-year prospective study

BACKGROUND/AIM

Although postoperative complications are rare, postadenoidectomy hemorrhage is one of the most frequent. The aim of this prospective study was to evaluate the incidence and timing of postadenoidectomy hemorrhage requiring hemostatic control under endotracheal anesthesia.

METHODS

A two-year prospective study of patients undergoing inpatient adenoidectomy, with (n = 462) or without tonsillectomy (n = 589), was undertaken. Surgery was performed in endotracheal anesthesia using an adenoid curette. Every bleeding event which needed procedure in general anesthesia for its treatment was recorded. The timing of postadenoidectomy hemorrhage was classified as primary or secondary.

RESULTS

Severe bleeding following adenoidectomy with tonsillectomy which needed hemostatic control under endotracheal anesthesia occurred in only 0.19% (2/1051) patients (average age = 7.5 years). Postadenoidectomy hemorrhage was primary in both of the patients.

CONCLUSION

Severe postoperative hemorrhage requiring hemostasis under endotracheal anesthesia can be expected in a small number of children undergoing adenoidectomy with tonsillectomy.

[Subcutaneous emphysema after adenotonsillectomy]

Adenotonsillectomy is a commonly performed procedure in otorhinolaryngology departments. A rare complication is cervicofacial subcutaneous emphysema, that often resolves spontaneously, but may progress to obstruct upper airways or spread to the thorax causing pneumomediastinum or pneumothorax and impair cardiorespiratory function. A case of cervicofacial emphysema in a young woman undergoing routine adenotonsillectomy is presented, and possible mechanisms and treatment options are discussed.

Randomised comparative study of adenotonsillectomy by conventional and coblation method for children with obstructive sleep apnoea

INTRODUCTION

Adenotonsillectomy is one of the most common surgical procedures throughout the world for children in otolaryngology. One of the current indications for adenotonsillectomy is adenotonsillar hypertrophy causing Obstructive Sleep Apnoea (OSA). The choice of surgical tools and technique affects the outcome and morbidity due to adenotonsillectomy.

AIM OF THE STUDY

To assess the efficacy and safety of coblation adenotonsillectomy as compared to dissection method. To evaluate the morbidity and to study complications associated with each procedure.

MATERIALS AND METHODS

This prospective and comparative study of dissection and coblation method of adenotonsillectomy was conducted in our institute, Madras ENT Research Foundation, Chennai over a period of 6 months. 50 cases of children with OSA age group between 5 and 12 years were randomly selected for each group and studied. Duration of surgical procedure, blood loss, post operative pain, post operative reactionary and secondary bleeding was noted and compared.

OBSERVATION AND RESULTS

Operative time was more in dissection method compared to coblation technique. Blunt dissection tonsillectomy was associated with greater blood loss than coblation tonsillectomy. Post operative pain was more in dissection method and it was less in coblation technique. Post operative bleeding in both the techniques were found to be minimal.

CONCLUSION

We conclude that the use of coblation for adenotonsillectomy may have several advantages over standard methods for the treatment of children with Obstructive Sleep Apnoea. It is highly efficacious, practical and safe with less morbidity and less complications.

Steroids for improving recovery following tonsillectomy in children

BACKGROUND

This is an update of a Cochrane Review first published in The Cochrane Library in Issue 1, 2003.Tonsillectomy continues to be one of the most common surgical procedures performed worldwide. Despite advances in anesthetic and surgical techniques, post-tonsillectomy morbidity remains a significant clinical problem.

OBJECTIVES

To assess the clinical efficacy of a single intraoperative dose of dexamethasone in reducing post-tonsillectomy morbidity.

SEARCH STRATEGY

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; BIOSIS Previews; Cambridge Scientific Abstracts; ISRCTN; and additional sources for published and unpublished trials. The date of the most recent search was 29 October 2010, following a previous search in September 2002.

SELECTION CRITERIA

Randomized, double-blind, placebo-controlled trials of a single dose of intravenous, intraoperative corticosteroid for pediatric patients (age < 18 years) who underwent tonsillectomy or adenotonsillectomy.

