A retrospective study of tonsillectomy in the under 2-year-old child: indications, perioperative management, and complications

OBJECTIVE

To retrospectively review the experience with tonsillectomy in the under 2-year-old child at an urban children's hospital.

METHODS

The medical records of 94 patients under 2 years old undergoing tonsillectomy between May 1, 1995, and May 31, 2000, were reviewed. The methods of tonsil and adenoid excision were noted, as was the use of perioperative steroids, antibiotics, and antiemetics. Outcome measures studied included the duration of postoperative inpatient observation, complications, time to first oral intake, prevalence of postoperative vomiting, type and duration of respiratory support, and improvement relative to operative indications.

RESULTS

Eighty-two patients (87%) underwent tonsillectomy and adenoidectomy (T&A). Twelve patients (13%) underwent tonsillectomy without adenoidectomy. Patient ages ranged from 12 to 23 months (mean 19.6+/-3.1). Indications included obstructive sleep apnea (OSA) in 51 patients (54%), chronic or recurrent tonsillitis in 30 (32%), both OSA and infection in 11 (12%), and acute tonsillitis with airway obstruction in two (2%). Comorbid conditions were numerous. Preoperative polysomnograms were obtained for eight patients (8%). Hospital stays ranged from 4 h to 16 days. Complications included hemorrhage in four patients (4%) and pneumonia in two (2%). Oxygen was required after discharge from the recovery room in 27 patients (29%), with seven more (7%) requiring either reintubation, continuous positive airway pressure, or nasopharyngeal airways. Of the 88 patients on oral diets, only five (5%) took longer than 24 h to resume oral intake. Two patients (2%) experienced significant emesis after surgery. Four patients (4%) required treatment for dehydration after discharge.

CONCLUSIONS

Tonsillectomy is a procedure with low morbidity in the otherwise healthy child under 2 years of age. However, we advocate routine postoperative overnight inpatient observation in this age group. We found that young children with comorbid conditions had a higher incidence of complications and required special postoperative management strategies.

Outcomes in suction coagulator adenoidectomy

OBJECTIVES

To assess the feasibility of suction coagulator adenoidectomy relative to adenoid size and to document patient-based outcomes and satisfaction with surgery.

DESIGN

Historical cohort study.

SETTING

Referral-based academic pediatric otolaryngology practice.

PARTICIPANTS

Consecutive series of 118 children older than 3 years (mean age, 6.5 years) undergoing adenoidectomy alone.

INTERVENTION

Video nasopharyngoscopy followed by suction coagulator adenoidectomy as part of routine clinical care. An outcome survey was completed by telephone.

OUTCOME MEASURES

Duration of surgery, estimated blood loss, complications, parent satisfaction, and clinical outcomes.

RESULTS

The distribution of preoperative adenoid grades as determined by nasal endoscopy were as follows: grade 2 (>or=33% to <66% choanal obstruction), 7%; grade 3 (>or=66% to <90% obstruction), 48%; and grade 4 (90%-100% obstruction), 45%. The mean (SD) surgical time of 10.5 (3.0) minutes was unrelated to adenoid grade (R = 0.014; P =.88). All blood loss was less than 15 mL (<5 mL for 67%), and the only complication was a loose tooth. The parents of 98 patients (83%) were contacted a mean of 30.4 days after surgery: 95 (97%) reported less-labored breathing, and 94 (96%) were satisfied with the surgical results. Only 5 patients (5%) required a follow-up visit within 30 days of surgery.

CONCLUSIONS

Suction coagulator adenoidectomy proved safe and rapid, regardless of the adenoid size. Surgical outcomes were very favorable, with nearly all parents reporting satisfaction with the procedure and improvement in their child's breathing.

