1
|
Abou-Abdallah M, Dar T, Mahmudzade Y, Michaels J, Talwar R, Tornari C. The quality and readability of patient information provided by ChatGPT: can AI reliably explain common ENT operations? Eur Arch Otorhinolaryngol 2024:10.1007/s00405-024-08598-w. [PMID: 38530460 DOI: 10.1007/s00405-024-08598-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 03/04/2024] [Indexed: 03/28/2024]
Abstract
PURPOSE Access to high-quality and comprehensible patient information is crucial. However, information provided by increasingly prevalent Artificial Intelligence tools has not been thoroughly investigated. This study assesses the quality and readability of information from ChatGPT regarding three index ENT operations: tonsillectomy, adenoidectomy, and grommets. METHODS We asked ChatGPT standard and simplified questions. Readability was calculated using Flesch-Kincaid Reading Ease Score (FRES), Flesch-Kincaid Grade Level (FKGL), Gunning Fog Index (GFI) and Simple Measure of Gobbledygook (SMOG) scores. We assessed quality using the DISCERN instrument and compared these with ENT UK patient leaflets. RESULTS ChatGPT readability was poor, with mean FRES of 38.9 and 55.1 pre- and post-simplification, respectively. Simplified information from ChatGPT was 43.6% more readable (FRES) but scored 11.6% lower for quality. ENT UK patient information readability and quality was consistently higher. CONCLUSIONS ChatGPT can simplify information at the expense of quality, resulting in shorter answers with important omissions. Limitations in knowledge and insight curb its reliability for healthcare information. Patients should use reputable sources from professional organisations alongside clear communication with their clinicians for well-informed consent and making decisions.
Collapse
Affiliation(s)
- Michel Abou-Abdallah
- Ear, Nose and Throat Department, Luton and Dunstable University Hospital, Lewsey Rd, Luton, LU4 0DZ, UK.
| | - Talib Dar
- Ear, Nose and Throat Department, Luton and Dunstable University Hospital, Lewsey Rd, Luton, LU4 0DZ, UK
| | - Yasamin Mahmudzade
- Foundation Programme, East and North Hertfordshire NHS Trust, Stevenage, UK
| | - Joshua Michaels
- Ear, Nose and Throat Department, Luton and Dunstable University Hospital, Lewsey Rd, Luton, LU4 0DZ, UK
| | - Rishi Talwar
- Ear, Nose and Throat Department, Luton and Dunstable University Hospital, Lewsey Rd, Luton, LU4 0DZ, UK
| | - Chrysostomos Tornari
- Ear, Nose and Throat Department, Luton and Dunstable University Hospital, Lewsey Rd, Luton, LU4 0DZ, UK
| |
Collapse
|
2
|
Abstract
Introduction: During the first years of life, the oro-pharyngeal lymphoid tissue gradually increases in size, causing in some children difficulty breathing and often leading to surgical removal of the tonsils and adenoids. The objective of the study is to assess the effects of the Mediterranean diet in children who had chronic upper airway obstruction. Material and methods: This was a prospective study pre-test/post-test comparison. Eighty-seven patients from two to eight years old were recruited. A food reeducation program based on the Mediterranean diet was applied for one year. Clinical, therapeutic, and anthropometric variables were studied. Results: The degree of nasal obstruction decreased in 95.1% of the patients. After the nutritional intervention, the number of colds with bacterial complications decreased by 80.26%; 60.9% had no bacterial complications during the year of the study. The use of antibiotics decreased by 81.94%. Symptomatic treatment decreased by 61.2%. Most patients did not require surgical intervention, and clinical evolution suggested that it would no longer be necessary. Conclusions: We can conclude by saying that the application of the traditional Mediterranean diet could be effective in the prevention and treatment of persistent nasal obstruction, limiting pharmacological and surgical intervention in many of these patients.
Collapse
|
3
|
Cheung JL, Dreyer C, Ranjitkar S. Opening up on airways: the purported effect of nasorespiratory obstruction on dentofacial growth. Aust Dent J 2021; 66:358-370. [PMID: 34031885 DOI: 10.1111/adj.12858] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/06/2021] [Indexed: 12/26/2022]
Abstract
Nasorespiratory obstruction has been purported to influence dentofacial growth adversely. This has sparked considerable debate for decades with a resurgence in interest in 'airway friendly orthodontics' among both general and specialist dental practitioners. This critical review aims to evaluate the current literature relating to two questions: does nasorespiratory obstruction alter dentofacial growth, and does early intervention targeted at alleviating nasorespiratory obstruction improve dentofacial growth? The strength of association between nasorespiratory obstruction, mouth breathing and a long face is weak. The common methodological flaws in research include unblinded and cross-sectional study designs, a lack of adequate controls, inadequate follow-up, subjective assessments and inadequate statistical power. Vertical dentofacial growth has a strong genetic influence, which implies a relatively minor contribution of environmental factors including airway obstruction. The current evidence does not support recommending procedures, such as adenotonsillectomy and maxillary expansion, with the singular aim of negating a hyperdivergent (vertical) dentofacial growth pattern. In light of low-quality evidence, both the World Health Organization guidelines and ethical principles dictate that greater emphasis is placed on avoiding harm and wastage of resources over alternative options. These findings call for quality improvement in undergraduate and postgraduate curricula and continuing professional development for health professionals.