DATA COLLECTION AND ANALYSIS

The first author extracted data regarding the primary outcome measures and measurement tools from the published studies. The first author also recorded data regarding study design, patient ages, procedures performed, dose of corticosteroid and method of delivery, as well as methodological quality. When data were missing from the original publications, we contacted the authors for more information. We performed data analysis with a random-effects model, using the RevMan 5.1 software developed by the Cochrane Collaboration.

MAIN RESULTS

We included 19 studies (1756 participants). We selected only randomized, placebo-controlled, double-blinded studies to minimize inclusion of poor quality studies. However, the risk of bias in the included studies was not formally assessed. Children receiving a single intraoperative dose of dexamethasone (dose range = 0.15 to 1.0 mg/kg) were half as likely to vomit in the first 24 hours compared to children receiving placebo (risk ratio (RR) 0.49; 95% confidence interval (CI) 0.41 to 0.58; P < 0.00001). Routine use in five children would be expected to result in one less patient experiencing post-tonsillectomy emesis (risk difference (RD) -0.24; 95% CI -0.32 to -0.15; P < 0.00001). Children receiving dexamethasone were also more likely to advance to a soft/solid diet on post-tonsillectomy day one (RR 1.45; 95% CI 1.15 to 1.83; P = 0.001) than those receiving placebo. Finally, postoperative pain was improved in children receiving dexamethasone as measured by a visual analog scale (VAS, 0 to 10) (MD -1.07; 95% CI -1.73 to -0.41; P = 0.001), which correlates clinically to a reduction in pain (on a VAS of 0 to 10) from 4.72 to 3.65. No adverse events were noted in the included studies.

AUTHORS' CONCLUSIONS

The evidence suggests that a single intravenous dose of dexamethasone is an effective, safe and inexpensive treatment for reducing morbidity from pediatric tonsillectomy.

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

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).

[Analysis of the causes of immediate bleeding after pediatric adenoidectomy]

OBJECTIVE

To evaluate the incidence of postoperative hemorrhage in children undergoing adenoidectomy, and to discuss its possible causes.

METHODS

Included in this study were children who underwent adenoid and/or tonsil surgery at Shenzhen Children's Hospital between January 2004 and November 2009. The change of hemoglobin (Hb) and hematocrit (Hct) were retrospectively analysed. The blood loss was estimated by the change of Hct.

RESULTS

There were 2078 cases that accomplished the inclusion criteria in the period of study. Ten children bled 0.5 - 4.0 hours after surgery, without superfluous hemorrhage during the operation and post-tonsillectomy. This represented an incidence of 0.48%of immediate postoperative haemorrhage among the 2078 procedures analyzed. Statistical differences were found between boys (0.21%) and girls (1.10%, χ² = 5.597, P < 0.05). The change of Hb and Hct was positively correlated (r = 0.95, P < 0.01), the blood loss was positively correlated with the bleeding time (r = 0.66, P < 0.05). The causes of postoperative hemorrhage were coagulation system deficits, chronic nasopharyngitis, deficient hemostasis and immoderate ravage. To control the postoperative hemorrhage, 2 postnasal packing under topical anaesthesia and 8 electrocautery under general anaesthesia were applied.

CONCLUSIONS

Poor operative technique and deficient hemostasis are the major causes of primary hemorrhage. Prompt operation to control the postoperative bleeding should be done 2 hours after bleeding under general anesthesia in order to avoid severe complications.

Practice parameters for the respiratory indications for polysomnography in children

