Factors influencing morbidity after paediatric tonsillectomy: a study of 18,712 patients in the National Tonsil Surgery Register in Sweden

Long-term complications after tonsil surgery: an analysis of 54,462 patients from the Swedish Quality Register for Tonsil Surgery

Objective

This study aims to evaluate long-term complications after tonsil surgery using an exploratory retrospective cohort study design based on data from the Swedish Quality Register for Tonsil Surgery (SQTS).

Methods

All patients registered in the SQTS between 1 January 2009 and 31 May 2021 were eligible for the study. In this study, a long-term complication is defined as any complication persisting for a minimum of 6 months after surgery. The definition of a complication was based on individual patient reports, provided in a free text format, of any remaining issues 6 months after tonsil surgery. Complications were categorized as follows: disturbed taste or sense of smell, dysphagia, miscellaneous and general symptoms and signs, miscellaneous throat problems, pain or discomfort in the mouth or throat, problems with jaws or teeth, problems with the ears or hearing, problems with the nose or sinuses, problems with throat secretions or throat clearing, problems with voice or speech, and sensory symptoms. A multivariable logistic regression analysis was used to identify independent predictors of long-term complications.

Results

In total, 54,462 patients were included in the study. A total of 3,780 patients (6.9%) reported one or more long-term complications. The most frequent long-term complications, with a plausible connection to the surgery, were found in the following categories: pain or discomfort in the mouth or throat (1.9%), problems with throat secretions or throat clearing (0.8%), dysphagia (0.6%), and problems with voice or speech (0.6%). Tonsillotomy was associated with a lower risk of long-term complications than tonsillectomy.

Conclusion

This study suggests that subjective long-term complications after tonsil surgery, in general, are relatively common (6.9%). However, complications with a plausible connection to the surgery were less common (4.0%), and specific complications seemed to be relatively rare, with no single specific problem reaching a prevalence of ≥0.6%.

Adenotonsillectomy and adenoidectomy in children: The impact of timing of surgery and post-operative outcomes

AIM

To investigate the impact of adenotonsillectomy (ADT) and adenoidectomy (AD) on child health and evaluated their post-operative complications.

METHODS

We included all children aged <16 years undergoing ADT (tonsillectomy ± adenoidectomy) or AD in New South Wales, Australia, 2008-2017. Health information was obtained from administrative hospitalisation data. Rates of post-operative complications and reoperation were evaluated using generalised estimating equations and Kaplan-Meier methods, respectively.

RESULTS

Out of 156 500 included children, 112 361 had ADT and 44 139 had AD. Population rates increased during 2008-2017 (ADT: 68-79 per 10 000 children; AD: 25-34 per 10 000), and children were increasingly operated on at a younger age. Overall, 7262 (6.5%) and 1276 (2.9%) children had post-operative complications (mostly haemorrhage), and 4320 (3.8%) and 5394 (12.2%) required reoperation, following ADT and AD, respectively. Complication rates were highest among children aged 0-1 years, lowest for those 2-5 years and increased with age thereafter. Three-year reoperation rates for children aged 0-1 years were 9.0% and 25.9% following ADT and AD, respectively, decreasing thereafter to 0.5% and 2.1% in children aged 12-13 years.

CONCLUSIONS

ADT and AD in Australian children have both increased in frequency and are being done at a younger age. Post-operative complications and reoperation rates highlight surgery is not without risk, especially for children under 2 years old. These findings support a more conservative approach to management of upper respiratory symptoms, with surgery reserved for cases where potential benefits are most likely to outweigh harms.

Comparison of perioperative indicators, treatment efficacy, and postoperative complications between tonsillotomy and tonsillectomy for children with obstructive sleep apnea hypopnea syndrome

OBJECTIVE

This study aimed to compare the perioperative indicators, treatment efficacy, and postoperative complications between tonsillotomy and tonsillectomy for children with obstructive sleep apnea hypopnea syndrome.

METHODS

A total of 134 children with obstructive sleep apnea hypopnea syndrome were divided into tonsillotomy group (n=66) and tonsillectomy group (n=68). The tonsillotomy group received tonsillotomy treatment with a power cutter, while the tonsillectomy group received tonsillectomy treatment. The perioperative indicators, treatment efficacy, and postoperative complications were compared between the two groups.

RESULTS

There was no significant difference in operative time between the two groups (p>0.05), with significant difference in amount of blood loss, postoperative Visual Analogue Scale score, food intake amount, and general diet-taking starting time between the two groups (p<0.05). The total effective rate of treatment had no significant difference between the two groups (p>0.05). There was significant difference in postoperative bleeding, upper respiratory tract infection, and pharyngeal scar grade between the two groups (p<0.05).

