Tonsillectomy or tonsillotomy?--A randomized study comparing postoperative pain and long-term effects

Reoperative treatment of obstructive sleep apnea

Over the last several decades, various surgical treatments have been advocated and used to treat obstructive sleep apnea. Treatments ranging from aggressive procedures, such as tracheostomy, to the least-invasive procedures, such as radioablation, have not yielded satisfactory results. One of the major causes for surgical failures and lower success rates lies in the inadequate understanding and appreciation of the anatomic and pathophysiologic factors that contribute to upper airway obstruction. In some cases, combinations of various surgical techniques may help improve the conditions. This article reviews several major types of surgical procedures, their complications, and the recommended approaches for retreatments.

A systematic review of faces scales for the self-report of pain intensity in children

CONTEXT

Numerous faces scales have been developed for the measurement of pain intensity in children. It remains unclear whether any one of the faces scales is better for a particular purpose with regard to validity, reliability, feasibility, and preference.

OBJECTIVES

To summarize and systematically review faces pain scales most commonly used to obtain self-report of pain intensity in children for evaluation of reliability and validity and to compare the scales for preference and utility.

METHODS

Five major electronic databases were systematically searched for studies that used a faces scale for the self-report measurement of pain intensity in children. Fourteen faces pain scales were identified, of which 4 have undergone extensive psychometric testing: Faces Pain Scale (FPS) (scored 0-6); Faces Pain Scale-Revised (FPS-R) (0-10); Oucher pain scale (0-10); and Wong-Baker Faces Pain Rating Scale (WBFPRS) (0-10). These 4 scales were included in the review. Studies were classified by using psychometric criteria, including construct validity, reliability, and responsiveness, that were established a priori.

RESULTS

From a total of 276 articles retrieved, 182 were screened for psychometric evaluation, and 127 were included. All 4 faces pain scales were found to be adequately supported by psychometric data. When given a choice between faces scales, children preferred the WBFPRS. Confounding of pain intensity with affect caused by use of smiling and crying anchor faces is a disadvantage of the WBFPRS.

CONCLUSIONS

For clinical use, we found no grounds to switch from 1 faces scale to another when 1 of the scales is in use. For research use, the FPS-R has been recommended on the basis of utility and psychometric features. Data are sparse for children below the age of 5 years, and future research should focus on simplified measures, instructions, and anchors for these younger children.

Surgical options for the treatment of obstructive sleep apnea

Obstructive sleep apnea (OSA) is a prevalent condition characterized by repetitive airway obstruction during sleep with associated increased morbidity and mortality. Although CPAP is the preferred treatment, poor compliance is common. Patients intolerant of conventional OSA medical treatment may benefit from surgical therapy to alleviate pharyngeal obstruction. Case series suggest that maxillomandibular advancement has the highest surgical efficacy (86%) and cure rate (43%). Soft palate surgical techniques are less successful, with uvulopalatopharyngoplasty having an OSA surgical success rate of 50% and cure rate of 16%. Further research is needed to more thoroughly assess clinical outcomes (eg, quality of life, morbidity), better identify key preoperative patient and clinical characteristics that predict success, and confirm long-term effectiveness of surgical modalities to treat OSA.

Making sense out of the tonsillectomy literature

BACKGROUND

With the increase in new technology and changing indications for tonsillectomy, the literature has exploded during the last 20 years with scores of publications reporting the relative effectiveness of many different techniques. Despite this "wealth of information," no single technique has been adopted by most surgeons.

OBJECTIVES

To systematically analyze the usefulness of this literature of the past 20 years concerning tonsillectomy technique in children. To propose the use of specific study parameters that could optimize clinical decision-making and future research.

METHODS

Detailed review of the methodologies and findings in articles which compared one or more tonsillectomy techniques in clinical trials of children, ages 1-23 years from 1987 through 2007.

RESULTS

The Medline search revealed 255 papers of which 89 studies were suitable for inclusion in our review. In these 89 studies (found in 87 papers), 9 dissection techniques, 3 planes of dissection, 8 methods of hemostasis, and 41 different outcome measures were reported. Forty-four (49%) were described as randomized, 63 (71%) prospective, 25 retrospective (28%), 1 case report, 1 matched pair, and 9 case series papers. Sixteen (18%) trials were non-blind, 23 (26%) were single blind, 17 (19%) were double blind, and 7 (8%) were not stated. Seventy-five (84%) were comparative and 14 (16%) non-comparative. Eight (9%) studies reported power analyses. Twelve (13%) had no follow-up; 67 (75%) of the studies performed had short-term follow-up in the peri-operative period; 10 (11%) had follow-up for greater than 1 year. Eleven (12%) mentioned outcomes related to the effectiveness of the procedure itself in relieving symptoms for which the surgery was done.

CONCLUSIONS

Tonsillectomy technique research is of obvious interest to the otolaryngologist. We found deficits in: the precise reporting of surgical techniques, adequate study design and useful outcome measures, all of which make the literature less useful than it could be. Guidelines for study design parameters which could lead to more valuable information for the clinician are suggested.

Phonological development in children with obstructive sleep-disordered breathing

Adeno-tonsillar hypertrophy with obstructive sleep disordered breathing (OSDB) is known to affect oral-motor function, behaviour, and academic performance. Adeno-tonsillectomy is the most frequently performed operation in children, with total tonsillectomy (TE) being more common than partial resection, 'tonsillotomy' (TT). In the present study 67 children, aged 50-65 months, with OSBD were randomized to TE or TT. The children's phonology was assessed pre-operatively and 6 months post-operatively. Two groups of children served as controls. Phonology was affected in 62.7% of OSBD children before surgery, compared to 34% in the control group (p < .001). Also, OSBD children had more severe phonological deficits than the controls (p < .001). Phonology improved 6 months equally after both surgeries. Despite improvement post-operatively, the gap to the controls increased. Other functional aspects, such as oral motor function, were normalized regardless of surgical method--TE or TT. The impact of OSBD should be considered as one contributing factor in phonological impairment.

Tonsillectomy vs. partial tonsillectomy for OSAS in children--10 years post-surgery follow-up

BACKGROUND

Today, obstructive hypertrophic tonsils are completely resected to remove the obstruction. Since tonsillar tissue has important protective characteristics, it is more logical to resect only the obstructive tonsillar tissue and leave remnants in the tonsillar beds, thereby presuming to preserve the immunological function of the tonsillar tissue. However, it is as yet unclear whether or not rehypertrophy of this remnant of the tonsils and/or tonsillitis reoccur in the long-term.

OBJECTIVES

To evaluate the remnants of the tonsils 10-14 years post-tonsillotomy in children who suffered from obstructive sleep apnea syndrome (OSAS) due to obstructive tonsils.

METHODS

We conducted a retrospective study, telephone survey and selective physical examination of 33 children who had obstructive hypertrophic tonsils (suffered from OSAS due to hypertrophic tonsils), and underwent tonsillotomy (TT) at Assaf Harofeh Medical Center between July 1990 and April 1993, and compared them with a group of 16 children treated by tonsillectomy (TE) for the same diagnosis.

RESULTS

No statistically significant difference was found between the TT and TE groups in all parameters compared: non-obstructing tonsils recurred (97% vs. 87%); snoring (3% vs. 12.5%); recurrent tonsillitis (6% vs. 6.25%); and recurrent obstruction and unilateral enlargement (3% vs. 12.5%).