Delayed infection, late tonsillectomy or adenoidectomy and adult leukaemia: a case-control study

In a population-based case-control study among adults in Italy, of 261 lymphoid and 313 myeloid leukaemias and 1718 controls, a later age at adenoidectomy and tonsillectomy (after age 10 years) increased considerably the risk of lymphocytic (but not myeloid) leukaemia (odds ratio 4.2, 95% confidence interval 1.1-16.2). We propose that late infection is a proliferative stimulus for B-cells.

Post-tonsillectomy and -adenoidectomy hemorrhage in nonselected patients

This retrospective study was undertaken to evaluate the incidence of hemorrhage in nonselected patients requiring surgical treatment after adenoidectomy (group 1; 7,785 patients) or tonsillectomy with or without adenoidectomy (group 2; 6,794 patients). Postoperative bleeding from the tonsillar fossae occurred in 200 patients (2.94%). Primary hemorrhage (< 24 hours) clearly prevailed in groups 1 (86%) and 2 (78%). There was 1 case with a lethal outcome following tonsillectomy (0.007%). Bleeding from the epipharynx occurred in 17 patients of group 1 (0.21%). A total of 5 patients received blood transfusions, all of them belonging to group 2 (0.07%). The latest bleeding occurred 6 days (adenoidectomy) and 18 days (tonsillectomy) after surgery. Hemorrhage following both procedures is a rare complication predominantly occurring several hours after surgery and in nonselected patients. Male gender, age over 70 years, infectious mononucleosis, and a history of recurrent tonsillitis were found to be risk factors for posttonsillectomy hemorrhage.

Steroids for improving recovery following tonsillectomy in children

BACKGROUND

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 intra-operative dose of dexamethasone in reducing post-tonsillectomy morbidity.

SEARCH STRATEGY

We searched the Cochrane Controlled Trials Register (Issue 1, 2002), MEDLINE (from 1966 - February 2002), EMBASE (from 1974 - February 2002) and reference lists of relevant articles. We contacted leading experts for information on any relevant unpublished data.

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

Data regarding the primary outcome measures and measurement tools were extracted by the first author from the published studies. Data regarding study design, patient ages, procedures performed, dose of corticosteroid and method of delivery, as well as methodologic quality were also recorded by the first author. When data were missing from the original publications, the authors were contacted for more information. Data analysis was performed with a random effects model, using the RevMan 4.1 software developed by the Cochrane Collaboration.

MAIN RESULTS

Children receiving a single intra-operative dose of dexamethasone (dose range = 0.15 to 1.0 mg/kg; maximum dose range = 8 to 25 mg) were two times less likely to vomit in the first 24 hours than children receiving placebo (RR = 0.54, CI95 = 0.42, 0.69; p < 0.00001). Routine use in four children would be expected to result in one less patient experiencing post-tonsillectomy emesis (RD = -0.25, CI95 = -0.37, -0.13; p = 0.00004). Additionally, children receiving dexamethasone were more likely to advance to a soft/solid diet on post-tonsillectomy day 1 (RR = 1.69, CI95 = 1.02, 2.79; p = 0.04) than those receiving placebo. Due to missing data and varied outcome measurement tools, pain could not be meaningfully analyzed as a distinct outcome measure.

REVIEWER'S CONCLUSIONS

The evidence suggests that a single intravenous dose of dexamethasone is an effective, relatively safe and inexpensive treatment for reducing morbidity from pediatric tonsillectomy. No adverse events attributable to dexamethasone were reported in these trials. Additionally, in our 10-year experience of routine use of a single intravenous dose of dexamethasone during pediatric tonsillectomy, there have been no attributable, adverse events. Lastly, we found no reports in the literature of complications from use of a single intravenous dose of corticosteroid during pediatric tonsillectomy.