CONCLUSIONS

Compared with tonsillectomy treatment for children with obstructive sleep apnea hypopnea syndrome, tonsillotomy treatment is more beneficial to optimize the perioperative indicators, relieve the postoperative pain, facilitate the postoperative recovery, and reduce the postoperative complications, which is worthy of clinical promotion.

A validation study of data in the National Tonsil Surgery Register in Sweden: high agreement with medical records ensures that data can be used to monitor clinical practices and outcomes

BACKGROUND

The ambition of the National Tonsil Surgery Register in Sweden (NTSRS) is to improve otorhinolaryngological care by monitoring trends in the clinical practices, complications, and outcomes of tonsil surgery. The NTSRS collects data from both surgeons and patients and provides the participating clinics with daily updated data on a publicly available website. On the website, national and local results can be compared and monitored. The use of NTSRS data necessitates that the data is valid, but the NTSRS has not yet been validated. With approximately half of the registered patients responding to the postoperative questionnaires, an analysis of responders and non-responders is also necessary. The aim of this study was to assess the criterion validity of NTSRS data. Another aim was to compare the characteristics and rates of complications between postoperative questionnaire responders and non-responders.

METHODS

Data in the NTSRS were compared with data in electronic medical records. The 200 most recent surgeries, up to 31 Dec 2019, in each of 11 surgical units were included. Criterion validity was analysed in terms of observed agreement, Cohens kappa, Gwet's AC₁, and positive and negative agreement. The sign test was used to analyse systematic differences between the NTSRS and the medical records. Comparisons of rates between groups were made with Fisher's exact test, the chi-square test, and Fisher's non-parametric permutation test.

RESULTS

A total of 1991 registrations were included in the study. All variables showed very high observed agreement ranging from 0.91 to 1.00, and all variables had AC₁ values corresponding to almost perfect agreement. The analysis of questionnaire responders and non-responders showed no statistically significant differences regarding age, indication, or type of surgery. The proportion of women was higher in the responder group. The rate of reoperation due to bleeding was higher in the responder group, but there were no differences regarding other complications.

CONCLUSIONS

The results of this study show that data in the NTSRS have criterion validity. The NTSRS is thus well suited for monitoring the clinical practices and outcomes of tonsil surgery. The quality of the data also implies that the registry can be used in both clinical improvement projects and research.

A randomized, double-blinded, placebo-controlled, single dose analgesic study of preoperative intravenous ibuprofen for tonsillectomy in children

PURPOSE

Tonsillectomy is a recognized treatment for children with tonsil hypertrophy and results in significant postoperative oropharyngeal pain. Fentanyl and other morphine-like analgesics are widely used as perioperative analgesia but are associated with side effects such as vomiting, nausea, and respiratory depression. As the least toxic non-steroidal anti-inflammatory drug, ibuprofen may be effective and safe for pain control after tonsillectomy. We aimed to explore whether the addition of intravenous (IV) ibuprofen administered at induction can reduce the need for early postoperativeanalgesics.

STUDY DESIGN AND METHODS

This randomized, double-blind, controlled clinical trial enrolled 95 pediatric patients who underwent tonsillectomy. Participants aged 6 months to 12 years were randomly assigned to either the experimental and control groups (1:1). The children were premedicated 15 min before surgery with IV ibuprofen 10 mg kg^-1 or placebo (normal saline). Pain was scored at 15, 30, and 120 min after extubation, and IV fentanyl (0.5 mcg kg^-1) was administered when the Faces, Legs, Activity, Cry, and Consolability (FLACC) Scale was ≥7 and deemed appropriate by the nursing staff in the post-anesthesia care unit (PACU). The visual analog scale was used as a supplementary evaluation for older children (≥7 years old) who were awake and could self-report pain. The primary outcome variable was the number of patients who received postoperative analgesia.

RESULTS

The requirement for rescue fentanyl was reduced by 18% with the addition of IV ibuprofen (P = 0.043). There were no signficant differences in the amount of fentanyl administered postoperatively (P = 0.127). Compared with the placebo group, the number of children who needed more than one dose of rescue fentanyl decreased in the experimental group, but the differences were not significant (P = 0.056). There were no significant differences between the groups in terms of operative blood loss (P = 0.978), vomiting, or postoperative bleeding (P = 0.474).

CONCLUSION

It is safe to administer IV ibuprofen 15 min before tonsillectomy, and it can significantly reduce the need for rescue fentanyl. IV ibuprofen should be considered as an important part of the multimodal approach for postoperative analgesia in children.

CLINICAL TRIAL REGISTRATION

Chictr.org.cn, identifier: ChiCTR2100044508.