Collapse
Affiliation(s)
- J-Ls Cheung
- Private Practice, Melbourne, Victoria, Australia
| | - C Dreyer
- Adelaide Dental School, University of Adelaide, Adelaide, South Australia, Australia
| | - S Ranjitkar
- Adelaide Dental School, University of Adelaide, Adelaide, South Australia, Australia.,Department of Dentistry and Oral Health, La Trobe Rural Health School, La Trobe University, Bendigo, Victoria, Australia
| |
Collapse
|
4
|
Screening for undiagnosed bleeding disorders in post-tonsillectomy bleed patients: Retrospective review and systematic review of the literature. Int J Pediatr Otorhinolaryngol 2019; 124:210-214. [PMID: 31229837 DOI: 10.1016/j.ijporl.2019.06.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Revised: 05/01/2019] [Accepted: 06/06/2019] [Indexed: 02/06/2023]
Abstract
OBJECTIVES There is currently no standard for screening children with post-tonsillectomy bleeds (PTB) for coagulopathy disorders. This study aims to identify children with occult coagulopathy diagnosed at PTB and to identify factors associated with diagnosis. A systematic review of the literature further identified trends in this topic. METHODS A retrospective chart review of patients returning to the operating room for PTB at a tertiary children's hospital was undertaken from 2012 to 2016. A systematic review using Medline OVID was subsequently performed. RESULTS Of 12,503 tonsillectomies, 311 children (52% male, mean age 8 years) required surgery for PTB (2.5% rate). Twenty-one patients (7%) had multiple episodes. Only two patients (0.6%) (both with known coagulopathy) underwent pre-tonsillectomy labs and 260 (84%) had labs at PTB. Six patients (2%) were diagnosed with a new coagulopathy, most commonly von Willebrand's Disease (vWD) in five (2%). Three patients (1%) were diagnosed at first PTB and three (1%) at second PTB. Of the three diagnosed at second PTB, two had normal partial thromboplastin time (PTT). In systematic review, 1243 manuscripts were reviewed and 8 papers discussing this topic are presented. CONCLUSION Occult coagulopathy was rarely diagnosed at PTB, but this may be limited by inconsistent screening. PT and PTT are not sensitive tests for vWD, and normal coagulation labs may lead to delayed diagnosis. The literature reveals occult coagulopathy is rare but often diagnosed after severe or recurrent hemorrhage. In order to provide efficient care and medical management, a standardized algorithm and sensitive labs for screening PTB patients are needed.
Collapse
|
5
|
Soldatova L, Doty RL. Post-tonsillectomy taste dysfunction: Myth or reality? World J Otorhinolaryngol Head Neck Surg 2018; 4:77-83. [PMID: 30035265 PMCID: PMC6051494 DOI: 10.1016/j.wjorl.2018.02.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Accepted: 02/28/2018] [Indexed: 11/17/2022] Open
Abstract
Lingual branches of the glossopharyngeal nerve (CN Ⅸ) are at risk of injury during tonsillectomy due to their proximity to the muscle layer of the palatine tonsillar bed. However, it is unclear how often this common surgery leads to taste disturbances. We conducted a literature search using PubMed, Embase, Cochrane Library, Google Scholar, PsychInfo, and Ovid Medline to evaluate the available literature on post-tonsillectomy taste disorders. Studies denoting self-reported dysfunction, as well as those employing quantitative testing, i.e., chemogustometry and electrogustometry, were identified. Case reports were excluded. Of the 8 original articles that met our inclusion criteria, only 5 employed quantitative taste tests. The highest prevalence of self-reported taste disturbances occurred two weeks after surgery (32%). Two studies reported post-operative chemical gustometry scores consistent with hypogeusia. However, in the two studies that compared pre- and post-tonsillectomy test scores, one found no difference and the other found a significant difference only for the left rear of the tongue 14 days post-op. In the two studies that employed electrogustometry, elevated post-operative thresholds were noted, although only one compared pre- and post-operative thresholds. This study found no significant differences. No study employed a normal control group to assess the influences of repeated testing on the sensory measures. Overall, this review indicates that studies on post-tonsillectomy taste disorders are limited and ambiguous. Future research employing appropriate control groups and taste testing procedures are needed to define the prevalence, duration, and nature of post-tonsillectomy taste disorders.