A comparison of two transfusion regimens in the perioperative management of children with sickle cell disease undergoing adenotonsillectomy

Adenotonsillar hypertrophy and chronic tonsillitis are common findings in patients with sickle cell disease (SCD). Various preoperative transfusion regimens have been suggested to reduce the population of sickle erythrocytes and correct the anemia, ranging from conservative (correcting the anemia) to aggressive (lowering the level of HbS to less than 30%). A total of 39 patients with SCD were included in the study. They were divided into 2 groups. Fourteen patients in group 1 were assigned aggressive exchange transfusion and 25 patients in group 2 were assigned a conservative (simple) transfusion. The 2 groups were compared for possible operative and postoperative complications. Thirty percent of patients in both groups had postoperative complications. They ranged from mild local infection to acute chest syndrome. Simple transfusion was not associated with higher incidence of complications and resulted in only one-third as many transfusion requirements.

Bacteremia during adenoidectomy

OBJECTIVE

Although adenoidectomy is one of the most commonly performed surgical procedures in children, there is no satisfactory information about the risk of bacteremia during adenoidectomy and necessity of antibiotic use. The aim of this study was to determine the incidence of bacteremia during adenoidectomy and identify the organisms leading to bacteremia.

METHODS

Thirty two patients who had undergone adenoidectomy at ENT Clinic of Sutcu Imam University were included in the study. They had received no antimicrobial therapy for at least 20 days before surgery. Adenoidal surface and deep tissue cultures were taken and venous blood samples were obtained for cultures before and immediately after adenoidectomy in which adenoid was removed with a curette.

RESULTS

While none of the blood cultures taken preoperatively was positive for any organisms, the cultures obtained postoperatively were positive in only two of 32 patients included in the study.

CONCLUSION

The results of this study suggest that there is an extremely low incidence of bacteremia during adenoidectomy. As a result, it may be concluded that the use of prophylactic antibiotics to prevent bacteremia or its complications is unnecessary unless the patient has a predisposing factor for cardiac infection like prosthetic valve replacement.

Postoperative behavioral changes in children after adenoidectomy

BACKGROUND

Pain is a common complaint after adenoidectomy. Behavioral changes after adenoidectomy in children have been reported, and it has been concluded that postoperative pain significantly affects the occurrence of behavioral changes. Behavioral changes, when a proactive pain treatment has been used, have not been systematically studied.

OBJECTIVE

To assess postoperative behavioral changes in children who have undergone day-case adenoidectomy with proactive pain treatment.

DESIGN

Prospective, longitudinal, randomized clinical trial.

SETTINGS

Ambulatory Care Unit, Department of Otorhinolaryngology, Kuopio University Hospital, Kuopio, Finland.

PATIENTS

Three hundred consecutive children, aged 1 to 10 years, who underwent day-case adenoidectomy during 1999 through 2000.

INTERVENTION

In the hospital, 213 children received the first dose of ketoprofen before surgery and 87 children received the first dose at discharge. For pain treatment after discharge, patients were given ketoprofen tablets or suppositories on a regular basis for 72 hours.

MAIN OUTCOME MEASURES

The number of postoperative behavioral changes were evaluated with 3 consecutive questionnaires, at baseline before surgery, 1 week after surgery, and 3 weeks after surgery.

RESULTS

A total of 294 questionnaires (98%) were returned after 1 week and 255 questionnaires (85%) after 3 weeks. Most children (91%) had pain after discharge and the mean for pain cessation was 3 days (range, 0-8 days). The mean of ketoprofen doses after discharge was 6 (range, 1-24 doses). Most of the children showed no or only trivial postoperative behavioral changes, and, furthermore, at 3 weeks, more positive than negative changes were reported. The child's age was a significant factor (P<.05) in affecting behavioral changes for all domains. Other significant factors were the worst pain at rest (P =.04) and during swallowing (P =.02) for daytime function disturbances, and fear of separation from parents (P =.03) for sleep disturbances.

CONCLUSION

Day-case adenoidectomy with proactive pain treatment seems to result in a negligible incidence of behavioral troubles in children.