BACKGROUND

There has been marked expansion in the literature and practice of pediatric sleep medicine; however, no recent evidence-based practice parameters have been reported. These practice parameters are the first of 2 papers that assess indications for polysomnography in children. This paper addresses indications for polysomnography in children with suspected sleep related breathing disorders. 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 American Academy of Neurology grading system was used to assess the quality of evidence. RECOMMENDATIONS FOR PSG USE: 1. Polysomnography in children should be performed and interpreted in accordance with the recommendations of the AASM Manual for the Scoring of Sleep and Associated Events. (Standard) 2. Polysomnography is indicated when the clinical assessment suggests the diagnosis of obstructive sleep apnea syndrome (OSAS) in children. (Standard) 3. Children with mild OSAS preoperatively should have clinical evaluation following adenotonsillectomy to assess for residual symptoms. If there are residual symptoms of OSAS, polysomnography should be performed. (Standard) 4. Polysomnography is indicated following adenotonsillectomy to assess for residual OSAS in children with preoperative evidence for moderate to severe OSAS, obesity, craniofacial anomalies that obstruct the upper airway, and neurologic disorders (e.g., Down syndrome, Prader-Willi syndrome, and myelomeningocele). (Standard) 5. Polysomnography is indicated for positive airway pressure (PAP) titration in children with obstructive sleep apnea syndrome. (Standard) 6. Polysomnography is indicated when the clinical assessment suggests the diagnosis of congenital central alveolar hypoventilation syndrome or sleep related hypoventilation due to neuromuscular disorders or chest wall deformities. It is indicated in selected cases of primary sleep apnea of infancy. (Guideline) 7. Polysomnography is indicated when there is clinical evidence of a sleep related breathing disorder in infants who have experienced an apparent life-threatening event (ALTE). (Guideline) 8. Polysomnography is indicated in children being considered for adenotonsillectomy to treat obstructive sleep apnea syndrome. (Guideline) 9. Follow-up PSG in children on chronic PAP support is indicated to determine whether pressure requirements have changed as a result of the child's growth and development, if symptoms recur while on PAP, or if additional or alternate treatment is instituted. (Guideline) 10. Polysomnography is indicated after treatment of children for OSAS with rapid maxillary expansion to assess for the level of residual disease and to determine whether additional treatment is necessary. (Option) 11. Children with OSAS treated with an oral appliance should have clinical follow-up and polysomnography to assess response to treatment. (Option) 12. Polysomnography is indicated for noninvasive positive pressure ventilation (NIPPV) titration in children with other sleep related breathing disorders. (Option) 13. Children treated with mechanical ventilation may benefit from periodic evaluation with polysomnography to adjust ventilator settings. (Option) 14. Children treated with tracheostomy for sleep related breathing disorders benefit from polysomnography as part of the evaluation prior to decannulation. These children should be followed clinically after decannulation to assess for recurrence of symptoms of sleep related breathing disorders. (Option) 15. Polysomnography is indicated in the following respiratory disorders only if there is a clinical suspicion for an accompanying sleep related breathing disorder: chronic asthma, cystic fibrosis, pulmonary hypertension, bronchopulmonary dysplasia, or chest wall abnormality such as kyphoscoliosis. (Option) RECOMMENDATIONS AGAINST PSG USE: 16. Nap (abbreviated) polysomnography is not recommended for the evaluation of obstructive sleep apnea syndrome in children. (Option) 17. Children considered for treatment with supplemental oxygen do not routinely require polysomnography for management of oxygen therapy. (Option)

CONCLUSIONS

Current evidence in the field of pediatric sleep medicine indicates that PSG has clinical utility in the diagnosis and management of sleep related breathing disorders. The accurate diagnosis of SRBD in the pediatric population is best accomplished by integration of polysomnographic findings with clinical evaluation.

Intravenous and peritonsillar infiltration of ketamine for postoperative pain after adenotonsillectomy: a randomized placebo-controlled clinical trial

OBJECTIVE

To evaluate the efficacy of preoperative intravenous or peritonsillar infiltration of ketamine for postoperative pain control in children following adenotonsillectomy.

PATIENTS AND METHODS

78 children between 5 and 18 years of age who were scheduled for elective adenotonsillectomy were randomly assigned to four groups: group 1 (n = 19) received intravenous ketamine (0.5 mg/kg), group 2 (n = 21) intravenous normal saline, group 3 (n = 19) ketamine (0.5 mg/kg) injected through the tonsillar capsule, and group 4 (n = 19) normal saline injected in the same location. The incidence of postoperative pain and vomiting as well as the severity of postoperative pain were compared between study groups during the 6-hour postoperative period using a visual analog scale (VAS) at rest, upon swallowing saliva, drinking liquids and eating ice cream.