Tonsillectomy in Adults over 40 Years of Age Does Not Increase the Risk of Pneumonia: A Three-Year Longitudinal Follow-Up Study

To evaluate the effect of tonsillectomy on the subsequent risk of pneumonia in an adult population, a longitudinal follow-up case control study was conducted using a national health screening cohort dataset between 2003 and 2012. A total of 1005 tonsillectomy participants were 1:4 matched with 4020 control participants for age, sex, income, and region of residence. The number of pneumonia diagnoses were counted from the index date (ID) to the date after the first-year (post-ID 1y), second-year (post-ID 2y), and third-year (post-ID 3y) periods. Simple linear regression and multiple linear regression were conducted to calculate estimated values (EVs) and 95% confidence intervals for each post-ID pneumonia and compared between the two groups. Subgroup analyses were performed according to age, sex, and the number of pneumonia cases during the year prior to the ID (pre-ID 1y). In the simple linear regression model, post-ID pneumonia did not show a significant correlation with tonsillectomy (post-ID 1y: EV = 0.003; post-ID 2y: EV = 0.007; post-ID 3y: EV = 0.013; all p > 0.05). In the multiple regression model, post-ID pneumonia also did not show a significant correlation with tonsillectomy (post-ID 1y: EV = 0.001; post-ID 2y: EV = 0.006; post-ID 3y: EV = 0.011; all p > 0.05). In the subgroup analyses, tonsillectomy did not show a significant correlation with post-ID pneumonia in either the simple linear regression or multiple linear regression models (all p > 0.05). Tonsillectomy performed in the adult population did not show any effect in increasing the incidence of pneumonia during the first three postoperative years.

Very-Low Energy Monopolar Reduces Post-Tonsillectomy Hemorrhage Versus Standard Energy Techniques

OBJECTIVES/HYPOTHESIS

To compare rates of post-tonsillectomy hemorrhage (PTH) between a very-low energy transfer monopolar technique (VLET) and standard energy techniques.

STUDY DESIGN

Retrospective controlled cohort study.

METHODS

All tonsillectomies performed by practice physicians during the period January 1, 2010 to August 31, 2019 were identified. Three groups were created based on surgeon technique utilization: the study group (VLET) and two control groups (exclusive standard energy monopolar [Standard]; exclusive "hot" technique without exclusive monopolar use [Mixed "Hot"]). Each group's PTH occurrences requiring surgical intervention (PTHRSI) were identified and rates compared.

RESULTS

During the study period 11,348 tonsillectomies were performed (4,427 Standard, 1,374 VLET, 5,547 Mixed "Hot"), and 167 (1.47%) PTHRSI events identified (14 primary (<24 hours), 153 secondary (>24 hours), 12 repeat (>1PTHRSI/patient). Compared to the Standard group secondary and total PTHRSI rates (1.47%, 1.60%), the Mixed "Hot" group experienced similar rates (1.57%, P = .54; 1.68%, P = .64), but the VLET group experienced significantly lower rates (0.15%, P = .0026, adjusted odds ratio [OR] 0.114 [0.028-0.469]; 0.22%, P = .0016, adjusted OR 0.155 [0.048-0.494]). Age was a significant risk factor for both secondary and total PTHRSI (P = .0025, P = .0024, adjusted OR 1.02/year [1.01-1.03]). No significant difference in rate of primary PTHRSI was seen collectively or in any age group. The <12VLET Group experienced 0 episodes of secondary PTHRSI and a total PTHRSI rate of 0.09% in 1060 tonsillectomies.

CONCLUSIONS

Standard energy techniques had an adjusted odds ratio over 8-fold higher for secondary PTHRSI and over 6-fold higher for total PTHRSI compared to the minimized energy transfer VLET technique.

LEVEL OF EVIDENCE

3 Laryngoscope, 2021.

Effect of tonsillectomy on antibiotic prescribing in children

INTRODUCTION

Tonsillectomy is the second most common surgical procedure performed in pediatric otolaryngology. Multiple courses of antibiotics are usually prescribed prior to surgical intervention. Surgery is indicated when patients reach a certain number of infective episodes, or their obstructive symptoms warrant intervention. Little is known about the role of tonsillectomy on long term postoperative antibiotic use. Recently, our group published a retrospective case series that described the clinical characteristics and outcomes of children under the age of 16 years who underwent tonsillectomy. This study is a follow-up on this previous case series and its purpose is to determine whether tonsillectomy in this group of children led to a reduction in the number of antibiotics prescribed in the year following surgery.

METHODS

Data were collected from the clinical records departments of two district health boards in Auckland, New Zealand. Hospital morbidity records were reviewed for all children younger than 16 years old, who underwent a tonsillectomy between December 2015 and December 2017 in the Auckland region. All antibiotics prescribed following surgery were obtained from New Zealand's national community prescribing database.