CONCLUSIONS

TT is as effective as TE for the long-term treatment of children suffering from OSAS due to hypertrophic tonsils.

Adenotonsillectomy for obstructive sleep apnoea in children

BACKGROUND

Current treatment of sleep apnoea in children consists of largely surgical based treatments. Adenotonsillectomy is the most commonly used intervention to treat sleep apnoea in children.

OBJECTIVES

To determine the efficacy of adenotonsillectomy in the treatment of obstructive sleep apnoea in children.

SEARCH STRATEGY

The Cochrane Airways Group Specialised Register was searched with pre-specified terms. Searches were current as of August 2008.

SELECTION CRITERIA

Randomised trials recruiting children with a diagnosis of obstructive sleep apnoea.

DATA COLLECTION AND ANALYSIS

Two reviewers examined the search results and collected data from the studies in terms of their characteristics before deciding which ones would be included in the review.

MAIN RESULTS

One study met the review entry criteria. This study addressed the relative merits of two surgical techniques in treating OSA in children (temperature controlled radiofrequency tonsillectomy and adenoidectomy, and complete tonsillectomy and adenoidectomy). No significant difference was apparent for either symptoms or respiratory disturbance index. More children in the TCFR&A group were able to return to normal diet at 7 days compared with complete T&A. No significant complications were observed in the study.

AUTHORS' CONCLUSIONS

One small study failed to find a difference between two surgical techniques, although return to normal diet was more frequent in the group treated by temperature controlled radiofrequency tonsillectomy and adenoidectomy. At present there is still debate as to the criteria required to diagnose significant obstructive sleep apnoea in children. Also the natural history of the condition has not been fully delineated. There is an absence of randomised controlled trials investigating the efficacy of treatment of confirmed obstructive sleep apnoea with adenotonsillectomy in children. Research is required before recommendations for the treatment of obstructive sleep apnoea in children can be formulated. The quality of research in this area could be improved with the use of sleep studies at baseline to determine the extent of severity of sleep apnoea in children who are recruited to studies in this area. Long-term follow up is also required in order to explore the effect of adenotonsillectomy on paediatric sleep apnoea.

The multiple challenges of obstructive sleep apnea in children: morbidity and treatment

PURPOSE OF REVIEW

To delineate some of the major morbid phenotypes that have emerged in pediatric obstructive sleep apnea (OSA), address new concepts in our understanding of OSA-associated morbidities, and elaborate on innovative therapeutic schemes that may improve outcomes for this condition. In addition, the conceptual framework whereby a childhood condition such as OSA can be linked to specific adult diseases will be presented.

RECENT FINDINGS

OSA in children is a frequent condition that affects up to 3% of nonobese, otherwise healthy children. In recent years, increased awareness of OSA and changes in obesity rates in children have contributed to significant changes in disease prevalence and clinical presentation, such that distinct morbidity-related phenotypes have become apparent. Furthermore, oxidative stress and systemic inflammatory pathways are mechanistically involved in the pathophysiology of OSA-associated morbidity. Adenotonsillectomy, the treatment of choice for pediatric OSA, may not be as efficacious as previously thought. Alternative nonsurgical therapies have started to emerge and may become an essential component of treatment.

SUMMARY

Pediatric OSA, particularly when obesity is concurrently present, is associated with substantial end-organ morbidities that primarily but not exclusively affect central nervous and cardiovascular systems. These morbidities are pathophysiologically mediated by inflammatory and free radical mediators. Although adenotonsillectomy remains the first line of treatment, more critical assessment of its role is needed, and incorporation of nonsurgical approaches to pediatric OSA seems warranted.

Impact of tonsillectomy on pediatric psychological status

OBJECTIVE

Tonsillectomy is one of the most commonly performed procedures in children. However, parents often hesitate to agree to the procedure because of concerns of the possible harmful impact on their child's psychological health. The present study was performed to examine the short-term psychological impact on children who had undergone tonsillectomy.

METHODS

Forty-three pediatric patients aged 3-11 years who underwent tonsillectomy were enrolled in the study. Postoperative pain was assessed using a 10-point visual analog scale (VAS) on postoperative days 1, 2, 7, and 21. The Korean version of the Child Behavior Checklist (K-CBCL) was given to the parents of the children to evaluate the psychosocial effect of tonsillectomy on the preoperative day and on postoperative day 21.

RESULTS

There were no significant differences in postoperative pain according to age, tonsil size, degree of adhesion, or operation time. There was no significant relationship between postoperative pain score and K-CBCL score. Sociality, total behavioral problems, externalizing problems, internalizing problems, anxiety/depression, social immaturity, and emotional lability domain scores on the K-CBCL were improved significantly.

CONCLUSIONS

Improvements in general emotional and social status were observed at 3 weeks after tonsillectomy. Tonsillectomy itself does not have a harmful effect on children's psychological status.

Tonsillotomy in the treatment of obstructive sleep apnea syndrome in children: polysomnographic results

INTRODUCTION

The therapy of choice in the treatment of pediatric obstructive sleep apnea syndrome (OSAS) consists of tonsillectomy or tonsillotomy combined with adenoidectomy. While tonsillectomy unfortunately has a notable risk of secondary hemorrhage and postoperative pain, tonsillotomy is safer and less painful for children. The effect of both surgical methods on symptoms of OSAS seems to be equal, but up to now postoperative polysomnographic data for children treated by tonsillotomy are missing.

MATERIALS AND METHODS

Twenty children aged 2-9 years (mean age: 4.1+/-2.0 years) with OSAS diagnosed by full-night polysomnography were included in the study. OSAS was defined as an apnea-hypopnea index (AHI) of 5 or more with minimum oxygen saturation (SaO(2) min) of less than 90%. Exclusion criteria were obesity, craniofacial abnormalities or other pulmonary, cardiac or metabolic diseases as well as a history of recurrent tonsillitis. All children were treated by CO(2) laser tonsillotomy and adenoidectomy. Three to 12 months (mean: 7.7 months) after the procedure a control-polysomnography was performed in all children.

RESULTS

No statistically significant changes were seen in the pre- and postoperative distribution of sleep stages, sleep efficacy and total sleep time. The AHI decreased from 14.9+/-8.7 to 1.1+/-1.6 (p<0.001), SaO(2) min increased from 71.1+/-11.1% to 91.2+/-3.5% (p<0.001). Thus, all children were cured by the operation.

DISCUSSION

These polysomnographic data show that CO(2) laser tonsillotomy in combination with adenoidectomy is highly effective in the treatment of pediatric OSAS and should be preferred over tonsillectomy because of less postoperative pain and a lower risk of postoperative bleeding.

Randomized controlled studies and the treatment of middle-ear effusions and tonsillar pharyngitis: How random are the studies and what are their limitations?

Objective

To determine the applicability and external validity of randomized control studies (RCTs) in the light of patient susceptibilities and vulnerabilities to the sequelae of otitis media with effusion (OME) and tonsillar pharyngitis (T&A) and the composition of their cohorts.

Study Design

RCTs for OME and T&A were analyzed to determine which intrinsic and extrinsic susceptibilities to the otolaryngic disease and its sequelae were included or excluded and the composition of the cohort.

Methods

A Medline and a Science Direct search were performed for all RCTs concerning OME and T&A through 2007. The articles selected to be included in this study are the OME RCTs that reported language and/or hearing outcomes and the T&A RCT studies in which the outcome measure was infection, alleviation of airway obstruction, and/or quality of life. These were analyzed for their inclusion or exclusion of intrinsic and extrinsic susceptibilities to the otolaryngic disease and their sequelae and the composition of the cohort. The pertinent otolaryngologic literature was assessed to determine applicable risk factors.