RESULTS

There were no demographic differences between the four groups. The incidence of postoperative pain was significantly lower in groups 1 [7 (36.8%) vs. 10 (47.6%); p = 0.032] and 3 [5 (31.5%) vs. 12 (63.2%); p = 0.001] compared with their controls. The amount (in milligrams) of pethidine and metoclopramide used for pain and nausea control was significantly lower in groups 1 (12.5 ± 5.3 vs. 19.6 ± 9.6 mg, p = 0.038, and 2.9 ± 1.1 vs. 4.6 ± 2.6 mg, p = 0.042, respectively) and 3 (8.6 ± 3.1 vs. 21.6 ± 8.4 mg, p < 0.001, and 1.6 ± 0.9 vs. 5.3 ± 3.2 mg, p = 0.002, respectively) compared with their controls. These values were also higher in group 1 compared with group 3. The VAS scores on swallowing saliva (3.9 ± 2.7 vs. 2.7 ± 1.2; p = 0.018), on drinking liquids (3.7 ± 2.6 vs. 2.8 ± 1.6; p = 0.013) and on eating ice-cream (4.3 ± 2.4 vs. 2.8 ± 1.5; p = 0.001) were also significantly higher in group 1 compared with group 3.

CONCLUSIONS

Our results show that peritonsillar infiltration of ketamine was more effective in reducing the postoperative pain severity, need for analgesics and need for antiemetics. Thus, peritonsillar infiltration of ketamine is suggested for postoperative pain control in those undergoing adenotonsillectomy.

Postoperative bleeding in paediatric ENT surgery. First results of the German ESPED trial

Bleeding after ear-nose-and throat surgery in children is a serious complication. With the help of the German Surveillance Unit for Rare Paediatric Disorders (Erhebungseinheit für seltene pädiatrische Erkrankungen in Deutschland; ESPED) a two year survey was performed to record the incidence, severity, reasons and treatment of haemorrhages. During the study period, 1069 bleeds were reported from 720 paediatric hospitals and departments of otorhinolaryngology after adenoidectomy and tonsillectomy. 713 reports could be analyzed. Two deaths occurred after adenoidectomy. Although laboratory screening was performed in more than 70% of all cases, bleeding complications were neither foreseeable nor preventable. Inherited coagulopathies were rare and in most cases not detected, neither by laboratory screening nor by taking a history. Since preoperative measures cannot help much to improve the situation, all efforts have to be taken to improve the postoperative period, especially since more than 20% of the hemorrhages occurred during weekends. Guidelines on postoperative care and behaviour should therefore be implemented and parents and patients must be informed on bleeding risks and on what to do in case of emergency. If bleeding occurs, extensive coagulation testing is mandatory.

A review of malpractice cases after tonsillectomy and adenoidectomy

OBJECTIVE

To examine sources of litigation following tonsillectomy and/or adenoidectomy.

STUDY DESIGN

Analysis of malpractice claims filed after tonsillectomy or adenoidectomy provided by 16 medical liability insurance companies.

SETTING

Not applicable.

SUBJECTS AND METHODS

Data was obtained from 16 members of the Physician Insurers Association of America. All claims were either filed or closed between 1985 and 2006. Claims were evaluated and categorized according to the type of complication.

RESULTS

One hundred and fifty-four claims were identified between 1985 and 2006. Six categories were created based on frequency of claims (bleeding complication n=27 [17.5%], airway fire n=2 [1.5%], burns n=28 [18.2%], consent related n=9 [5.8%], medication related n=9 [5.8%] and residual tissue/recurrence n=9 [5.8%]). Other less frequent claims were grouped as miscellaneous n=70 [45.5%].

CONCLUSIONS

A significant portion of malpractice claims following tonsillectomy or adenoidectomy are related to complications not commonly discussed in the literature.