Collapse
|
6
|
Barry N, M Miller K, Ryshen G, Uffman J, Taghon TA, Tobias JD. Etiology of postanesthetic and postsedation events on the inpatient ward: data from a rapid response team at a tertiary care children's hospital. Paediatr Anaesth 2016; 26:504-11. [PMID: 26972832 DOI: 10.1111/pan.12874] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/07/2016] [Indexed: 12/16/2022]
Abstract
INTRODUCTION The goal of this study was to identify the etiology of events and demographics of patients that experience complications requiring activation of the Rapid Response Team (RRT) during the first 24 h following anesthetic care. METHODS We performed a retrospective review of the Quality Improvement database from the Department of Anesthesiology & Pain Medicine at Nationwide Children's Hospital. The database was searched to identify those patients who had a RRT evaluation activated within 24 h of receiving anesthesia or procedural sedation. These patients' charts were reviewed to obtain demographic information, etiology of the RRT call, and outcomes. RESULTS The study cohort included 106 RRT calls that were made over a 3-year period. Six patients were excluded from analysis due to incomplete datasets. One hundred patients remained for analysis including 60 males and 40 females. Patients ranged in age from 0.08 to 31.21 years (7.8 ± 7.7 years, median 5.3 years). Seventy-one patients were American Society of Anesthesiologists' (ASA) status 3 or 4 and 29 patients were ASA status 1 or 2. Five calls were made for patients who had undergone procedural sedation while the other 95 were on patients who received general anesthesia. The average time to the RRT call after the end of anesthetic care was 11.4 ± 6.6 h. Respiratory concern was the most common reason for RRT initiation, accounting for 71 of the 100 calls. Forty-nine patients had a recent respiratory illness, chronic respiratory-related disease, or history of preterm birth. Fifty patients (50%) were transferred to a higher level of care following the RRT consult. There was no significant difference between age, gender, ASA status, or etiology of the event for patients transferred vs. those who were not. A significant difference was noted in the Pediatric Early Warning Score of patients transferred to a higher level of care in comparison to patients who remained on the floor (4 ± 2 vs. 3 ± 2, P = 0.0097). CONCLUSION RRT calls were most common for respiratory concerns. High ASA status, general anesthesia administration, and the presence of acute or chronic conditions prior to anesthetic administration predispose a patient to perioperative complications resulting in the need for an RRT call.
Collapse
Affiliation(s)
- N'Diris Barry
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Karen M Miller
- The Ohio State University College of Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Gregory Ryshen
- Quality Improvement Services, Nationwide Children's Hospital, Columbus, OH, USA
| | - Joshua Uffman
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Thomas A Taghon
- Department of Anesthesiology, Dayton Children's Hospital, Dayton, OH, USA
| | - Joseph D Tobias
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| |
Collapse
|
7
|
|
8
|
Hakim M, Krishna SG, Syed A, Lind M, Elmaraghy C, Tobias JD. Oropharyngeal oxygen and volatile anesthetic agent concentration during the use of laryngeal mask airway in children. Paediatr Anaesth 2016; 26:72-6. [PMID: 26545067 DOI: 10.1111/pan.12801] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/25/2015] [Indexed: 01/14/2023]
Abstract
BACKGROUND The laryngeal mask airway is increasingly used as an airway adjunct during general anesthesia. Although placement is generally simpler than an endotracheal tube, complete sealing of the airway may not occur, resulting in contamination of the oropharynx with anesthetic gases. Oropharyngeal oxygen enrichment may be one of the contributing factors predisposing to an airway fire during adenotonsillectomy. The current study prospectively assesses the oropharyngeal oxygen and volatile anesthetic agent concentration during laryngeal mask airway use in infants and children. METHODS Following the induction of general anesthesia and placement of a laryngeal mask airway, the oropharyngeal gas sample was obtained by placing a 14-gauge catheter attached to the gas sampling tube into the oropharynx above the laryngeal mask airway. The oropharyngeal concentration of the oxygen and the anesthetic agent were recorded for five breaths during both spontaneous ventilation (SV) and positive pressure ventilation (PPV). RESULTS The study included 238 patients. The oropharyngeal concentration of sevoflurane was >50% of the inspired sevoflurane concentration during SV in 10 of 238 (4.2%) patients and during PPV in 135 of 238 (56.7%) patients. Similarly, during SV and PPV, the oropharyngeal oxygen concentration was >21% in 30 of 238 (12.6%) patients and in 188 of 238 (79%) patients, respectively. Significantly, we also noticed that the oropharyngeal oxygen concentration exceeded 50% in 5 of 238 (2.1%) patients during SV and in 139 of 238 patients (58.4%) patients during PPV. CONCLUSIONS With the use of a laryngeal mask airway and the administration of 100% oxygen, there was significant contamination of the oropharynx during both PPV and SV. The oropharyngeal concentration of oxygen was high enough to support combustion in a significant number of patients. The use of a laryngeal mask airway does not ensure sealing of the airway and may be one risk factor for an airway fire during adenotonsillectomy.