RESULTS

A total of 1538 children underwent tonsillectomy during the study period. Following surgery, antibiotics were prescribed to 828 (54%) patients at the time of discharge, with an average of 1.2 ± 0.1 courses in the year following surgery. This was significantly reduced compared to preoperative antibiotic intake (3.4 ± 0.1 courses) in the year preceding surgery (p < 0.001). Readmission within 30 days of discharge was not associated with increased antibiotic usage postoperatively. In the two weeks following surgery, 25% of patients were prescribed a course of antibiotics for a presumed postoperative infection.

CONCLUSIONS

These findings support the benefit of tonsillectomy in reducing antibiotic consumption in the year following surgery. Furthermore, it has highlighted areas of practice, such as perioperative antibiotic prescription, which can be improved to further reduce the prescription of antibiotics for children with tonsillar hyperplasia.

The first experiences of implementation of the Swedish tonsil register in Denmark

Background: Tonsil surgery is a daily procedure at Ear, Nose and Throat (ENT) departments as well as ENT practices. Despite national tonsil guidelines in Denmark, no national survey has been introduced.Objectives: To display the process of implementing a Danish version of the Swedish tonsil register including a presentation and validation of the first year's results.Methods: The Swedish tonsil register was translated into Danish. Minor modifications were executed and the register was implemented at the ENT department, Region Hospital West Jutland, Denmark. All patients undergoing surgery due to benign tonsil and/or adenoid diseases were eligible. Written informed consent was obtained. Indication for surgery, comorbidity, surgical and haemostasis techniques, and complications were registered by the surgeon.Results: Several obstacles were encountered due to legal procedures, daily work, IT organisation, and discontinuous information. 58% of eligible patients were registered. The incidence of post-tonsillectomy haemorrhage requiring secondary surgery was 6.4%. The potential underlying risk factors were easily retrieved from the register.Conclusions and significance: The Danish version of the national Swedish tonsil database is a useful, easily accessible, and informative tool for monitoring and validation of tonsil/adenoid surgery. We recommend a nationwide register with a central steering committee.

Virtual reality exposure before elective day care surgery to reduce anxiety and pain in children: A randomised controlled trial

BACKGROUND

Pre-operative anxiety in children is very common and is associated with adverse outcomes.

OBJECTIVE

The aim of this study was to investigate if virtual reality exposure (VRE) as a preparation tool for elective day care surgery in children is associated with lower levels of anxiety, pain and emergence delirium compared with a control group receiving care as usual (CAU).

DESIGN

A randomised controlled single-blind trial.

SETTING

A single university children's hospital in the Netherlands from March 2017 to October 2018.

PATIENTS

Two-hundred children, 4 to 12 years old, undergoing elective day care surgery under general anaesthesia.

INTERVENTION

On the day of surgery, children receiving VRE were exposed to a realistic child-friendly immersive virtual version of the operating theatre, so that they could get accustomed to the environment and general anaesthesia procedures.

MAIN OUTCOME MEASURES

The primary outcome was anxiety during induction of anaesthesia (modified Yale Preoperative Anxiety Scale, mYPAS). Secondary outcomes were self-reported anxiety, self-reported and observed pain, emergence delirium, need for rescue analgesia (morphine) and parental anxiety.

RESULTS

A total of 191 children were included in the analysis. During induction of anaesthesia, mYPAS levels (median [IQR] were similar in VRE, 40.0 [28.3 to 58.3] and CAU, 38.3 [28.3 to 53.3]; P = 0.862). No differences between groups were found in self-reported anxiety, pain, emergence delirium or parental anxiety. However, after adenoidectomy/tonsillectomy, children in the VRE condition needed rescue analgesia significantly less often (55.0%) than in the CAU condition (95.7%) (P = 0.002).

CONCLUSION

In children undergoing elective day care surgery, VRE did not have a beneficial effect on anxiety, pain, emergence delirium or parental anxiety. However, after more painful surgery, children in the VRE group needed rescue analgesia significantly less often, a clinically important finding because of the side effects associated with analgesic drugs. Options for future research are to include children with higher levels of anxiety and pain and to examine the timing and duration of VRE.

TRIAL REGISTRATION

Netherlands Trial Registry: NTR6116.

Practice, complications and outcome in Swedish tonsil surgery 2009-2018. An observational longitudinal national cohort study

Background: To assure a high quality in tonsil surgery, it is necessary to monitor trends in clinical practice, complications and outcome.Aims/objectives: To describe rates and trends regarding indications, methods, techniques, complications, and outcome of tonsil surgery.Material and method: 98 979 surgeries from the National Tonsil Surgery Register 2009-2018. Groups were categorised by indication and method.Results: The proportion of patients undergoing tonsillotomy with adenoidectomy due to obstruction-snoring (mean age 5.3 y.) increased from 2009-2018. Hot tonsillectomy, but not tonsillotomy, techniques were related to a higher risk for postoperative bleeding. The use of cold techniques increased for all types of surgeries. The rates of patients reporting contact due to postoperative pain were associated with indication and method, with the lowest rate reported for tonsillotomy (4.5% in 2018) and the highest for tonsillectomy (34.5% in 2009). The rate of patients reporting that their symptoms were gone 6 months after surgery decreased.Conclusions and significance: All hot tonsillectomy techniques should be avoided as they are related to a higher risk for postoperative bleeding. The high rate of postoperative contacts due to pain after tonsillectomy indicates a need for improvement in pain management. The declining rates of symptom relief must be investigated further.