Changes in growth pattern after adenotonsillectomy in children under 12 years old

The aim of the present study was to determine the effects of adenotonsillectomy on height, weight and body mass index (BMI) in children under 12 years old, with or without airway obstruction and evaluation of the risk of overweight in them. In this case-control study, 120 children with the age of 2-12 years old were studied; 60 children as case group who underwent adenotonsillectomy and 60 healthy children as control group. After collecting the data related to appetite status and sleep breathing disorder of the case group, height, weight and BMI have been measured for all children in two stages; preoperatively and 6 months later. Also in the case group, BMI percentiles, pre and postoperatively have been calculated. Patients with Low appetite in the initiation and at the end of the study in the case group were 80% and 8.3% respectively (P=0.01). Mean of height, weight and BMI variation after 6 months were significantly different between case and control groups (P<0.05). BMI percentiles in the case group preoperatively were: 20% underweight, 67% healthy weight, 10% at risk of over weight, 3% over weight. Postoperatively, after 6 months BMI percentiles in order of above frequency were: 10%, 57%, 22% and 11% (P=0.02). Analysis of the results showed that adenotonsillectomy can lead to increase of height, weight, BMI and appetite not only in the children with low weight due to airway obstruction but also in the normal weight and over weight children. Therefore risk of overweight should be mentioned as a probable undesirable outcome of adenotonsillectomy.

[A preliminary study of the secondary postoperative haemorrhage in pediatric coblation adenotonsillectomy]

OBJECTIVE

To compare secondary postoperative haemorrhage rate of coblation with the conventional pediatric adenotonsillectomy. And to analyze possible reasons which cause the secondary bleeding after coblation adenotonsillectomy.

METHODS

A retrospective study was applied to compare the secondary postoperative haemorrhage rate and the bleeding moment between two groups in which 1-14 years old children from April 2005 to September 2009 in Guangzhou Children's Hospital were included. Group A was pediatric patients who had conventional adenoidectomy and/or tonsillectomy (dissection, without heat damage to the tissue) from April 2005 to July 2006 in Department of Otorhinolaryngology. Group B was pediatric patients who had coblation adenoidectomy and/or tonsillectomy from April 2008 to September 2009 in Department of Otorhinolaryngology.

RESULTS

Two of 484 cases in group A had secondary postoperative bleeding, the rate was 0.4%. One happened 2 days after operation, another after 3 days. Eleven of 502 cases in group B had secondary postoperative bleeding, the rate was 2.2%. Secondary bleeding happened 2 to 12 days after surgery, median 6.0 days. The secondary postoperative haemorrhage rate of operating by the freshman was 2.6%(10/385), and it was 0.9%(1/117) by the senior. The rate of secondary bleeding was higher in group B than group A (chi(2) = 5.987, P < 0.05). There was no significant difference of secondary bleeding time in both groups (Mann-Whitney U score was 2.500, P > 0.05). Six of 13 cases who had secondary bleeding suffered wound or upper respiratory tract infection. Three of 13 ate inappropriately after the operation.

CONCLUSIONS

Pediatric coblation adenotonsillectomy is a new method. The most possible reasons of secondary bleeding are poor surgery skills and ill experience. And, infection, inappropriate eating after the operation may be the other reasons of secondary bleeding.

[Hypoxaemia and bradycardia in children during guillotine adenotonsillectomy without intubation]

OBJECTIVE

To study the incidence of hypoxaemia and bradycardia in children who undergo guillotine adenotonsillectomy in a sitting position, without intubation and under inhalation anaesthesia.

DESIGN

Retrospective study.

METHOD

Analysis of age, weight, sex, oxygen saturation, heart rate and subsequent bleeding in all children up to the age of 11 years who underwent guillotine adenotonsillectomy in the period December 1999 to December 2007. Hypoxaemia was defined as oxygen saturation of less than 85% for longer than 60 s. Bradycardia was defined as a heart rate of less than 60/min for longer than 30 s.

RESULTS

We analysed data from 2963 patients. The mean age was 4.7 years and mean weight 18.8 kg. There was no significant relationship between age, weight and the onset of incidental desaturation or bradycardia. A total of 132 patients (4.5%) had hypoxaemia and 280 patients (9.4%) had bradycardia. Twenty-five patients had both hypoxaemia and bradycardia, of whom 3 (0.1%) had bradycardia immediately following hypoxaemia. In none of the recorded episodes of hypoxaemia and bradycardia did this lead to peri- or postoperative complications.