Altered speech following adenoidectomy: a 20 year experience

Altered speech related to velopharyngeal insufficiency is a rare but well-recognised complication of adenoidectomy. Over a 20 year period, 42 patients were referred to the Edinburgh cleft team for investigation of altered speech persisting for more than 12 months after adenoidectomy. We studied the cases to ascertain the incidence, clinical features and causes of altered speech in these patients and to assess the efficacy of a selective treatment policy. All data were prospectively collected when the patients were assessed in a multidisciplinary clinic and investigated by videofluoroscopy. Nasopharyngoscopy was also possible in half of the patients. Overall, 27 patients were male and 15 were female, and their mean age was 6.5 years. The incidence was one in 1200 adenoidectomies. Diagnoses included five submucous cleft palates, six occult submucous cleft palates, 22 cases of velopharyngeal disproportion, seven developmental or neurological causes, one iatrogenic palatal injury and one case that defied diagnosis. In six patients treatment was not required, 13 responded to speech therapy and 23 required surgical intervention. The choice of operation was based on the findings at investigation. Ten patients were treated by a superiorly based pharyngeal flap, 10 underwent a sphincteric pharyngoplasty and three had an intravelar veloplasty. Speech outcome was assessed in 36 cases. Treatment resulted in significantly improved speech in all but one patient and normal speech in 16 patients. Persistently altered speech is a rare complication of adenoidectomy. Preoperative screening by clinical examination will prevent some but not all of such problems. When patients present they should undergo multidisciplinary assessment and multi-modality investigation. A good outcome can be anticipated in most patients.

Incidence of post-tonsillectomy hemorrhage in children and adults: a study of 4,848 patients

We conducted a retrospective study of 4,848 patients to evaluate the age-specific incidence of post-tonsillectomy hemorrhage that required surgical treatment. We reviewed the charts of 2,567 patients younger than 15 years (pediatric group) and 2,281 patients aged 15 years and older (adult group) who had undergone tonsillectomy with or without adenoidectomy. We found that post-tonsillectomy hemorrhage occurred significantly more often in the adult group (3.9 vs 1.6%; p < 0.001). Moreover, primary hemorrhage (< 24 hr postoperatively) was also significantly more common in the adult group than in the pediatric group (82.9 vs 65.9%, p = 0.023). Analysis of other parameters revealed that post-tonsillectomy hemorrhage was significantly more common in males and in patients who had a history of chronic or recurrent throat infection. Awareness of these risk factors should help improve patient care and outcomes.

Monopolar electrocautery in adenoidectomy as a possible risk factor for Grisel's syndrome

OBJECTIVES/HYPOTHESIS

Grisel syndrome is a nontraumatic atlantoaxial subluxation after an inflammatory process in the upper cervical region. It results from a peripharyngeal infection as well as a rare complication following adenotonsillectomy. After the introduction of monopolar suction electrocautery in adenoidectomy, an increased incidence of Grisel's syndrome has been observed. The purpose of the study was to evaluate monopolar suction electrocautery as a possible risk factor.

STUDY DESIGN

Retrospective chart review along with current measurements of monopolar and bipolar electrocautery during adenoidectomy.

METHODS

The charts of 1431 consecutive cases of adenoidectomy were reviewed before (n = 710) and after (n = 721) the introduction of monopolar suction electrocautery for intraoperative hemostasis. Moreover, energy of delivered current of electrocautery was measured in 30 pediatric patients during adenoidectomy.

RESULTS

Three cases of Grisel's syndrome occurred as a postoperative complication in 721 adenoidectomies (0.4%) after the introduction of monopolar suction electrocautery. In contrast, no Grisel's syndrome was observed in 710 procedures before the use of monopolar electrocautery. Current measurements demonstrate an almost fourfold higher level of electrical energy using monopolar electrocautery compared with bipolar coagulation for bleeding control in adenoidectomy.

CONCLUSION

Monopolar suction cautery in adenoidectomy may be considered as a risk factor for Grisel's syndrome.

Complications of adenotonsillectomy

OBJECTIVE

To review the immediate, short-term, and long-term complications of adenotonsillectomy.

STUDY DESIGN

Review.