Regional variability of hemorrhage following tonsil surgery in 1,520,234 cases

PURPOSE

To evaluate, whether the regional variability of tonsil surgery in terms of the 16 Federal States of Germany was mirrored by a comparable variability of bleeding complications in male and female patients.

METHODS

A longitudinal population-based inpatient cohort study was performed including all patients who had undergone tonsil surgery between 2005 and 2018. The database was provided by the Federal Statistical Office of Germany and included all inpatient cases after tonsillectomy (with or without adenoidectomy), tonsillotomy, abscess-tonsillectomy and secondary tonsillectomy. The population was stratified by region (16 Federal States) and gender. Operation rates were calculated in relation to the end-year population number of each region. Bleeding percentages were calculated for each calendar year and region as the number of procedures to achieve hemostasis divided by the total number of operations.

RESULTS

The surgical rates varied significantly between the 16 Federal States in male, female and all patients (p = 0.001). Revision surgery to achieve hemostasis was predominantly performed in male patients (5.2-11.4% male vs. 3.7-7.6% female patients). Bleeding percentages did not differ significantly from national values in male and female patients in 5 Federal States, but were significantly higher than the national average in 3 Federal States and significantly lower in 7 Federal States for both genders (p < 0.05), while in 1 Federal State it was significantly lower only for the male patients. Pearson's correlation coefficient for surgical and bleeding rates was positive and statistically significant (p < 0.05) for all Federal States, except for two. This phenomenon was emphasized by female gender.

CONCLUSIONS

Gender had an impact not only on surgical rates but also on bleeding percentages and this was independent from the decrease in the total number of operations. Surprisingly, there was a clear correlation between the rates of both variables in the majority of the Federal States of Germany. It needs further studies to clarify, why a higher prevalence of surgical practice, thus surgical experience, was not followed by lower bleeding complications.

Self-Reported Complications after Tonsillectomy: Comparison of Responders and Nonresponders to a Mailed Questionnaire

Some studies of tonsillectomy outcomes have low response rates to mailed quality control questionnaires. This study evaluated the effect of nonresponders to mailed questionnaires about posttonsillectomy complications by determining whether mail responders and nonresponders differ. Questionnaires were mailed to patients 3-6 weeks after tonsillectomy to assess postoperative complications, defined as contact with a private practitioner and/or hospital readmission related to postsurgical bleeding, pain, or infection. Nonresponders to the mailed questionnaire were interviewed by telephone 7-11 weeks postoperatively, and responses of mail and telephone responders were compared. Of 818 patients undergoing tonsillectomy during the study period, 66.3% responded by mail, and 29.5% were interviewed by telephone, for a total response rate of 95.7%. The mail response rate was significantly higher among parents of pediatric patients than among adult patients (71.4% versus 58.7%, p < 0.001). In the pediatric group, overall complication rates were 65% higher among mail responders than telephone responders (20.9% versus 12.7%, p=0.049), likely due to their higher rates of both visits to private practitioners and infection, as there were no differences in rates of pediatric readmission, bleeding, or pain between the responder groups. Among adult patients, mail and telephone responders did not differ with respect to their overall complication rate (40.9% versus 34.1%, p=0.226) or their rates of readmission or bleeding. However, similar to the pediatric group, visits to a private practitioner were slightly more common among adult mail responders than telephone responders (30.6% versus 21.1%, p=0.065), as were reports of pain (p=0.001) and infection (p=0.006). Studies relying on mailed questionnaires with low response rates likely overestimate the rate of minor complications handled outside the hospital, but rates of major complications involving readmission are unlikely to be seriously biased by low response rates. Supplementing mailed questionnaires with telephone interviews may increase the validity of surgical outcome studies.

Postoperative pain and bleeding after adenotonsillectomy versus adenotonsillotomy in pediatric obstructive sleep apnea: an RCT

Purpose

Our previous randomized controlled trial (RCT) of children with obstructive sleep apnea (OSA) showed no significant differences between adenotonsillectomy (ATE) and adenotonsillomy (ATE) in improving nocturnal respiration and symptoms after one year. This is the continuous report with the evaluation of postoperative morbidity concerning bleeding and pain.