Results

The analysis of the inclusion or exclusion of risk factors showed that for OME 0 percent were included and 16 percent were excluded, and there were no data for 84 percent. The T&A findings were similar in that 1 percent of risk factors were included, 8 percent excluded, and there were no data for 92 percent. Both the OME and the T&A cohorts data were similar in that approximately half of the suitable candidates completed the study; 25 percent of the OME and 13 percent of the T&A enrolled subjects were either withdrawn or placed into a different experimental group. On the average, with data available, it took 4.6 years to recruit the OME sample and 5.5 years to recruit the T&A sample.

Conclusion

The results of RCTs for these conditions are only applicable to narrowly defined and highly circumscribed populations. They cannot be generalized to the entire patient population because of their limited external validity. Future RCT protocols should be designed to control for the intrinsic and extrinsic susceptibilities that result in a propensity to acquire the disease and/or an exacerbation of the disease's sequelae. These studies would determine the most effective strategies for preventing disorders and/or their deleterious sequelae.

Partial tonsillectomy with scalpel in children with obstructive tonsillar hypertrophy

OBJECTIVE

To compare postoperative pain of partial tonsillectomy (PT) with scalpel and total classical tonsillectomy (TT).

METHODS

Prospective, randomized study at a tertiary care institution. Ninety-six children who were diagnosed with obstructive tonsillar hypertrophy were included to the study. Children's tonsils were removed totally (Group TT) by classical dissection tonsillectomy or partially (Group PT) using scalpel and tissue scissors. The parents were instructed to fill out a form daily for nine postoperative days; recording total amount of analgesics administered that day and a Visual Analog Scale (VAS) each day assessing child's life quality and daily activities.

RESULTS

Eighty-one children (2-14 years old) who completed the study were included in the analysis. Total tonsillectomy group (Group TT) consisted of 41 patients and partial tonsillectomy group (Group PT) consisted of 40 patients. There was no difference between two groups' operative parameters such as operation time [21.3 min (PT) and 22.3 min (TT)] and blood loss [44.2 ml (PT) and 46.0 ml (TT)] (p>0.05). PT group received significantly less dosage of analgesics per day; 1.18+/-1.27 vs. 2.00+/-1.45 (p<0.005). Total used analgesic dose in PT group were also lower than TT group (10.7+/-7.13 vs. 18.02+/-6.99 doses). When each day's analgesic use was compared separately a significant difference was found (p<0.05) in all days except 9th postoperative day (p>0.05). There was no difference in the pain scores between two techniques (p>0.05).

CONCLUSION

Unlike tonsillectomy, PT aims to remove the tonsilla palatina subtotally. It is especially performed in children with obstructive tonsils. PT with scalpel is an inexpensive and safe method necessitating only standard surgical instruments. It causes less postoperative pain than classical dissection tonsillectomy.

Tonsillectomy versus tonsillotomy performed with scissors in children with tonsillar hypertrophy

OBJECTIVE

We sought to determine the morbidity and the short and long-term effectiveness of tonsillotomy (partial tonsillectomy) performed with scissors compared with conventional cold knife (total) tonsillectomy.

METHODS

We conducted a 2-year prospective non-randomized study at a tertiary children's hospital. One thousand and twenty-three children were recruited (243 in the tonsillotomy and 780 in the tonsillectomy group). Age, sex, weight, and time of operation, immediately post-operative complications and pain were recorded. Eighteen months after the operation data on weight, parents' satisfaction and recurrence of obstructed symptoms was obtained in 60 randomly selected children of each group.

RESULTS

Post-operative complications rates were very low in both groups and their differences did not reach statistical significance. However, tonsillotomies were significantly better than tonsillectomies in relation to post-operative pain the 1st (P<0.001) and the 7th (P<0.001) post-operative day, and lasted an average of 2.5 min less. Concerning long-term effects, both methods resulted in an increase of patients' weight without the difference in weight increase be statistically significant. In addition, parents' satisfaction as well as oral malodour do not seem to differ significantly. Finally, although twice as many children in the tonsillotomy group had a recurrence of snoring compared to tonsillectomy group, only in about half of them was the problem regarded significant enough by their parents to require medical consultation or reoperation. At the end, an estimated 3.5% of the tonsillotomy group was offered a tonsillectomy in the long term.

CONCLUSION

This trial shows that scissors tonsillotomy in combination with an adenoidectomy is a viable therapeutic option with less immediate post-operative morbidity than tonsillectomy in young children whose sleep disorder breathing is due to a combination of tonsilar and adenoid hypertrophy. However, parents should be informed of the possibility of regrowth and reoperation.

Pediatric obstructive sleep apnea: complications, management, and long-term outcomes

Obstructive sleep apnea (OSA) in children has emerged not only as a relatively prevalent condition but also as a disease that imposes a large array of morbidities, some of which may have long-term implications, well into adulthood. The major consequences of pediatric OSA involve neurobehavioral, cardiovascular, and endocrine and metabolic systems. The underlying pathophysiological mechanisms of OSA-induced end-organ injury are now being unraveled, and clearly involve oxidative and inflammatory pathways. However, the roles of individual susceptibility (as dictated by single-nucleotide polymorphisms), and of environmental and lifestyle conditions (such as diet, physical, and intellectual activity), may account for a substantial component of the variance in phenotype. Moreover, the clinical prototypic pediatric patient of the early 1990s has been insidiously replaced by a different phenotypic presentation that strikingly resembles that of adults afflicted by the disease. As such, analogous to diabetes, the terms type I and type II pediatric OSA have been proposed. The different manifestations of these two entities and their clinical course and approaches to management are reviewed.

Tonsillar regrowth following partial tonsillectomy with radiofrequency

OBJECTIVES

To assess regrowth potential of the tonsils following partial tonsillectomy performed by using radiofrequency.

METHODS

Follow-up results of 42 children (aged from 1 to 10 years) who consecutively had partial tonsillectomy with radiofrequency due to obstructive sleep apnea or snoring were evaluated for regrowth of the tonsils.

RESULTS

Regrowth of the remaining tonsillar tissue was observed in 7 of 42 patients (16.6%). The upper respiratory tract obstruction symptoms recurred in 5 of these 7 patients while the remaining 2 patients were asymptomatic. The tonsils of symptomatic patients were removed completely.

CONCLUSION

Partial tonsillectomy may have a significant potential for regrowth and thereby recurrence of the obstructive symptoms. Although the cause of this regrowth remains unknown, this problem should be remembered by the surgeons, and an informed consent should be obtained from the families prior to radiofrequency tonsillotomy.

Coblation tonsillectomy: a prospective, double-blind, randomised, clinical and histopathological comparison with dissection–ligation, monopolar electrocautery and laser tonsillectomies

Introduction:

Coblation tonsillectomy is a relatively recently introduced surgical technique which attempts to bridge the gap between ‘hot’ and ‘cold’ tonsillectomy methods.

Aim:

To compare coblation tonsillectomy with three commonly used surgical techniques: cold dissection–ligation, monopolar electrocautery and CO2 laser.

Materials and methods:

A prospective, randomised, double-blinded clinical trial was undertaken of 60 adult patients divided into three equal study groups. Patients in each group were randomly assigned to have one tonsil removed with coblation and the second with one of the other three tonsillectomy techniques. Ten randomly selected tonsils resected by each method were sent for histopathological evaluation.