Collapse
Affiliation(s)
- Mumin Hakim
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Senthil G Krishna
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Anesthesiology, The Ohio State University, Columbus, OH, USA
| | - Ahsan Syed
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Anesthesiology, The Ohio State University, Columbus, OH, USA
| | - Meredith Lind
- Department of Otolaryngology and Head & Neck Surgery, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Otolaryngology and Head & Neck Surgery, The Ohio State University, Columbus, OH, USA
| | - Charles Elmaraghy
- Department of Otolaryngology and Head & Neck Surgery, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Otolaryngology and Head & Neck Surgery, The Ohio State University, Columbus, OH, USA
| | - Joseph D Tobias
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Anesthesiology, The Ohio State University, Columbus, OH, USA
| |
Collapse
|
9
|
Tobias JD. Pediatric airway anatomy may not be what we thought: implications for clinical practice and the use of cuffed endotracheal tubes. Paediatr Anaesth 2015; 25:9-19. [PMID: 25243638 DOI: 10.1111/pan.12528] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/14/2014] [Indexed: 01/20/2023]
Abstract
One of the long held tenets of pediatric anesthesia has been the notion that the pediatric airway is conical shape with the narrowest area being the cricoid region. However, recent studies using radiologic imaging techniques (magnetic resonance imaging and computed tomography) or direct bronchoscopic observation have questioned this suggesting that the narrowest segment may be at or just below the glottic opening. More importantly, it has been clearly demonstrated that the airway is elliptical in shape rather than circular with the anterior-posterior dimension being greater than the transverse dimension. These findings coupled with the development of a new generation of cuffed endotracheal tubes (ETTs) with a thin, polyurethane cuff have caused a transition in the practice of pediatric anesthesiology with an increased use of cuffed ETTs, even in neonates and infants. The following article reviews the historical data leading to the assumption that the pediatric airway is conical as well as the more recent imaging and direct bronchoscopic observational studies which refute this tenet. The transition to the use of cuffed ETTs is discussed and potential advantages presented in both the operating room and the intensive care unit. Issues regarding the monitoring of intracuff pressure and techniques to limit potential morbidity related to a high intracuff pressure are outlined.
Collapse
Affiliation(s)
- Joseph D Tobias
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA; Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA; Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
| |
Collapse
|
10
|
|
11
|
|
12
|
Coté CJ, Posner KL, Domino KB. Death or neurologic injury after tonsillectomy in children with a focus on obstructive sleep apnea: houston, we have a problem! Anesth Analg 2014; 118:1276-83. [PMID: 23842193 DOI: 10.1213/ane.0b013e318294fc47] [Citation(s) in RCA: 125] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Obesity is epidemic in the United States and with it comes an increased incidence of obstructive sleep apnea (OSA). Evidence regarding opioid sensitivity as well as recent descriptions of deaths after tonsillectomy prompted a survey of all members of the Society for Pediatric Anesthesia regarding adverse events in children undergoing tonsillectomy. METHODS An electronic survey was sent to 2377 members of the Society for Pediatric Anesthesia. Additionally, data from the American Society of Anesthesiologists Closed Claims Project were obtained. Adverse events during or after tonsillectomy with or without adenoidectomy in children were included. Children at risk for OSA were identified as either having a positive history for OSA or a post hoc application of the American Society of Anesthesiologists OSA practice guidelines. These children were compared with all other children by Fisher exact test for proportions and t test for continuous variables. RESULTS A total of 129 cases were identified from the 731 replies to the survey, with 92 meeting inclusion criteria for having adequate data. Another 19 cases with adequate data were identified from the 45 from the American Society of Anesthesiologists Closed Claims Project. A total of 111 cases were included in the final analysis. Death and permanent neurologic injury occurred in 86 (77%) cases and were reported in the operating room, postanesthesia care unit, on the ward, and at home. Sixty-three (57%) children fulfilled American Society of Anesthesiologists criteria to be at risk for OSA. Children categorized as at risk for OSA were more likely than other children to be obese and to have comorbidities (P < 0.0001). A larger proportion of at risk children had the event attributed to apnea (P = 0.016), whereas all others had a larger proportion of events attributed to hemorrhage (P = 0.006). CONCLUSIONS Deaths or neurologic injury after tonsillectomy due to apparent apnea in children suggest that at least 16 children could have been rescued had respiratory monitoring been continued throughout first- and second-stage recovery, as well as on the ward during the first postoperative night. A validated pediatric-specific risk assessment scoring system is needed to assist with identifying children at risk for OSA who are not appropriate to be cared for on an outpatient basis.