Methods

A double-blinded RCT including 79 children, aged 2–6 years, with moderate to severe OSA, randomized to either ATE (n = 40) or ATT (n = 39). From one to ten days postoperatively, parents filled in a logbook with six pain-related outcomes (parent and child grading pain at different levels, days of analgesic use and return to normal diet). Peri- and postoperative bleeding were also registered.

Results

63 patients (80%) returned the logbook. There were significant differences between groups in only two of the six pain-related outcomes in favor of the ATT group; first day when the children graded themselves as pain free (p = 0.021, Log Rank Test), and first day the caregiver estimated pain VAS ≤ 5 (p = 0.007, Log Rank Test). Two (5%) cases of postoperative bleeding occurred in the ATE group, one of which needed a return to theatre. No case of postoperative bleeding was seen in the ATT group.

Conclusions

The results from this RCT are in line with previous comparative studies between ATT and ATE. Children operated with ATT had significantly less postoperative pain in one-third of the outcomes, and less bleeding than ATE. However, as the differences in morbidity between the surgical methods were minor the clinical significance is uncertain.

Trial registration

This study was approved by the Swedish Regional Ethics Board in Stockholm, Sweden (Dnr 2011/925-32 and 2013/2274-32) and registered at ClinicalTrials.gov (Trial registration number NCT01676181).

Pre-emptive scalp infiltration with ropivacaine plus methylprednisolone versus ropivacaine alone for relief of postoperative pain after craniotomy in children (RP/MP vs RP): a study protocol for a randomised controlled trial

INTRODUCTION

Pre-emptive scalp infiltration with local anaesthetics is the simplest and most effective method to prevent postoperative incisional pain. However, local infiltration of an anaesthetic only provides relatively short-term pain relief. Methylprednisolone (MP) treatment, administered as an adjuvant at the wound site, has been shown to provide satisfactory pain management after lumbar laminectomy. However, there is no evidence regarding the efficacy of MP infiltration for the relief of postoperative pain after craniotomy. Currently, postoperative pain after craniotomy in children is undertreated. Therefore, we aim to investigate whether pre-emptive scalp infiltration with ropivacaine (RP) plus MP is superior to RP alone to improve postoperative pain after craniotomy in children.

METHODS AND ANALYSIS

The RP/MP versus RP trial is a prospective, single-centre, randomised, parallel-group study of 100 children aged 8-18 years undergoing intracranial surgery. Participants will be randomly allocated to receive pre-emptive scalp infiltration with either RP plus MP or RP alone. The primary outcome will be the cumulative fentanyl dose administered by patient-controlled intravenous analgesia within 24 hours postoperatively. The secondary outcomes will include postoperative Numerical Rating Scale scores, pain control satisfaction scores, length of stay and adverse events. Data will be analysed by the intention-to-treat principle.

ETHICAL APPROVAL AND DISSEMINATION

The study protocol has been approved by the Institutional Review Board of Beijing Tiantan Hospital Affiliated to Capital Medical University (Approval Number: KY 2018-066-02). The results will be disseminated in international academic meetings and published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT03636165; Pre-results.

Postoperative Pain and 14-Day Recovery in Children Undergoing Adenotonsillectomy: Low Thermal Damage Device Versus Electrosurgery

This was a randomized controlled trial of low thermal damage device versus traditional electrosurgery in children 3 to 17 years old with a clinical diagnosis of sleep disordered breathing, obstructive sleep apnea with adenotonsillar hypertrophy, or recurrent adenotonsillitis. Pain score (Wong-Baker FACES pain scale) was recorded each morning before eating, drinking, or administering pain medication for 14 days postoperatively. Seventy-five children were enrolled. There was no difference in the rate of decrease in pain scores. A significant interaction between rate of pain decrease and number of pain medication doses was present ( P < .0001). Median number of pain medication doses was greater with electrosurgery (36, range: 7-49) versus low thermal device (21, range: 2-124; P = .001). Pain scores reached 0 after a median of 7 days (95% confidence interval [CI], 5.2-8.6) for low thermal device and 9 days (95% CI, 8.0-10.0) for electrosurgery ( P = .67). One child randomized to electrosurgery was withdrawn due to hospitalization for postoperative bleed. In children, low thermal device results in significantly less pain medication used during the postoperative period than electrosurgery.

Surgeons’ preferences and anxiety levels in paediatric adenotonsillectomy: European perspective

Objective

This study assessed the preferences of surgeons regarding surgical modalities used for adenotonsillectomy, and determined anxiety levels related to the adenotonsillectomy procedure.

Methods

A 10-question survey created by the authors was administered to 413 ENT specialists attending the 4th Congress of Otorhinolaryngology Head and Neck Surgery, held in October 2017 in Barcelona, Spain.