Results:

Coblation was significantly faster to perform than laser and produced significantly less intra-operative blood loss than both the dissection–ligation and laser techniques. Subjective visual analogue scale comparisons showed a non-significant pain score difference between coblation and dissection–ligation on most post-operative days. Coblation produced consistently highly significantly (p < 0.001) less pain, compared with electrocautery up to the 12th post-operative day and laser up to the 10th post-operative day. There was no significant difference in tonsillar fossa healing, comparing coblation to both dissection–ligation and laser techniques. Monopolar electrocautery produced significantly slower healing than coblation after 7 post-operative days, with no significant difference after 15 post-operative days. Histopathological evaluation showed that coblation inflicted significantly less thermal tissue injury than either electrocautery (p = 0.001) or laser (p = 0.003).

Conclusions:

In adult patients, coblation tonsillectomy offers some significant advantages in terms of post-operative pain and healing, compared with other tonsillectomy techniques.

Intracapsular vs. extracapsular tonsillectomy: a comparison of pain

OBJECTIVE

To measure differences in postoperative pain in children undergoing intracapsular tonsillectomy vs. extracapsular tonsillectomy.

STUDY DESIGN

Prospective clinical trial carried out at a tertiary children's hospital over 1 year.

METHODS

The study included 43 patients age 5 to 19 years with adenotonsillar hypertrophy, 27 undergoing extracapsular tonsillectomy and 16 undergoing intracapsular tonsillectomy. Tonsillectomy was performed in either an intracapsular or extracapsular fashion using bipolar electrosurgical scissors and monopolar suction cautery for hemostasis. Residents under faculty supervision performed all operations. Postoperative pain was assessed using the Wong-Baker Faces Pain Scale through postoperative day 10. The patients recorded in a standardized diary pain scores and analgesic use. The main outcome measure was postoperative pain as measured by the Wong-Baker Faces Pain Scale. The quantity of postoperative pain medicine consumed was a secondary outcome measure.

RESULTS

Average postoperative pain for extracapsular tonsillectomy was 5.21 on a 10-point scale versus 2.75 for intracapsular tonsillectomy (P < .0001).

CONCLUSIONS

Intracapsular tonsillectomy with bipolar scissors results in less postoperative pain than extracapsular tonsillectomy with bipolar scissors in children age 5 to 19 years.

Microdebrider-assisted partial tonsillectomy: short- and long-term outcomes

Microdebrider-assisted partial tonsillectomy has gained popularity in recent years. However, no prospective long-term follow-up exists in the literature and the risk of increase in tonsillitis is still a concern. We conducted a prospective randomized controlled study to assess the short-term benefits of microdebrider-assisted partial tonsillectomy (group 1) compared to electrocautery-assisted total tonsillectomy (group 2), to monitor the durability of the improvement and watch for any change in the rate of tonsillitis. Patients with symptomatic tonsillar hyperplasia were included and underwent either technique of tonsillar surgery. Duration of operation, amount of intra-operative blood loss, immediate and late complications, postoperative pain, return to normal activity and diet, and relief of obstructive symptoms were measured. Recurrence of symptoms and change in rate of tonsillitis in group 1 were monitored. We studied 143 patients, 77 in group 1 and 66 in group 2. There was no significant difference in the surgical time (P>0.05) or postoperative bleeding (P>0.05) but more blood loss in group 1 (P<0.05) and more dehydration in group 2 (P<0.05) were encountered. All patients had complete relief of symptoms. Group 1 returned earlier to normal activity (2.19 vs. 5.71 days; P<0.05), to normal diet (5.28 vs. 8.16 days; P<0.05) and needed less frequent analgesics (2.14 vs. 6.1 days; P<0.05). More than two-thirds of group 1 and less than one-third of group 2 were pain free after day 3. Most group 1 parents (96.1%) were highly satisfied, at initial follow-up, regarding the decision to perform the surgery in contrast to group 2 parents (19.7%). No recurrence of symptoms and no increase in rate of tonsillitis were noticed among group 1 after 20 months mean follow-up (median 20.6, range 1-36.2 months). Group 1 showed short-term benefits over group 2 and maintained the resultant improvement on the long-term with no infectious drawbacks.

Surgery for Pediatric Sleep Apnea

Sleep-related breathing disorders (SRBD) in children are caused by a diverse group of anatomic and physiologic pathologies. These disorders share a common clinical presentation as stertor or sonorous breathing, occasionally accompanied by apneic events of variable duration. Successful management depends on accurate identification of the site of obstruction and the severity of obstruction. Intervention, both surgical and nonsurgical, is tailored to the disorder. In children with SRBD, such intervention may alter behavior and cognition, improve sleep and feeding, or even save a life.

Electromyography in evaluation of pain after different types of tonsillectomy: prospective randomized study

BACKGROUND

Combined surface electromyography (sEMG) and visual analogue scale (VAS) pain assessment was performed on randomly assigned adults following tonsillectomy to research the effect of fibrin sealant (Group 1, n = 25), CO(2) laser (Group 2, n = 18) and electrocoagulation (Group 3, n = 40) on postsurgical pain.

METHODS

Timing and amplitude of sEMG activity of masseter, infrahyoid and submandibular muscles were measured during swallowing simultaneously with VAS assessment and compared to normative database.

RESULTS

Postsurgical electric activity of masseter and infrahyoid was significantly higher in comparison with normative database. sEMG and VAS data showed that tonsillectomy ended with fibrin sealant caused less pain than laser or electrocoagulation techniques with no correlation between the VAS score and duration of swallows.

CONCLUSION

Tonsillectomy affects muscle activity significantly by involving additional muscles (infrahyoid) in swallowing. Combined sEMG and VAS data indicated electrocautery as the most painful, laser as less painful, and fibrin sealant as the least painful technique.

Tonsil Surgery in Youths: Good Results With A Less Invasive Method

OBJECTIVE

Comparison of two types of tonsil surgery for 16- to 25-year-old patients, with respect to primary morbidity, snoring, and recurrent infections after 1 year. Teenagers and young adults are a significant proportion (26%) of the population that receive tonsil surgery each year and appear to suffer more pain than younger children. Recurrent tonsillitis, in combination with obstructive problems, is the main indication for surgery.

METHOD

One hundred fourteen patients 16 to 25 years of age were randomized to tonsillotomy (TT) with radiosurgery (RF) (Ellman International) or to cold tonsillectomy (TE). Pain and analgesics were logged until patients were pain free.

RESULTS

Thirty-two patients were operated on with TT and 44 with TE. The TT group had less blood loss during surgery and no postoperative bleedings, compared with the TE group (2 primary and 4 late hemorrhages). The TT group recorded significantly less pain from the first day, had less need of analgesics (diclofenac and paracetamol), and were pain free and in school/at work 4 days earlier than the TE group. After 7 days, the TE patients had lost a mean of 1.8 kg compared with TT, with no significant weight loss. After 1 year, both groups were satisfied. The positive effect on snoring was the same for both groups. There were few throat infections in both groups.

CONCLUSION

TT with RF is an effective method for tonsil surgery for many teenagers and young adults, with much less postoperative morbidity than regular TE. Long-term follow-up is necessary.