METHODS

Complications of adenotonsillectomy and methods for preventing and treating them were reviewed.

RESULTS

The most common complications of adenotonsillectomy, such as bleeding, generally occur in the immediate perioperative period but can develop up to 2 weeks postoperatively. Long-term complications, such as nasopharyngeal stenosis, may appear months to years after surgery. These more unusual sequelae result from scar contracture and maturation.

CONCLUSION

Although rare, complications associated with adenotonsillectomy can be taxing for patients and health care resources. The most common complications, namely, anesthesia risks, pain, otalgia, and bleeding, should be discussed with patients' caregivers.

Powered partial adenoidectomy

OBJECTIVE

To confirm our clinical impression that the powered microdebrider is superior to curettes for performing partial adenoidectomy (removal of the superior one half to three fourths of the adenoid pad).

DESIGN

Observational study of 100 children undergoing partial adenoidectomy with the powered microdebrider compared with 40 children undergoing conventional partial adenoidectomy with curettes.

SETTING

Private and public tertiary care centers.

PATIENTS

All patients younger than 20 years undergoing partial adenoidectomy at the respective institutions during the study period.

INTERVENTIONS

Partial adenoidectomy as indicated for chronic otitis media, airway obstruction, or chronic or recurrent tonsillitis with either the powered microdebrider or curettes.

MAIN OUTCOMES MEASURES

Operative time (with specific quantification of the time required for tissue removal and hemostasis), blood loss, complications, and subjective ease of use.

RESULTS

Operative time was 59% shorter for the microdebrider group (mean, 3 minutes 22 seconds; range, 1 minute 6 seconds to 12 minutes 45 seconds) than for the conventional group (mean, 8 minutes 8 seconds; range, 1 minute 2 seconds to 22 minutes 0 seconds) (P<.001). Blood loss was comparable for both groups (powered group: mean, 2.0 mL/kg; range, 0.4 to 9.4 mL/kg; conventional group: mean, 2.0 mL/kg; range, 0.3 to 6.7 mL/kg; P=.34). There were no intraoperative or postoperative complications in either group. Surgeon satisfaction with the microdebrider was high.

CONCLUSIONS

The powered microdebrider for partial adenoidectomy is quicker and is not associated with blood loss or complications above that of conventional partial adenoidectomy. The degree of control afforded by the microdebrider technique is of utmost value in preventing complications such as velopharyngeal insufficiency, and this is now our procedure of choice.

The case for an outpatient "approach" for all pediatric tonsillectomies and/or adenoidectomies: a 4-year review of 1419 cases at a community hospital

OBJECTIVE

We sought to document the safety and efficacy of approaching all pediatric tonsillectomies and/or adenoidectomies (T/A) as outpatient procedures.

STUDY DESIGN AND SETTING

We conducted a 4-year retrospective study of 1419 pediatric patients undergoing T/A at an outpatient center with procedures performed by a single group of surgeons.

RESULTS

None of the 593 patients undergoing an adenoidectomy and only 5 (0.6%) of those having a tonsillectomy had significant bleeding postoperatively. There were no readmissions for airway problems. Children younger than age 3 were most likely to have complications and to be held for overnight observations.

CONCLUSIONS

Most children can be safely discharged after T/A. The higher incidence of perioperative complications in children who are younger than 3 years of age paralleled their higher rate of overnight observation.

SIGNIFICANCE

Children less than 3 years of age require more careful observation, especially after tonsillectomy and more likely will need to be observed overnight than older children.