Results

Cold knife dissection was the preferred surgical modality for both adenoidectomy and tonsillectomy. Most participants reported encountering one to five patients with post-tonsillectomy bleeding throughout their entire career. The mean anxiety levels during surgery and the 10-day post-operative period were 3.39 ± 2.14 and 4.18 ± 2.63, respectively (p < 0.05). There was a significant negative correlation between anxiety level and surgeon's experience (p < 0.05).

Conclusion

Cold dissection is still the preferred surgical modality for adenotonsillectomy, while both suture ligation and electrocautery are used for haemostasis. Paediatric adenotonsillectomy is likely to generate anxiety in ENT surgeons, and the possibility of secondary post-tonsillectomy bleeding increases the anxiety levels of surgeons in the post-operative period.

Role of antibiotics in post-tonsillectomy morbidities; A systematic review

OBJECTIVE

To evaluate the role of postoperative antibiotics on post-tonsillectomy morbidities.

STUDY DESIGN

Systematic Review.

METHODS

Published papers and electronic databases (Medline, Web of Science, Embase) were searched from January 1985 up to March 2016 using the following key words in different combinations; Tonsil; Tonsillectomy; Post-tonsillectomy; Adenotonsillectomy; Antibiotics; Post-tonsillectomy morbidity; Bleeding; Secondary Hemorrhage. Twelve randomized control clinical trials fit the inclusion criteria and were included in the meta-analysis. We evaluated 5 outcomes, hemorrhage, return to normal diet, return to normal activities, fever and pain.

RESULTS

As regards secondary hemorrhage pooled analysis of 1397 patients revealed a relative risk (risk ratio, RR) of 1.052 with a 95% confidence interval (95% CI) of 0.739-1.497 (P-value, 0.779). As for return to normal diet pooled analysis of 527 patients showed a standardized mean difference (SMD) of -0.058 day with 95% CI of -0.233 to 0.118 (P-value, 0.518). As for return to normal activities pooled analysis of 257 patients showed a SMD of -0.014 day with a 95% CI of -0.258 to 0.230 (P-value, 0.908). As for Fever pooled analysis of 656 patients revealed a relative risk of 1.265 with 95% CI of 0.982-1.629 (P-value, 0.068). Finally for the postoperative pain due to the variability in the parameters used to assess the pain following tonsillectomy, we could not perform meta-analysis for this outcome.

CONCLUSION

The results of this study fail to support clear evidence to use routinely post-operative antibiotics to reduce post-tonsillectomy morbidities.

Clinical characteristics of obstructive sleep apnea versus infectious adenotonsillar hyperplasia in children

INTRODUCTION

Children who undergo adenotonsillectomy have a range of symptoms. Some present with infective symptoms, others with obstructive symptoms, and many with a combination of both. The most common surgical indication has changed over the past several decades from infective symptoms to obstructive symptoms. However, there are few data available to differentiate these groups of children in terms of their clinical characteristics. This study aimed to determine the clinical characteristics of children with obstructive sleep apnea versus infectious adenotonsillar hyperplasia.

METHODS

Data were obtained from the medical records of two district health boards in Auckland, New Zealand. Extraction of clinical information was performed following the identification of all patients under the age of 16 years undergoing adenotonsillectomy between December 2015 and December 2017.

RESULTS

A total of 1538 children were included in this study. There were 112 (7.3%) with recurrent tonsillitis (RT) symptoms only, 624 (40.6%) with RT and sleep-disordered breathing symptoms (SDB), and 802 (52.1%) with symptoms suggestive of obstructive sleep apnea (OSA). Children with OSA were more likely to be male (p < 0.001), younger (p < 0.001), and have lower body mass indexes at time of surgery (p < 0.001). There was no difference between groups in the number of antibiotic courses prescribed in the year before surgery (p = 0.7). There was no significant difference in tonsil or adenoid grade between groups (p = 0.2). Children with OSA were more likely to have a diagnosis of asthma (p < 0.001) and allergic rhinitis (p < 0.001), but less likely than those with RT to have a diagnosis of eczema (p < 0.001). Children with OSA were more likely to have otitis media with effusion requiring ventilation tube insertion (p < 0.001) and a documented history of speech delay (p < 0.001). Thirty-day readmission rates were higher in the OSA (8.5%) and SDB/RT (9.3%) groups when compared to those with RT (1.8%) (p = 0.03).

CONCLUSION

Children with OSA have different perioperative characteristics than those with recurrent tonsillitis, including increased risk of postoperative bleeding and need for post op readmission. Therefore, management strategy may vary according to the indications for tonsillectomy and adenoidectomy.