Wertigkeit der Anamnese bei der Indikationsstellung zur Tonsillotomie

BACKGROUND

In pre-school children suffering from pure non-inflammatory hyperplasia of the tonsils, tonsillotomy has recently been recommended in preference to tonsillectomy. Absence of inflammatory tonsillitis in the previous medical history is accepted as evidence that tonsillotomy is indicated. In this study, we therefore examine whether and to what degree the medical history correlates with the histological findings.

PATIENTS AND METHOD

In a prospective study 59 children admitted to our department for tonsillectomy were each allocated to one of three groups according to how many episodes of acute tonsillitis they had been suffering from per year prior to admission: group 1, 0 episodes of tonsillitis/year; group 2, 1 or 2 episodes/year; group 3, >2 episodes/year. These groups were then compared with the diagnoses yielded by histological examination of the excised tonsils, which were classified into (1) pure hyperplasia; (2) chronic inflammatory tonsillitis; (3) hyperplasia and chronic inflammatory hyperplasia; and (4) chronic inflammation with peritonsillar scarring.

RESULTS

In group 1 (n=23) pure hyperplasia was found in only 2 cases, while the tonsils of all other children were affected by chronic inflammatory tissue changes, either alone or in association with hyperplasia. In groups 2 und 3 most tonsillar specimens showed histological characteristics of chronic inflammation, but non-inflammatory hyperplasia alone was also found in 5 cases.

CONCLUSION

There is no correlation between the medical history of children undergoing tonsillectomy and the histological diagnosis. In other words, the medical history does not appear to be an appropriate way of reaching a differential diagnosis between non-inflammatory hyperplasia and chronic tonsillitis. This means that tonsillotomy may well leave remnants of chronically inflamed tonsillar tissue in place. Appropriate counselling of the parents seems to be necessary.

Comparison of microdebrider subcapsular tonsillectomy to harmonic scalpel and electrocautery total tonsillectomy

OBJECTIVE

The aim of this study was to compare microdebrider subcapsular tonsillectomy (MST) with total tonsillectomies either by harmonic scalpel (TTH) or electrocautery (TTE) in children with obstructive sleep-disordered breathing from tonsillar hypertrophy.

DESIGN

Retrospective review of prospectively collected data.

SETTING

Tertiary academic hospital.

PATIENTS

Eighty consecutive children with obstructive sleep-disordered breathing from tonsillar hypertrophy who underwent MST between January and April of 2003 were compared with a smaller historical cohort of 25 patients who underwent TTEs and TTHs from January to December of 2001.

MAIN OUTCOME MEASURES

Primary: days to no narcotic pain medicine use and days to solid food intake; secondary: estimated blood loss, surgical time, and postoperative complications.

RESULTS

Fifty-four patients who underwent MSTs and 25 patients who underwent total tonsillectomies met study criteria for a total of 79 patients. The cohorts showed no significant demographic differences between groups. The MST group had a significantly shorter duration of pain medicine use (3.7 +/- 0.5 days) than the TTE (7.0 +/- 0.6 days) or TTH groups (6.8 +/- 0.7 days; P < .001). The MST group (3.5 +/- 0.6 days) and the TTH group (3.6 +/- 0.8 days) achieved solid food intake faster than the TTE group (5.4 +/- 0.7 days; P = 0.004). There was a significantly higher estimated blood loss with the MST group (38.8 +/- 6.1 mL) than the TTH group (19 mL +/- 8.2) and the TTE group (15.1 +/- 7.4 mL; P < .001). TTH (27.3 +/- 3.1 minutes) took longer than MST (20.3 +/- 2.3 minutes) and TTE (21.9 +/- 2.8 minutes; P = .018).

CONCLUSION

Microdebrider subcapsular tonsillectomy is valuable in treatment of children with tonsillar hypertrophy because of the decreased pain medicine use and more rapid return to solid food.

Pediatric Tonsillotomy with Radiofrequency Technique: Long-Term Follow-Up

OBJECTIVES

Compare the effects of partial tonsil resection using a radiofrequency technique, tonsillotomy (TT), with total tonsillectomy (TE, blunt dissection) after 1 and 3 years. Compare frequency of relapse in snoring or infections and possible long-term changes in behavior among TT children with those in TE children.

METHOD

Ninety-two children (5-15 yr) randomized to TT (n = 49) or TE (n = 43) groups because of obstructive problems with or without recurrent tonsillitis. One year after surgery, general health, degree of obstruction, history of infections, and behavior were investigated using two questionnaires, the Qu1 and Child Behavior Checklist, as well as an ENT visit. After 3 years, two questionnaires, Qu2 and the Glasgow Children's Benefit Inventory, were answered by mail.

RESULTS

: After 1 year, both groups were in good health. The effect on snoring and total behavior was the same for both groups, and the rate of recurrence of infections was not higher in the TT group. After 3 years, two children in the TT group were tonsillectomized (4%, 2/49), one because of peritonsillitis and another because of increased snoring. Otherwise, no differences existed between the groups in general health, snoring, or number of infections.

CONCLUSION

Removing only the protruding parts of the tonsils has the same beneficial long-term effect on obstructive symptoms and recurrent throat infections as complete TE in the majority of cases. The need for re-operation is low; therefore, it appears inadvisable to follow the current common practice of routinely removing the whole tonsil given its higher morbidity and risk for serious complications.

Pre-surgical child behavior ratings and pain management after two different techniques of tonsil surgery

OBJECTIVE

The purpose of this investigation was to compare child behavior before surgery with experience of pain and anxiety in relation to two techniques of tonsil surgery, to relate previous experiences of surgery/tonsillitis with anxiety and pain, and to compare the children's, parent's and nurse's rating of pain.

METHOD

Ninety-two children (5-15 years) with sleep-disordered breathing (SDB) and with or without recurrent tonsillitis were randomized to partial tonsil resection/tonsillotomy (TT) or full tonsillectomy (TE).

MEASURES

Parents: Child Behavior Checklist (CBCL). Children: State-Trait-Anxiety Inventory for Children (STAIC) and seven-point Faces Pain Scale (FPS). Parents/staff: seven-point Verbal Pain Rating Scale (VPRS). Pain relievers were opoids, paracetamol and diclophenac.

RESULTS

These children with SDB scored significantly higher on CBCL than did normative groups, but no connection was observed between CBCL rating and experience of pain. There was no relation between pre-operative anxiety and pain. The post-operative anxiety level (STAIC) correlated with pain. The TE-group scored higher on STAIC after surgery. Previous experience of surgery or tonsillitis did not influence post-operative pain. The TE-group rated higher experience of pain despite more medication. The nurses scored pain lower than the parents/children and under-medicated.

CONCLUSION

SDB may influence children's behavior, but with no relation to post-operative pain. The surgical method predicts pain better than does the child's behavior rating. The nurses underestimated the pain experienced by the child.

Systematic review on analgesics given for pain following tonsillectomy in children

In this systematic review effectiveness of analgesics for pain after tonsillectomy in children was evaluated and trial methodology of the included studies explored. Databases were searched for randomised, controlled studies on systemic paracetamol, NSAIDs and opioids. Eighty-four studies were evaluated for inclusion. Thirty-six studies were included and 48 excluded. Only in two studies investigated analgesics were given postoperatively for pain. All other studies investigated prophylactic administration of analgesics. Only five studies were truly placebo controlled. Trial methodology of the included studies varied greatly in respect to analgesics and doses used, duration of follow-up periods, methods of pain measurement, rescue analgesics and criteria for administrating rescue analgesia used. Sensitivity of studies was often unclear. Only 16 out of 36 studies were considered to be sensitive. Because of highly variable methodology and lack of sensitivity only limited conclusions on clinical efficacy of analgesics investigated can be drawn. No analgesic in single prophylactic dose provided analgesia for day of operation. Further studies are needed to find the optimal analgesic(s) for pain after tonsillectomy in children.