Collapse
Affiliation(s)
- Charles J Coté
- From the *Department of Anesthesia, Critical Care, and Pain Medicine, Harvard Medical School/The MassGeneral Hospital for Children, Boston, Massachusetts; and †Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
| | | | | |
Collapse
|
13
|
Subramanyam R, Chidambaran V, Ding L, Myer CM, Sadhasivam S. Anesthesia- and opioids-related malpractice claims following tonsillectomy in USA: LexisNexis claims database 1984-2012. Paediatr Anaesth 2014; 24:412-20. [PMID: 24417679 DOI: 10.1111/pan.12342] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/29/2013] [Indexed: 11/26/2022]
Abstract
BACKGROUND Although commonly performed, tonsillectomy is not necessarily a low-risk procedure for litigation. We have reviewed malpractice claims involving fatal and nonfatal injuries following tonsillectomy with an emphasis on anesthesia- and opioid-related claims and their characteristics. METHODS Tonsillectomy-related malpractice claims and jury verdict reports from the United States (US) between 1984 and 2012 found in the LexisNexis MEGA™ Jury Verdicts and Settlements database were reviewed by two independent reviewers. LexisNexis database collects nationwide surgical, anesthesia, and other malpractice claims. Data including years of case and verdicts, surgical, anesthetic and postoperative opioid-related complications, details of injury, death, cause of death, litigation result, and judgment awarded were analyzed. When there were discrepancies between the two independent reviewers, a third reviewer (SS) was involved for resolution. Inflation adjusted monetary awards were based on 2013 US dollars. RESULTS There were 242 tonsillectomy-related claim reports of which 98 were fatal claims (40.5%) and 144 nonfatal injury claims (59.5%). Verdict/settlement information was available in 72% of cases (n = 175). The median age group of patients was 8.5 years (range 9 months to 60 years). Primary causes for fatal claims were related to surgical factors (n = 39/98, 39.8%) followed by anesthesia-related (n = 36/98, 36.7%) and opioid-related factors (n = 16/98, 16.3%). Nonfatal injury claims were related to surgical (101/144, 70.1%), anesthesia (32/144, 22.2%)- and opioid-related factors (6/144, 4.2%). Sleep apnea was recorded in 17 fatal (17.4%) and 15 nonfatal claims (10.4%). Opioid-related claims had the largest median monetary awards for both fatal ($1 625 892) and nonfatal injury ($3 484 278) claims. CONCLUSIONS Tonsillectomy carries a high risk from a medical malpractice standpoint for the anesthesiologists and otolaryngologists. Although surgery-related claims were more common, opioids- and anesthetic-related claims were associated with larger median monetary verdicts, especially those associated with anoxic, nonfatal injuries. Caution is necessary when opioids are prescribed post-tonsillectomy, especially in patients with sleep apnea.
Collapse
Affiliation(s)
- Rajeev Subramanyam
- Department of Anesthesia, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | | | | | | | | |
Collapse
|
14
|
Suction diathermy adenoidectomy performed in the district general hospital. The Journal of Laryngology & Otology 2014; 128:78-81. [PMID: 24423942 DOI: 10.1017/s0022215113003411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Adenoidectomy is often carried out in children for conditions such as nasal obstruction, otitis media with effusion, and obstructive sleep apnoea. Traditionally, it is performed as a blind procedure with a St Clair Thomson curette. An acceptable alternative technique is suction diathermy adenoidectomy. This study aimed to ensure that the complication rate of this latter technique was within published rates and national guidelines. METHOD A retrospective case note review was conducted, and information regarding surgery, indications and complications was collected. RESULTS Post-operative haemorrhage was recorded for 2 of 121 patients (at days 10 and 11 post-operatively): 1 returned to the operating theatre and the other was managed conservatively. Two patients were diagnosed with infection post-operatively and managed with oral antibiotics. A further four patients re-presented with pain; in all cases, this was recorded as secondary to tonsillar fossa infection, rather than being pain related to adenoidectomy. CONCLUSION Given the rare but serious potential complications, the authors support National Institute for Health and Clinical Excellence guidance, which recommends that only surgeons with specific training perform this technique. By using the standard procedures for clinical governance, it is possible to ensure safe practice of even little-used techniques.
Collapse
|
15
|
Windfuhr JP. Malpractice claims and unintentional outcome of tonsil surgery and other standard procedures in otorhinolaryngology. GMS CURRENT TOPICS IN OTORHINOLARYNGOLOGY, HEAD AND NECK SURGERY 2013; 12:Doc08. [PMID: 24403976 PMCID: PMC3884543 DOI: 10.3205/cto000100] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Septoplasty, tonsillectomy (with and without adenoidectomy) and cervical lymph node excision are amongst the most common 50 inpatient operations in Germany. Intracapsular tonsillectomies (i.e. tonsillotomies) are increasingly performed. The aim of this study was to evaluate technical traps and pitfalls as well as alleged medical malpractice associated with tonsillectomy (TE), adenoidectomy (AE), tonsillotomy (TT), septoplasty (SP) and cervical lymph node excision (LN). METHODS A questionnaire was sent to the Regional Medical Conciliation Boards, Medical Services of the Health