Implication of immunological abnormalities after adenotonsillotomy

The adenoids and tonsils are thought to be essential parts of the system protecting organism against pathogens invading the upper respiratory tracts. Human adenoids and tonsils are known to be immunologically reactive lymphoid organs, which manifest specific antibodies and B and T cells activity in response to variety of antigens carrying out the functions of humoral and cellular immunity. The purpose of the study was to observe the changes in systemic immunity in children with hypertrophy of adenoids and tonsils treated in Department of Laryngology, Children's Hospital in Warsaw in period 1994-1999. The study comprised 80 patients (33 girls and 47 boys, aged from 3 to 14 years, mean age 6.8 years) with diagnosed hypertrophy of adenoids and tonsils. The diagnosis of hypertrophy of adenoids and tonsils was based on characteristic history and laryngological examination. All patients were scheduled for adenotonsillotomy. The control group comprised 40 people (14 girls and 26 boys, aged from 3 to 15 years, mean age 7.6 years) without history of the recurrent upper tract infections. In all patients we carried out following examinations: serum levels of immunoglobulins A, G, M (humoral immunity); percentage of T lymphocytes (CD3); percentage of T helper (CD4) and T cytotoxic (CD8) lymphocytes (cellular immunity) and delayed cutaneous hypersensitivity-Multitest CMI (cell mediated immunity). Our study demonstrate that in children with hypertrophy of adenoids and tonsils exist changes in the immunological parameters. The observed changes appear not only locally but also generally. In the early period after adenotonsillotomy there was statistically significant decrease of the values of humoral and cellular immunity parameters. However, 6 months after operation we observed normalization of examined immunological parameters. We think that the examinations of parameters of immunological system (humoral and cellular) are necessary before planned adenotonsillotomy.

Molecular typing of paired bacterial isolates from the adenoid and lateral wall of the nose in children undergoing adenoidectomy: implications in acute rhinosinusitis

OBJECTIVE

Recent studies have suggested that the origin of bacteria that enter the lateral wall of the nose and paranasal sinuses arise from the nasopharynx. The purpose of this study was to compare the molecular biological profiles of potential pathogens found in the nasopharynx and lateral wall of the nose concomittantly in children undergoing surgery for upper respiratory tract disease.

STUDY DESIGN AND SETTING

Fifty-two children undergoing adenoidectomy for either tonsillectomy or adenoidectomy (hypertrophy) or otitis media with effusion were studied. Bacterial cultures were taken from the crypts of the adenoids and from the lateral wall of the nose under endoscopic control after sterilization of the vestibule and inferior turbinate. Routine cultures of these areas were performed in the bacteriology laboratory of the Children's Hospital of Buffalo.

RESULTS

Bacterial pathogens were isolated from 79% of adenoids and 46% of lateral walls of the nose. Molecular typing of pairs of nontypable Haemophilus influenzae, Streptococcus pneumoniae, and Moraxella catarrhalis revealed that in 16 of 18 pairs (89%) the identical strain was present in both sites simultaneously.

CONCLUSIONS

These results support the concept that when potential bacterial pathogens that may cause acute bacterial rhinosinusitis are found concomitantly in the nasopharynx and lateral wall of the nose, they are usually identical.

The need for routine pre-operative coagulation screening tests (prothrombin time PT/partial thromboplastin time PTT) for healthy children undergoing elective tonsillectomy and/or adenoidectomy

In some medical centers, the routine pre-operative evaluation of healthy children undergoing elective tonsillectomy and/or adenoidectomy (T and A) includes coagulation screening tests (PT, prothrombin Time; PTT, partial thromboplastin time; and INR, international normalized ratio). In this retrospective study, we determined whether there is a positive correlation between prolonged PT/PTT/INR tests in healthy children, with no prior medical history of coagulation problems, and bleeding during surgery and/or bleeding in the month following surgery. We reviewed the records of 416 elective T and A surgeries performed at the Soroka University Medical Center in Beer-Sheva, Israel, over the course of 1999. One hundred and twenty-one (29.1%) patients had preoperative prolonged PT values but only four (3.3%) of these patients experienced light bleeding during surgery. Seven (5.8%) of the 121 patients with prolonged PT tests experienced bleeding episodes during the 1st month subsequent to the surgery. Of the 65 (15.6%) patients who had prolonged pre-operative INR values, only three (4.6%) experienced light bleeding during surgery. Two (3.1%) patients with prolonged INR values experienced light bleeding during the 1st month subsequent to surgery. Sixty-one (14.7%) patients had prolonged first preoperative PTT values, only five of whom (8.2%) experienced light bleeding during surgery. Two (3.3%) of the 61 with prolonged PTT values experienced light bleeding during the 1st month subsequent to surgery. We therefore concluded that pre-operative coagulation screening tests provide low sensitivity and low bleeding predictive value. As such, routine coagulation tests before T &A are not indicated unless a medical history of bleeding tendency is suspected.