Laser-tonsillotomy for treatment of obstructive tonsillar hyperplasia in early childhood: a retrospective review

INTRODUCTION

Tonsillar hyperplasia leading to dyspnea, dysphagia and other symptoms of obstruction represents a common problem especially in young children where tonsillectomy should be avoided in order to preserve the immunological function of the tonsils. Aim of the study was to assess carbon-dioxide-laser-tonsillotomy as a considered alternative procedure to reduce the tonsillar volume in these children.

METHODS

Between 1993 and 2004, 109 children with tonsillar hyperplasia without former episodes of tonsillitis received laser-tonsillotomy mostly (n=98) combined with adenoidectomy. The protruding part of the tonsil was reduced by a CO2-laser. Seventy-five children were available for follow-up with a standard questionnaire. Five patients required a subsequent tonsillectomy due to a recurrence of tonsillar hyperplasia. Histological investigations were performed. Twenty-two children were reevaluated by clinical examination.

RESULTS

Most of the patients were relieved from obstructive symptoms. There was no occurrence of postoperative hemorrhage or peritonsillar abscesses. The histological investigations on the specimens from later performed tonsillectomy (n=5) showed no evidence of inflammation or scar formations, but open and deep crypts. The clinical examination did not reveal any signs of chronic infections.

CONCLUSION

In this retrospective study tonsillotomy with CO2-laser in early childhood leads to a long-term elimination of obstructive symptoms due to tonsillar hyperplasia with minimal discomfort for the patient while preserving normally functioning immunocompetent tonsillar tissue. Further prospective studies are planned.

Surgery for obstructive sleep apnoea

BACKGROUND

Obstructive sleep apnoea/hypopnoea syndrome(OSAHS) is the periodic reduction or cessation of airflow during sleep. The syndrome is associated with loud snoring, disrupted sleep and observed apnoeas. Surgery for obstructive sleep apnoea/hypopnoea syndrome aims to alleviate symptoms of daytime sleepiness, improve quality of life, and reduce the signs of sleep apnoea recorded by polysomnography.

OBJECTIVES

The objective of this review was to assess the effects of any type of surgery for the treatment of the symptoms of obstructive sleep apnoea/hypopnoea syndrome in adults.

SEARCH STRATEGY

We searched the Cochrane Airways Group Specialised Register and reference lists of articles. We contacted experts in the field, research dissemination bodies and other Cochrane Review Groups. Searches were current as of July 2005.

SELECTION CRITERIA

Randomised trials comparing any surgical intervention for obstructive sleep apnoea/hypopnoea syndrome with other surgical or non-surgical interventions or no intervention.

DATA COLLECTION AND ANALYSIS

Two reviewers assessed electronic literature search results for possibly relevant studies. Characteristics and data from studies meeting the inclusion criteria were extracted and entered into RevMan 4.2.

MAIN RESULTS

In the 2005 update for this review eight studies (412 participants) of mixed quality met the inclusion criteria. Data from seven studies were eligible for assessment in the review. No data could be pooled. Uvulopalatopharyngoplasty (UPPP) versus conservative management (one trial): An un validated symptom score showed intermittent significant differences over a 12-month follow-up period. No differences in Polysomnography (PSG) outcomes were reported. Laser-assisted uvulopalatoplasty (LAUP) versus conservative management/placebo (two trials): One study recruited mixed a population, and separate data could not be obtained for this trial. In the other study no significant differences in Epworth scores or quality of life reported. A significant difference in favour of LAUP was reported in terms of apnoea hypopnoea index (AHI) and frequency and intensity of snoring. UPPP versus oral appliance (OA) (one trial): AHI was significantly lower with OA therapy than with UPPP. No significant differences were observed in quality of life. UPPP versus lateral pharyngoplasty (lateral PP) (one trial): No significant difference in Epworth scores, but a greater reduction in AHI with lateral PP was reported. Tongue advancement (mandibular osteotomy) + PPP versus tongue suspension + PPP (one trial): There was a significant reduction in symptoms in both groups, but no significant difference between the two surgery types. Complications reported with all surgical techniques included nasal regurgitation, pain and bleeding. These did not persist in the long term. An additional study assessed the effects of four different techniques. No data were available on between group comparisons. Multilevel temperature-controlled radiofrequency tissue ablation (TCRFTA) versus sham placebo and CPAP (one trial): There was an improvement in primary and secondary outcomes of TCRFTA over sham placebo and but no difference in symptomatic improvement when compared with CPAP.

AUTHORS' CONCLUSIONS

There are now a small number of trials assessing different surgical techniques with inactive and active control treatments. The studies assembled in the review do not provide evidence to support the use of surgery in sleep apnoea/hypopnoea syndrome, as overall significant benefit has not been demonstrated. The participants recruited to the studies had mixed levels of AHI, but tended to suffer from moderate daytime sleepiness where this was measured. Short-term outcomes are unlikely to consistently identify suitable candidates for surgery. Long-term follow-up of patients who undergo surgical correction of upper airway obstruction is required. This would help to determine whether surgery is a curative intervention, or whether there is a tendency for the signs and symptoms of sleep apnoea to re-assert themselves, prompting patients to seek further treatment for sleep apnoea.

Long-term effects of intracapsular partial tonsillectomy (tonsillotomy) compared with full tonsillectomy

OBJECTIVE

To compare the long-term effects (six years after surgery) of two techniques for pediatric tonsil surgery with respect to snoring, apneas, eating difficulties, infections and general health. The two methods were intracapsular partial tonsillectomy (tonsillotomy, "TT") using CO(2)-laser technique and traditional (total) blunt dissection tonsillectomy (TE).

STUDY DESIGN

A questionnaire distributed by mail to the parents of children, who, in 1998, were included in a prospective clinical randomized study in one tertiary care ENT clinic.

METHOD

A 10 question survey follow-up of 41 children, between 9 and 15 years of age, who originally, six years earlier had been randomized to either TT with CO(2)-laser (n=21) or TE (n=20). The main indication for the surgery was a history of sleep related breathing distress (SRBD). Before the present study, all of the children had participated in earlier follow-ups at six months and one year after surgery.

RESULTS

All the children in both groups answered the questionnaire. There were no significant differences between the answers from the two groups in any respects: the effect on snoring and apneas was equally stable for both groups. The number of children who remained free from snoring decreased from 40 after the first year to 25 after six years (11 TT, 14 TE). Snoring in the recurrent cases was not rated to be as frequent or as loud as before the surgery. Infections of the upper respiratory tract (URI) that had been treated with antibiotics occurred to the same extent in both groups. None had eating difficulties. The patients' satisfaction with the results of the surgery was high or very high in 18/21 TT and 20 TE cases, and the vast majority of the parents rated their children's present health status as improved compared with the preoperative condition.

CONCLUSION

Tonsillotomy with CO(2)-laser seems to be a reliable method for tonsil surgery with substantially less primary morbidity than conventional tonsillectomy and with the same positive long-term effects after six years.