Reducing post-tonsillectomy haemorrhage rates through a quality improvement project using a Swedish National quality register: a case study

Purpose

Tonsillectomy (TE) is one of the most frequently performed ENT surgical procedures. Post-tonsillectomy haemorrhage (PTH) is a potentially life-threatening complication of TE. The National Tonsil Surgery Register in Sweden (NTSRS) has revealed wide variations in PTH rates among Swedish ENT centres. In 2013, the steering committee of the NTSRS, therefore, initiated a quality improvement project (QIP) to decrease the PTH incidence. The aim of the present study was to describe and evaluate the multicentre QIP initiated to decrease PTH rates.

Methods

Six ENT centres, all with PTH rates above the Swedish average, participated in the 7-month quality improvement project. Each centre developed improvement plans describing the intended changes in clinical practice. The project’s primary outcome variable was the PTH rate. Process indicators, such as surgical technique, were also documented. Data from the QIP centres were compared with a control group of 15 surgical centres in Sweden with similarly high PTH rates. Data from both groups for the 12 months prior to the start of the QIP were compared with data for the 12 months after the QIP.

Results

The QIP centres reduced the PTH rate from 12.7 to 7.1% from pre-QIP to follow-up; in the control group, the PTH rate remained unchanged. The QIP centres also exhibited positive changes in related key process indicators, i.e., increasing the use of cold techniques for dissection and haemostasis.

Conclusions

The rates of PTH can be reduced with a QIP. A national quality register can be used not only to identify areas for improvement but also to evaluate the impact of subsequent improvement efforts and thereby guide professional development and enhance patient outcomes.

Patient reported pain-related outcome measures after tonsil surgery: an analysis of 32,225 children from the National Tonsil Surgery Register in Sweden 2009-2016

The objective of this study was to describe factors affecting pain after pediatric tonsil surgery, using patient reported pain-related outcome measures (pain-PROMs) from the National Tonsil Surgery Register in Sweden. In total, 32,225 tonsil surgeries on children (1 to <18 years) during 2009-2016 were included; 13,904 tonsillectomies with or without adenoidectomy (TE ± A), and 18,321 tonsillotomies with or without adenoidectomy (TT ± A). Adjustments were made for variables included in the register to compensate for contributable factors in the analysis. When compared to TE ± A for surgical indication obstruction, TT ± A resulted in lower pain-PROMs, shorter use of postoperative analgesics, earlier return to regular food intake, and lower risk for contact with health care services due to pain. Children who underwent TE ± A because of obstruction problems stopped taking painkillers and returned to normal eating habits sooner, compared to children who underwent TE ± A for infectious indications. In both indication groups, TE ± A performed with hot rather than cold technique (dissection and haemostasis) generally resulted in higher pain-PROMs. Older children reported more days on analgesics and a later return to regular food intake after TE ± A than younger ones. No clinically relevant difference between sexes was found. Between 2012 and 2016 (pre-and post-implementation of Swedish national guidelines for pain treatment), the mean duration of postoperative analgesic use had increased. In conclusion, TE ± A caused considerably higher ratings of pain-related outcome measures, compared to TT ± A. For TE ± A, cold surgical techniques (dissection and haemostasis) were superior to hot techniques in terms of pain-PROMs. Older children reported higher pain-PROMs after TE ± A than younger ones.

Postoperative Bleeding and Associated Utilization following Tonsillectomy in Children

Objective To assess posttonsillectomy hemorrhage (PTH), associated nonoperative readmissions/revisits, and reoperations in children. Data Sources MEDLINE, EMBASE, and the Cochrane Library. Review Methods Two investigators independently screened studies against predetermined criteria and extracted key data. Investigators independently assessed study risk of bias and the strength of the evidence of the body of literature. We calculated unadjusted pooled estimates of PTH frequency and conducted a Bayesian meta-analysis to estimate frequency of primary and secondary PTH and PTH-associated reoperation and revisits/readmissions by partial and total tonsillectomy and surgical approach. Results In meta-analysis, the frequency of primary and secondary PTH associated with total and partial tonsillectomy was <4% for any technique and with overlapping confidence bounds. Pooled frequencies of PTH were also <5% overall (4.2% for total tonsillectomy, 1.5% for partial tonsillectomy) in comparative studies. Fewer PTH episodes occurred with tonsillectomy for obstructive sleep-disordered breathing than for throat infection. In meta-analysis, frequency of PTH-associated nonoperative revisits/readmission or reoperation ranged from 0.2% to 5.7% for total tonsillectomy and from 0.1% to 3.7% for partial tonsillectomy. At least 4 deaths were reported in case series including 1,778,342 children. Conclusions PTH occurred in roughly 4% of tonsillectomies in studies included in this review. Although studies typically did not report bleeding severity or amount, relatively few episodes of PTH necessitated reoperation for hemostasis. Nonetheless, tonsillectomy is not without risk of harm. Frequency of PTH across techniques was similar; thus, we cannot conclude that a given technique is superior.