Post-adenoidectomy inflammatory pseudotumor

PROBLEM

Inflammatory pseudotumor is a rare pathology in the head and neck area. Multiple post-adenoidectomy complications have been described in the literature without alluding to such an entity.

METHOD

A case report of an inflammatory pseudotumor following an adenoidectomy.

MAIN RESULTS

Pseudotumor of the nasopharynx should be added to the list of possible complications of adenoidectomy.

CONCLUSION

Inflammatory pseudotumor of the nasopharynx is a rare complication that confronts the otolaryngologist and the pathologist with a diagnostic challenge. Surgical excision remains the best therapeutic option.

Post-tonsillectomy and adenotonsillectomy morbidity & complications at District Headquarter Hospital Daggar

BACKGROUND

Tonsillectomy or adenotonsillectomy is one of the commonly performed operations in ENT practice. Morbidity & complications associated with tonsillectomy and adenotonsillectomy include severe otalgia, pyrexia, odynophagia and haemorrhage.

METHODS

A prospective study was undertaken from April 1996 to April 2001 to report the experience regarding postoperative morbidity/complications in tonsillectomy and/or adenotonsillectomy. A total of 1500 patients undergoing tonsillectomy or adenotonsillectom for chronic/recurrent tonsillitis or adenotonsillar hypertrophy were included. These patients received antibiotic in the form of amoxycillin and clavulanic acid and non-salicylate analgesics for 7 days postoperatively. 100 patients were lost to follow up.

RESULTS

Seventy percent of patients were female and thirty percent males with maximum number of patients between the age of 11-22 years. Postoperative complications developed in 25 out of 1400 patients, 14 of them developed post-operative bleeding and 9 developed postoperative infection.

CONCLUSIONS

It was found that postoperative morbidity/complications were less in this study with regard to secondary haemorrhage, operative site infection, intensity & duration of postoperative pain, postoperative pyrexia and time for return to normal activities.

Cervical subcutaneous emphysema: an unusual complication of adenotonsillectomy

Removal of the tonsils and adenoid tissue because of recurrent infection and/or respiratory obstruction is one of the most commonly performed operations. A rare complication during this intervention is subcutaneous surgical emphysema. The awareness of anaesthesiologists and otolaryngological surgeons will protect the patient from serious consequences. We report our experience with this complication and provide a review of the literature.

Hemorrhage following pediatric tonsillectomy before puberty

OBJECTIVE

Control of postoperative bleeding, considered as the major complication following tonsillectomy, serves as a landmark for the safety of the operation. There is a constant decrease of the concentration of hemoglobin during childhood with lowest values around 6 years of age with normal values at the beginning of puberty accompanied by a constant decrease of the number of platelets after birth. Dehydration, poor oral intake and airway problems are predominant complications in early childhood. A retrospective study was undertaken to evaluate if the incidence of bleeding is associated with certain age groups in pediatric patients. We assessed if there is a questionable higher risk for blood transfusions due to the age-specific lower hemoglobin concentration in children.

METHODS

Between January 1988 and August 2000, 2330 patients under 12 years of age underwent tonsillectomy, with or without adenoidectomy, in St. Anna Hospital, Duisburg. Group A (age<6 years) consisted of 1467 patients of whom 59.6% were male. Group B (aged 6-12 years) consisted of 863 patients, of whom 48.1% were male.