CONCLUSION

Hypoxaemia and bradycardia occurred during guillotine adenotonsillectomy in non-intubated children in a sitting position under inhalation anaesthesia. The simultaneous onset of hypoxaemia and bradycardia is rare, however, and does not lead to perioperative complications. A further study is required using adenotonsillectomy with a large number of intubated and non-intubated children in order to compare the incidence of hypoxaemia and bradycardia and the occurrence of complications.

Determination of optimum dosage of intraoperative single dose dexamethasone in pediatric tonsillectomy and adenotonsillectomy

OBJECTIVE

Our objective is to determine the optimum dosage of intraoperative single dose dexamethasone and its effect upon postoperative morbidity in pediatric tonsillectomy and adenotonsillectomy patients.

STUDY DESIGN AND METHODS

Totally 150 pediatric patients whom underwent adenotonsillectomy or tonsillectomy surgery are offered to participate in this study at otorhinolaryngology clinic between 2002 and 2003. 150 patients are divided into three randomized groups, each composed of fifty patients. Anesthesia protocol is standardized in each group and 0.2 mg/kg intraoperative dexamethasone is given to first group, 0.7 mg/kg (maximum dose 25 mg) intraoperative dexamethasone is given to second group and third group is accepted as control group without giving any intravenous dexamethasone. Each group is compared for postoperative nausea, vomiting and tolerability to take oral foods within first 24h with the same questionnaire.

RESULTS

There is significantly higher ratio of postoperative nausea and vomiting within first 24h in group III (80%) when compared with group I (8%) (p: 0.001; p<0.01) and group II (4%) (p: 0.001; p<0.01). Also there is significantly higher ratio of patient's tolerability to take oral semisolid/solid foods within postoperative first 24h in group II (94%) when compared with group I (58%) (p: 0.001; p<0.01) and group III (12%) (p: 0.001; p<0.01). We didn't encounter any side effect of dexamethasone in group I and II.

CONCLUSIONS

We thought that 0.7 mg/kg dosage of IV dexamethasone is much a preferable choice depending of its effectiveness on decreasing postoperative morbidity rather than 0.2 mg/kg dosage and beside to this advantage we didn't encounter any side effects.

Surgical emergencies in pediatric otolaryngology

OBJECTIVE

To obtain baseline data on the most common surgical emergencies in pediatric otolaryngology in Saudi Arabia.

METHODS

This report is a retrospective study of all children presenting to the pediatric otolaryngology emergency service at King Abdulaziz University Hospital in Riyadh, Kingdom of Saudi Arabia. Between January 2001 to January 2006 data were carefully collected and then analyzed for patients requiring emergent surgical intervention by the pediatric otolaryngology service.

RESULTS

A total of 15,850 children presented to our pediatric otolaryngology emergency service. Surgical intervention was indicated in 183 children (1.2%). The larynx/head & neck was the most common site involved. Foreign body related emergencies were the most common presentation requiring surgical interventions (42%). The aero-digestive tract was the most common site for foreign body retrieval (54%).

CONCLUSION

Pediatric patients have always constituted a significant portion of the general otolaryngology service. Most pediatric otolaryngology emergencies are relatively benign. Aero-digestive tract foreign bodies are the most common indication for surgical intervention in ped iatric otolaryngology.

The prophylactic effect of rectal acetaminophen on postoperative pain and opioid requirements after adenotonsillectomy in children

BACKGROUND

Postoperative pain in children is common after adenotonsillectomy. Rectal acetaminophen has been used effectively for postoperative pain management in small children. The aim of this randomized double blind study was to evaluate the prophylactic effect of rectal acetaminophen on postoperative pain management and opioid requirements in children undergoing adenotonsillectomy.

MATERIALS AND METHODS

104 children, 7 to 15 yr, ASA I or II scheduled for elective adenotonsillectomy were recruited for the study. Patients were randomized to receive either rectal acetaminophen 40 mg/kg or nothing after induction of standard anesthesia. The postoperative pain was assessed using visual analog scale (VAS) every 2 hours for the first 6 hours. The need for rescue analgesic, intravenous pethedine of 0.5 mg/kg, was recorded at 24 hours after surgery.