Insurance Companies (MDK) and Regional Institutes of Forensic Medicine in Germany to collect anonymized cases of complications following TE, TT, AE, LN and SP. The results were discussed in the light of the contemporary medical literature and published trials and verdicts in Germany. RESULTS The response rate of our survey was 55.9%. The Institutes of Forensic Medicine contributed nine cases, 49 cases were submitted by the Regional Conciliation Boards and none by MDK. All forensic cases were associated with exsanguinations following tonsillectomy including two children (5 and 8 years of age) and seven adults (aged 20 to 69 years). The fatal post-tonsillectomy hemorrhage (PTH) had occurred 8.7 days on average; four patients experienced the bleeding episode at home (day 5, 8, 9 and 17, respectively). Repeated episodes of bleeding requiring surgical intervention had occurred in 6 patients. Three Conciliation Boards submitted decicions associated with TT (1), AE (4), LN (3), SP (16) and TE (25). Cases with lethal outcome were not registered. Only three of the 49 cases were assessed as surgical malpractice (6.1%) including lesion of the spinal accessory nerve, wrong indication for TE and dental lesion after insertion of the mouth gag. The review of the medico legal literature yielded 71 published verdicts after AE and TE (29), LN (28) and SP (14) of which 37 resulted in compensation of malpractice after LN (16; 57%), TE (10; 37%), SP (8; 57%) and AE (2; 100%). There were 16 cases of PTH amongst 27 trials after TE resulting either in death (5) or apallic syndrome (5). Bleeding complications had occurred on the day of surgery in only 2 patients. 16 trials were based on malpractice claims following SP encompassing lack of informed consent (6), anosmia (4), septal perforation (2), frontobasal injury (2) and dry nose (2). Trials after LN procedures were associated exclusively with a lesion of the spinal accessory nerve (28), including lack of informed consent in 19 cases. 49 cases (69%) were decided for the defendant, 22 (31%) were decided for the plaintiff with monetary compensation in 7 of 29 AE/TE-trials, 9 of 28 LN-trials and 6 of 14 SP-trials. Lack of informed consent was not registered for AE/TE but LN (11) and SP (2). CONCLUSION Complicated cases following TE, TT, ATE, SP and LN are not systematically collected in Germany. It can be assumed, that not every complicated case is published in the medical literature or law journals and therefore not obtainable for scientific research. Alleged medical malpracice is proven for less than 6% before trial stage. Approximately half of all cases result in a plaintiff verdict or settlement at court. Proper documentation of a thourough counselling, examination, indication, informed consent and follow-up assists the surgeon in litigation. An adequate complication management of PTH is essential, including instructions for the patients/parents, instructions for the medical staff and readily available surgical instruments. Successful outcome of life-threatening PTH is widely based on a proper airway management in an interdisciplinary approach. Electrosurgical tonsillectomy techniques were repeatedly labeled as a risk factor for bleeding complications following TE. Institutions should analyse the individual PTH rate on a yearly basis. Contradictory expert opinions and verdicts of the courts concerning spinal accesory nerve lesions following LN are due to a lack of a surgical standard.
Collapse
Affiliation(s)
- Jochen P. Windfuhr
- Department of Otorhinolaryngology, Plastic Head and Neck Surgery, Kliniken Maria Hilf, Mönchengladbach, Germany
| |
Collapse
|
16
|
Smith ME, Lakhani R, Bhat N. Consenting for risk in common ENT operations: an evidence-based approach. Eur Arch Otorhinolaryngol 2013; 270:2551-7. [PMID: 23609098 DOI: 10.1007/s00405-013-2464-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2013] [Accepted: 03/20/2013] [Indexed: 12/30/2022]
Abstract
Pre-operative consent discussion and documentation is an essential process that should follow relevant guidance, and include all serious or frequently occurring risks. We assessed the appropriateness of consent for grommet insertion, tonsillectomy, septoplasty, and hemithyroidectomy, by comparing the risks listed in current consenting practice to published complication data for the relevant operation. 120 consent forms and associated clinic letters were analysed. A literature search identified published complication data for comparison. There was great variation in consent practice for each operation type, and poor correlation with published risk incidence. Only 'bleeding' post-tonsillectomy and 'recurrent laryngeal nerve injury' post hemithyroidectomy were listed in 100 % of relevant cases. Common and serious complications were frequently omitted from forms. The number and type of risks consented for a procedure significantly differed between consultant and non-consultant staff. The potential requirement for blood transfusion was discussed in only 20 % of tonsillectomy cases. Currently, the pre-operative consent for commonly performed ENT operations does not reflect operative risks. Consenting for surgical complications should be evidence based using published or personal data. A change in the consent process is required to protect patient autonomy and meet both legal and professional body requirements.
Collapse
Affiliation(s)
- M E Smith
- Department of Ear, Nose and Throat Surgery, Peterborough and Stamford Hospitals NHS Foundation Trust, Edith Cavell Campus, Bretton Gate, Peterborough, PE3 9GZ, UK.