Safety and efficacy of powered intracapsular tonsillectomy in children: a multi-center retrospective case series

OBJECTIVE

To determine the efficacy of powered intracapsular tonsillectomy (PIT, e.g. regrowth rate) in children who underwent PIT at three different institutions. We also wanted to determine if the trend to greater safety through reduced bleeding and re-admission for dehydration, noted in our initial reports, would become statistically significant in a larger sample.

STUDY DESIGN AND SETTING

Multi-center retrospective case series.

PATIENTS AND METHODS

We retrospectively reviewed all charts' of children who underwent PIT at three different institutions: the Children's Hospital at the Cleveland Clinic, Alfred I. DuPont Hospital for Children, and the New York Otolaryngology Institute. For comparison, we reviewed the outpatient and inpatient records of all children who underwent conventional tonsillectomy performed by the same surgeons at the Children's Hospital at the Cleveland Clinic and Alfred I. DuPont Hospital for Children during the same period. No comparison group was available for the New York Otolaryngology Institute group. Three outcome measures were recorded: regrowth, bleeding and re-admission for dehydration rates. All statistical analyses were performed using SAS, and P < 0.05 was considered statistically significant.

RESULTS

We identified 870 children that underwent PIT at three different institutions. In addition, 1121 children underwent conventional tonsillectomy at two of the three institutions. The mean follow-up for the PIT group was 1.2 years (range, 0.1-2.6 years) and 1.5 years (range, 0.1-3.0 years) for the conventional tonsillectomy group. The incidence of and 95% CI for the outcome measures were as follows regrowth 0.5% (0%, 1.4%), delayed post-operative bleeding 0.7% (0%, 1.9%), re-admission for dehydration 1.3% (0.05%, 2.6%), and overall major complications 0.46% (0.009%, 0.9%). When comparing conventional tonsillectomy to PIT, the bleeding rate, re-admission for dehydration, and the overall incidence of major complications were significantly lower in the PIT group (P = 0.001, P = 0.002, and P < 0.001, respectively).

CONCLUSION

PIT is a safe and effective technique in the management of obstructive sleep disordered breathing in children. PIT has the advantages of decreased pain, dehydration and post-operative bleeding, and with a mean follow-up of 1.2 years, a low incidence of tonsillar regrowth thus far.

Radiofrequency Volume Tissue Reduction of the Tonsils: Case Report and Histopathologic Findings

Innovative new techniques to resect tonsillar tissue have been described in the recent literature. We report the case of a patient who underwent volume reduction of tonsillar tissue by radiofrequency energy under local anesthesia in an office setting. Treatment resulted in a reduction of tonsillar size with minimal pain, which can be attributed to the avoidance of mucosal interruption. The patient subsequently underwent standard tonsillectomy, which allowed us to examine the histopathology of the tissue that was treated with radiofrequency. In doing so, we noted an absence of fibrosis and preservation of normal histologic architecture. We conclude that performing volume reduction of tonsillar tissue by applying radiofrequency energy to the stroma of the tonsils without temperature control results in objective improvement in airway size with minimal effects on the histopathology of the tonsillar stroma. Mucosa-sparing tonsillar reduction may be a preferable alternative to other techniques of tonsillar reduction, especially for young children, who would experience a nearly pain-free procedure.

Imagery reduces children's post-operative pain

This un-blinded experimental study investigated the effectiveness of imagery, in addition to routine analgesics, in reducing tonsillectomy and/or adenoidectomy pain and anxiety after ambulatory surgery (AS) and at home. Seventy-three children, aged 7-12, were recruited from five AS settings. Thirty-six children randomly assigned to the treatment group watched a professionally developed videotape on the use of imagery and then listened to a 30-min audio tape of imagery approximately 1 week prior to surgery (T1). They listened to only the audio tape 1-4 h after surgery (T2), and 22-27 h after discharge from AS (T3). The 37 children in the attention-control group received standard care. Pain and anxiety were measured at each time-point in both groups. Measures of sensory pain were the Oucher and amount of analgesics used in AS and home; affective pain was measured with the Facial Affective Scale (FAS). Anxiety was measured using the State Trait Anxiety Inventory for Children (STAIC). When controlling for trait anxiety and opioid and non-opioid intake 1-4 h before the pain measures, MANCOVA showed significantly lower pain and anxiety in the treatment group at T2, but not at T3. When controlling for trait anxiety, a two-way RM MANCOVA indicated no significant group differences in combined opioid and non-opioid use between the groups, or between times. Appropriately trained health care providers should use imagery to reduce post-operative pain following tonsillectomy and/or adenoidectomy in AS. Teaching parents about adequate home administration of analgesics may increase the effectiveness of imagery at home.

Pediatric Tonsillotomy with the Radiofrequency Technique: Less Morbidity and Pain

OBJECTIVE

To compare two techniques for pediatric tonsil surgery with respect to pain and postoperative morbidity. The two methods were the partial tonsil resection using radiofrequency (RF) technique (tonsillotomy [TT]) versus traditional tonsillectomy (TE).

STUDY DESIGN

Prospective clinical randomized study in one tertiary care ENT clinic and two secondary care clinics.

METHOD

One hundred fifty children, between 5 and 15 years of age, were randomized to either TT with RF using the Surgitron Ellman, 1.7 MHz, or regular TE. Randomization was performed from the waiting list, including children with both a history of obstructive problems and recurrent tonsillitis. The TT was performed with a specially made sling electrode using a cut/coagulation mode.

RESULTS

Forty-nine children were operated on with TT and 43 with TE. There was significantly less bleeding in the TT group, although two cases of primary postoperative bleeding occurred among the TT children and one in the TE group. The pain recordings showed significantly less pain for the TT children from the second hour postoperatively onward, and the TT children were pain free and in school 3 days earlier than the TE group. The TT group had less need of the prescribed drugs (diclofenac and paracetamol). After 9 days, 73% of the TT children were completely healed, but only 31% of the TE children. By that time, the TE children had lost a mean of 660 g, and the TT children had gained 127 g. The effect on snoring was the same for both groups.

CONCLUSION

RF appears to be a safe and reliable method for tonsil surgery with much less postoperative morbidity than regular TE.

Complications of Microdebrider-Assisted Powered Intracapsular Tonsillectomy and Adenoidectomy

OBJECTIVES

To study complications of powered intracapsular tonsillectomy and adenoidectomy (PITA) in pediatric patients with obstructive sleep apnea (OSA).

STUDY DESIGN

Retrospective chart review and long-term follow-up in office or by telephone interview.

METHODS

We studied 278 patients who underwent PITA between September 2000 and October 2002. Outcome measures were postoperative bleeding, velopharyngeal insufficiency, need for hospital readmission, tonsil regrowth, and return of snoring or sleep apnea symptoms.

RESULTS

All 278 children treated by PITA had immediate resolution of symptoms of OSA. Complications were noted in 11 patients (3.9%). Nine patients (3.2%) experienced tonsil regrowth with snoring, two of whom evolved to a return of OSA that was definitively managed by means of a complete tonsillectomy. Two patients (0.7%) had self-limited bleeding. None of the patients developed persistent velopharyngeal insufficiency or required hospital readmission.

CONCLUSIONS

Microdebrider-assisted PITA is a safe and effective alternative for children otherwise treated with traditional tonsillectomy for symptoms of OSA due to adenotonsillar hypertrophy. This series suggests a 3.9% overall rate of complications, with the most common noted as tonsillar regrowth without recurrence of OSA. Prospective trials with longer follow-up may define higher complication rates.