RESULTS

Pain scores were significantly lower in acetaminophen group at different times (p<0.001) and needed less rescue analgesic (p<0.001).

CONCLUSION

We conclude that prophylactic rectal acetaminophen is effective in reducing pain after adenotonsillectomy and postoperative analgesic requirement.

Cine Magnetic Resonance Imaging: Evaluation of Persistent Airway Obstruction after Tonsil and Adenoidectomy in Children with Down Syndrome

OBJECTIVE/HYPOTHESIS

Although usually successful, not all obstructive sleep apnea is cured by removal of the tonsils and adenoids (T&A). This is particularly true in children with Down syndrome and craniofacial anomalies. This is because of the multiple levels of obstruction in their airways, with obstruction present not only at the level of the tonsils and adenoids but also from base of tongue obstruction, soft palate collapse, and hypopharyngeal collapse. The cine magnetic resonance image (MRI) is useful in evaluating the upper airway in those patients who have not achieved a normal polysomnogram after T&A surgery.

STUDY DESIGN

Prospective case series.

METHODS

Fifteen children with Down syndrome who had previously undergone a T&A but continued to have abnormal postoperative polysomnograms underwent a cine MRI with fast gradient cine MRI images.

RESULTS

The cine MRI identified different areas and levels of obstruction that ultimately affected the children's treatment courses. Recurrent adenoid tissue, glossoptosis, soft palate collapse, hypopharyngeal collapse, and enlarged lingual tonsils were identified. The results as well as several illustrative cases are presented.

CONCLUSION

Cine MRI evaluates upper airway obstruction in children who may have multiple sources of obstruction causing their obstructive sleep apnea. This is particularly helpful in children with Down syndrome and craniofacial anomalies. This technology is useful in all children with complex upper airway obstruction.

Retraction Notice: Current Management of Vomiting after Tonsillectomy in Children

Formal retraction notice of article entitled Current Management of Vomiting after Tonsillectomy in Children (Curr Drug Saf. 2009 Jan;4(1):62-73) by Dr Y. Fujii. This article is being retracted as a result of: Failure of Dr. Fijii's institution as well as of himself to rationalize the legitimacy of the study and/or its data as stipulated in request by the Editors-in-Chief of the journals extended on April 9, 2012.

Major haemorrhage related to surgery in patients with type 1 and possible type 1 von Willebrand disease

Patients with von Willebrand disease (VWD) frequently bleed under a challenge. The aim of our study was to identify predictive markers of perioperative major haemorrhage in type 1 (VWF:RCo = 15-30 IU dl(-1)) and possible type 1 (VWF:RCo = 31-49 IU dl(-1)) VWD patients. We recorded perioperative bleeding complications previous to diagnosis and laboratory parameters in 311 patients with 498 surgical procedures. The patients were grouped according to the absence (A) or presence (B) of perioperative major haemorrhages. Eighty-one patients (26%) and 87 surgical procedures (17.5%) presented major haemorrhages associated with surgeries. There was no difference between the percentage of type 1 and possible type 1 VWD patients who had major haemorrhages (32.6% and 24.8% respectively; p = ns). No difference in the prevalence of O blood group, age, gender, positive family history and laboratory test results (FVIII and VWF) was observed, independent of the haemorrhagic tendency. Bleeding after tooth extraction was the most frequent clinical feature observed in patients with perioperative major haemorrhages. The bleeding score and the number of bleeding sites (> or = 3) were not predictors of major haemorrhage associated with surgery. Caesarean section and adenotonsillectomy showed the highest frequency of major haemorrhages (24.6% and 22.3%, respectively). In conclusion, type 1 and possible type 1 VWD patients showed similar incidence of perioperative major haemorrhages. Laboratory tests and positive family history did not prove to be effective at predicting major haemorrhages in patients that had either type 1 or possible type 1 VWD. The history of bleeding after tooth extraction could define risk factors of major haemorrhage.