| | | | | |
Collapse
|
17
|
Dyer SR, Bathula S, Durvasula P, Madgy D, Haupert M, Dworkin J, Sana S. Intraoperative use of FloSeal with adenotonsillectomy to prevent adverse postoperative outcomes in pediatric patients. Otolaryngol Head Neck Surg 2013; 149:312-7. [PMID: 23569201 DOI: 10.1177/0194599813486253] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE The purpose of this study was to compare postoperative complications associated with monopolar dissection adenotonsillectomy, with and without the application of FloSeal at the completion of the procedure. STUDY DESIGN Retrospective cohort study. SETTING Tertiary care pediatric hospital. SUBJECTS AND METHODS This was a retrospective cohort study of 800 cases of adenotonsillectomy. Two cohorts of patients were identified based on whether or not FloSeal was used intraoperatively during the completion of the monopolar dissection adenotonsillectomy. Outcomes that were measured included: (1) age, (2) sex, (3) diagnosis, (4) primary hemorrhage, (5) secondary hemorrhage, (6) return to operating room, and (7) dehydration. All binomial outcomes measured were subjected to chi-square and t tests. RESULTS Age and gender were similar between the 2 groups. Chronic tonsillitis was the primary indication more often in the control group; this was statistically significant. Primary hemorrhage occurred in 1 subject from each group (0.28%); secondary hemorrhage occurred in 11 subjects from the FloSeal group (3.22%) and 7 from the control group (1.87%). Both outcomes were not statistically different between the 2 groups. Return to operating room showed no statistically significant difference between groups. The need for postoperative admission for dehydration failed to show statistical significance between groups. CONCLUSION In our experience, the application of FloSeal hemostatic matrix after monopolar adenotonsillectomy demonstrates no additional reduction in postoperative adverse events encountered in the pediatric population. Specifically, our data failed to demonstrate statistically significant reduction of: (1) primary hemorrhage, (2) secondary hemorrhage, (3) return to operating theatre, or (4) dehydration.
Collapse
Affiliation(s)
- Steven R Dyer
- Michigan State University, Detroit Medical Center, Detroit, Michigan, USA.
| | | | | | | | | | | | | |
Collapse
|
18
|
Subramanyam R, Varughese A, Willging JP, Sadhasivam S. Future of pediatric tonsillectomy and perioperative outcomes. Int J Pediatr Otorhinolaryngol 2013; 77:194-9. [PMID: 23159321 DOI: 10.1016/j.ijporl.2012.10.016] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2012] [Revised: 10/18/2012] [Accepted: 10/19/2012] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Although commonly performed, pediatric tonsillectomy is not necessarily a low risk procedure due to potentially life threatening perioperative complications. There is paucity of literature on lethal anesthesia and surgical complications of tonsillectomy. In this article, we have reviewed both minor and serious complications following tonsillectomy. Hemorrhage, burn injuries, respiratory complications, postoperative nausea and vomiting, and pain management are discussed. We have highlighted our practice of pain management at Cincinnati Children's Hospital after tonsillectomy recent warning about codeine by the FDA on children undergoing tonsillectomy. We describe post-tonsillectomy outcomes including postanesthesia care unit stay, post discharge maladaptive behavioral outcomes and finally effective ways to identify children at risk for anesthesia and a few preventive strategies. METHODS In addition to literature review, the LexisNexis "MEGA™ Jury Verdicts and Settlements" database was reviewed from 1984 through 2010 for deaths and complications during and following tonsillectomy. Data including year of case, cause of death, surgical, anesthetic and postoperative opioid related complications, injury, case result, and judgment awarded were collected and analyzed. RESULTS The results of this analysis are presented with an emphasis on hemorrhage and on anesthesia and opioid related claims and their characteristics. Two hundred and thirty-three claim reports were reviewed. There were 96 deaths (41%) and 137 perioperative injuries (59%). Deaths were primarily related to surgery (n=46, 48%) with post-tonsillectomy bleed the most frequent cause (n=38, 40%) followed by opioid toxicity (n=17, 18%) and anesthesia complications (n=9, 9%). Non-fatal injuries included, postoperative bleeding (n=59, 25%), impaired function (n=29, 12%), anoxic events (n=20, 9%) and postoperative opioid toxicity (n=20, 8.6%). Anoxic event was noted to have the highest monetary award with a mean award at $9,017,379. Injuries (including anoxia) had higher mean monetary awards than deaths. CONCLUSION Tonsillectomy in children carries a high risk of perioperative complications and malpractice claims. Though postoperative bleeding is the most common complication associated with malpractice claims, anoxia related to anesthesia and opioids had the greatest overall risk from a monetary standpoint.
Collapse
Affiliation(s)
- Rajeev Subramanyam
- Department of Anesthesia, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
| | | | | | | |
Collapse
|
19
|
Abstract
Pediatricians play an important role in the perioperative care of hospitalized children after tonsillectomy and are often called upon to manage posttonsillectomy problems in the outpatient setting. The tonsillectomy operation has changed in recent years. More children are operated upon for sleep disordered breathing and fewer for recurrent pharyngitis. New instruments now permit less invasive surgery. Systematic reviews by the Cochrane Collaboration and others have helped define best practices for preoperative assessment and postoperative care. This article will outline these practices as defined in the 2011 American Academy of Otolaryngology-Head and Neck Surgery Foundation clinical practice guideline "Tonsillectomy in Children." It will describe the different tonsillectomy operations, discuss patterns of normal healing, and review management of pain and posttonsillectomy hemorrhage to form a foundation for improved pediatric care.