Outpatient laser tonsillar ablation under local anaesthetic

Outpatient laser ablation of the palatine tonsils under local anaesthetic is an alternative technique to capsular tonsillectomy for recurrent tonsillitis under general anaesthetic. Laser tonsillotomy ablates up to 70% of the tonsillar tissue and is performed when patients choose not to have a conventional tonsillectomy, or are unfit for a general anaesthetic. The technique described here is an adaptation of Krespis' laser-assisted serial tonsillectomy (LAST) whereby only one sitting is required. Krespis' technique effectively eliminates recurrent tonsillitis in 96% of the cases over a 4-year follow-up period and represents the only substantial study looking at treating recurrent tonsillitis with outpatient laser ablation. This study is a retrospective postal survey of 19 patients who underwent laser tonsillar ablation under local anaesthetic for recurrent chronic tonsillitis from 1997 to 2001 and was performed in liaison with the clinical audit department at Basildon Hospital. We had a response rate of 74% and an admission rate of 0%, which compares favourably with day case tonsillectomy surgery. Of the patients, 75% did not experience further episodes of tonsillitis 12 months after the procedure and 77% of the patients were glad they had the operation. Although this technique does not completely eliminate tonsillitis, it offers an alternative for those patients who prefer a procedure that is done quickly in an outpatient setting without the additional problems of general anaesthesia, overnight hospital admission and long waiting lists.

Intracapsular Tonsillar Reduction (Partial Tonsillectomy): Reviving a Historical Procedure for Obstructive Sleep Disordered Breathing in Children

OBJECTIVE: We sought to reintroduce a historical procedure—intracapsular tonsillar reduction (partial tonsillectomy or tonsillotomy)—for tonsillar hypertrophy causing obstructive sleep disordered breathing (OSDB) in children, as well as to determine whether partial tonsillectomy, compared with conventional (total) tonsillectomy when performed by more than one surgeon, is equally effective for the relief of OSDB while resulting in less pain and more rapid recovery.

STUDY DESIGN: We conducted a retrospective case series at a tertiary children's hospital. The charts of children who underwent partial tonsillectomy and total tonsillectomy (1998 through 2002) for postoperative complications were reviewed. The caregivers were surveyed to assess postoperative pain, rapidity of recovery, and effectiveness of surgery for relieving symptoms of OSDB.

RESULTS: Two hundred forty-three children underwent partial tonsillectomy and 107 children underwent total tonsillectomy. There were no significant differences in immediate and delayed complications between the groups. Both operations were equally effective in relieving OSDB. Children who had partial tonsillectomy had significantly less postoperative pain and significantly more rapid recovery.

CONCLUSION: Intracapsular tonsillar reduction with an endoscopic microdebrider relieves OSDB as effectively as conventional tonsillectomy, but results in less postoperative pain and a more rapid recovery.

Tonsillectomy--clinical consequences twenty years after surgery?

Tonsillectomy (T) is one of the most common surgical procedures performed on children. Long-term follow-up studies concerning its consequences are lacking. This study is the first study done on a group of patients that underwent T in their childhood, about 20 years ago. The investigation is a cohort study, which followed-up 18 patients who were tonsillectomized 20 years ago. It was to be determined whether these subjects suffer from more respiratory tract infections (or other infections) today, than people who are not tonsillectomized. A group of 54 age-matched subjects were selected for comparison. A questionnaire was mailed to the study population. No significant differences were found between the groups in the frequency of upper respiratory tract infection (URI). The mean number of URI's was approximately [MSOffice1]2.5 per year in both groups. The duration of the URI's was identical in each group. A high temperature was present to the same extent in each group. Absence from work, number of visits to physicians and the use of antibiotics were the same in each group. However, the prevalence of chronic disease was greater in the T-group than in the comparison group. The difference was significant with a Relative Risk of 9.41 and a Confidence Interval differing from 1 (1.13<RR<78.14) for the T-population to develop chronic disease. Because of the small number of the present study population, the results must be validated by further immunological and epidemiological studies on long-term effects of tonsillectomy.

Radiofrequency tonsil reduction: safety, morbidity, and efficacy

OBJECTIVES

To evaluate the safety, morbidity, and efficacy of radiofrequency tissue volume reduction of tonsils using two different surgical techniques and to compare these two techniques with each other and with classic tonsillectomy.

STUDY DESIGN

A nonrandomized retrospective review of tonsil reductions was made between 2000 and 2002 using in vivo studies associated with tonsil reduction and tonsillectomy performed either in the hospital operating room or in the outpatient treatment area.

METHODS

We studied 150 patients and divided them into three main groups based on surgical technique. Group A consisted of 50 consecutive patients who underwent tonsil "ablation," Group B contained another 50 consecutive individuals who received tonsil "coblation," and Group C consisted of 50 patients who underwent classic tonsillectomy (cold dissection). Each group consisted of two subcategories of children (age range, 1-12 y) and adults (age range, 12-60 y) with chronic tonsillar hypertrophy. Most of the pediatric patients underwent adenoidectomy during the same surgical procedure. Indications for tonsillectomy were those listed by the American Academy of Otolaryngology-Head and Neck Surgery. A retrospective chart review was used to assess procedures, safety, morbidity, and efficacy of tonsil reduction and tonsillectomy. Four specific end points of morbidity were investigated: pain, return to normal diet, return to normal activity, and use of pain medication. Efficacy of tonsillectomy was determined by the clinical observation of the remaining tonsillar tissue and compared with pretreatment photographs of the tonsils.

RESULTS

There were no complications in any of the groups. Efficacy was assessed based on the mean tonsil reduction and was found to be 100% for tonsillectomy, 86% for the tonsil coblation technique, but only 53.6% for the ablation technique. Morbidity was minimal in groups A and B and significantly greater in Group C. The number of pain days, narcotic-use days, and days before return to normal diet and activity were greatly reduced in groups A and B when compared with classic tonsillectomy (group C). Pain levels on day 1 were less than 3 (on a scale of 1-10) in groups A and B. The number of pain days and narcotic-use days was less than 4 days in groups A and B. Similarly, most patients returned to solid diet and normal activity by day 4. Pain levels, number of narcotic-use days, and number of days to return to normal diet and activity were significantly higher for classic tonsillectomy.

CONCLUSIONS

Tonsil coblation has distinct advantages when compared with tonsil ablation and standard tonsillectomy. Tonsil coblation resulted in greater than 86% elimination of tonsillar tissue in both children and adults. In most patients, pain levels were minimal and limited to the first 48 hours after surgery. Return to normal diet and activity was much earlier in the coblation group versus classic tonsillectomy.

Treatment of obstructive sleep apnea in children: do we really know how?

Obstructive sleep apnea syndrome (OSAS) is a frequent, albeit underdiagnosed problem in children. If left untreated, OSAS may lead to substantial morbidities affecting multiple target organs and systems. The immediate consequences of OSAS in children include behavioral disturbance and learning deficits, pulmonary hypertension, as well as compromised somatic growth. However, if not treated promptly and early in the course of the disease, OSAS may also impose long-term adverse effects on neurocognitive and cardiovascular function, thereby providing a strong rationale for effective treatment of this condition. This review provides a detailed description of the current treatment modalities for pediatric OSAS, and uncovers the potential limitations of the available data on these issues. Furthermore, we postulate that OSAS will persist relatively often after tonsillectomy and adenoidectomy, and that critical studies need to be conducted to identify such patients and refine the clinical management algorithm for pediatric OSAS.