RESULTS

Postoperative bleeding from the tonsillar fossae requiring treatment under general anesthesia occurred in group A (1%) and B (2.3%). Bleeding from the adenoidectomy site was treated in group A (0.3%) and B (0.3%). Primary bleeding occurred in the majority of patients in both groups group A (55%) and group B (75%). The latest bleeding was observed 6 days (group A) and 10 days (group B) following surgery, due to statistical analysis the difference was found to be significant (P<0.025). In group A there was one 42-month-old boy who died due to massive bleeding despite ligature of the external carotid artery and blood transfusions. Statistical evaluation shows a significant increase of postoperative bleeding with age (P=0.024). No blood transfusion was required in other patients.

CONCLUSION

Tonsillectomy can be safely performed in children under 6 years of age with no increased risk of postoperative bleeding or risk of receiving blood transfusion. Rare cases of secondary hemorrhage seem to occur more frequently in younger children and should be treated immediately under general anesthesia to avoid severe complications.

Medial medullary injury during adenoidectomy

We report medullary injury during adenoidectomy in two children who received injections of local anesthetic agents into the operative bed. Initial manifestations included hemiparesis, nystagmus, and ataxia. Magnetic resonance imaging showed hemorrhagic, paramedian medullary lesions in both patients. The mechanism of injury is likely to be injection of fluid into the medulla.

Prospective study of morbidity after tonsillectomy in children

Post-operative morbidity was prospectively studied in 384 children after tonsillectomy or adenotonsillectomy, using visual analogue scores to record symptom levels, and questionnaires to monitor satisfaction scores from the children and their families. Assessments were performed between the 7th and 14th day post-operatively. Two hundred children were assessed before the introduction of a pre-admission programme which consisted of an instructional videotape session in the ward and an advice booklet. Department practice was also changed to provide a bottle of paracetamol on discharge routinely for each child. Following these changes in practice a further 184 children were assessed. The provision of relatively simple measures in the programme increased parental satisfaction rates (P<0.05) and reduced GP contact rates (35--17%, P<0.05) post-operatively. The actual levels of morbidity were unchanged despite the provision of analgesia.

Lingual artery embolization for severe and uncontrollable postoperative tonsillar bleeding

We performed emergent angiography of the external carotid artery to evaluate a patient who experienced uncontrollable oropharyngeal bleeding 3 days following an adenotonsillectomy. Angiography demonstrated a left lingual artery disruption and hemorrhage. We then performed a coil embolization of the left lingual artery, which immediately halted the hemorrhage. We conclude that coil embolization is a rapid and effective strategy for the management of massive, uncontrollable postoperative tonsillar bleeding.

Bleeding predisposition assessments in tonsillectomy/adenoidectomy patients using fuzzy interquartile encoded neural networks

A fuzzy set theoretic methodology is described that serves as a classification preprocessing strategy for supervised feed-forward neural networks. This methodology, fuzzy interquartile encoding, determines the respective degrees to which a feature belongs to a collection of fuzzy sets that overlap at the respective quartile boundaries of the feature. These membership values are subsequently used in place of the original feature. This transformation has a normalizing effect on the feature space and is more robust to feature outliers. Its effectiveness is scrutinized using several synthetic data sets with various underlying distributions. Fuzzy interquartile encoding is shown to consistently improve the discriminatory power of the underlying classifiers. The methodology is also applied to two biomedical data sets relating to tonsillectomy and/or adenoidectomy patients who may or may not have had a predisposition to excessive bleeding during their operation. The features of the first data set are blood sample test results acquired from a coagulation laboratory and the class labels are one of three hemostatic defects as identified by the reference tests. The second data set consists of patient responses to queries from a bleeding tendency questionnaire. Normal and abnormal class labels were derived from a hematology expert system designed in consultation with a pediatric hematologist. Fuzzy interquartile encoding effected an 11% improvement in the classification accuracy of the underlying neural network classifier with the former data set and 18% with the latter.