Collapse
Affiliation(s)
- Glenn Isaacson
- Department of Otolaryngology-Head & Neck Surgery, Temple University School of Medicine, 1077 Rydal Rd, Suite 201, Rydal, PA 19046, USA.
| |
Collapse
|
20
|
Raman V, Tobias JD, Bryant J, Rice J, Jatana K, Merz M, Elmaraghy C, Kang DR. Effect of cuffed and uncuffed endotracheal tubes on the oropharyngeal oxygen and volatile anesthetic agent concentration in children. Int J Pediatr Otorhinolaryngol 2012; 76:842-4. [PMID: 22444738 DOI: 10.1016/j.ijporl.2012.02.055] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2011] [Revised: 02/15/2012] [Accepted: 02/17/2012] [Indexed: 12/30/2022]
Abstract
BACKGROUND Over the past 5 years, there has been a change in the clinical practice of pediatric anesthesiology with a transition to the use of cuffed instead of uncuffed endotracheal tubes (ETTs) in infants and children. As the trachea is sealed, one advantage is to eliminate the contamination of the oropharynx with oxygen which should be advantageous during adenotonsillectomy where there is a risk of airway fire. The current study prospectively assesses the oropharyngeal oxygen and volatile anesthetic agent concentration during adenotonsillectomy in infants and children. METHODS Following the induction of general anesthesia in patients scheduled for adenoidectomy, tonsillectomy or adenotonsillectomy, the trachea was intubated. The use of a cuffed or uncuffed ETT and the use of spontaneous (SV) or positive pressure ventilation (PPV) were at the discretion of the anesthesia team. The oxygen concentration was kept at 100% oxygen until the study was completed. Following placement of the mouth gag, the otolaryngolist placed into the oropharynx a small bore catheter, which was attached to a standard anesthesia gas monitoring device which sampled the gas at 150mL/min. The concentration of the oxygen and the concentration of the anesthetic agent in the oropharynx were measured for 5 breaths. RESULTS The cohort for the study included 200 patients ranging in age from 1 to 18 years. With the use of a cuffed ETT and either SV or PPV, the oxygen concentration in the oropharynx was 20-21% and the volatile agent concentration was 0% in all 118 patients. With the use of an uncuffed ETT and the administration of 100% oxygen, there was significant contamination of the oropharynx noted during both PPV and SV. The mean oxygen concentration was 71% during PPV with an uncuffed ETT and 65% during SV with an uncuffed ETT. In these patients, the oropharyngeal oxygenation concentration exceeded 30% in 73 of the 82 patients (89%). The oropharyngeal oxygen and agent concentration was greater when the leak around the uncuffed ETT was ≥10cmH(2)O versus less than 10cmH(2)O and when the leak around the uncuffed ETT was ≥15cmH(2)O versus less than 15cmH(2)O. CONCLUSIONS With the use of an uncuffed ETT and the administration of 100% oxygen, there was significant contamination of the oropharynx noted during both PPV and SV. The oropharyngeal concentration of oxygen is high enough to support combustion in the majority of patients. The use of a cuffed ETT eliminates oropharyngeal contamination with oxygen during the administration of anesthesia and may be useful in limiting the incidence of an airway fire.
Collapse
Affiliation(s)
- Vidya Raman
- Department of Anesthesiology, Nationwide Children's Hospital and the Ohio State University, Columbus, OH 43205, USA
| | | | | | | | | | | | | | | |
Collapse
|
21
|
Mathew R, Asimacopoulos E, Walker D, Gutierrez T, Valentine P, Pitkin L. Analysis of Clinical Negligence Claims following Tonsillectomy in England 1995 to 2010. Ann Otol Rhinol Laryngol 2012; 121:337-40. [DOI: 10.1177/000348941212100509] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Objectives: We determined the characteristics of medical negligence claims following tonsillectomy. Methods: Claims relating to tonsillectomy between 1995 and 2010 were obtained from the National Health Service Litigation Authority database. The number of open and closed claims was determined, and data were analyzed for primary injury claimed, outcome of claim, and associated costs. Results: Over 15 years, there were 40 claims of clinical negligence related to tonsillectomy, representing 7.7% of all claims in otolaryngology. There were 34 closed claims, of which 32 (94%) resulted in payment of damages. Postoperative bleeding was the most common injury, with delayed recognition and treatment of bleeding alleged in most cases. Nasopharyngeal regurgitation as a result of soft palate fistulas or excessive tissue resection was the next-commonest cause of a claim. The other injuries claimed included dentoalveolar injury, burns, tonsillar remnants, and temporomandibular joint dysfunction. Inadequate informed consent was claimed in 5 cases. Conclusions: Clinical negligence claims following tonsillectomy have a high success rate. Although postoperative bleeding is the most common cause of negligence claims, a significant proportion of claims are due to rare complications of surgery. Informed consent should be tailored to the individual patient and should include a discussion of common and serious complications.
Collapse
|
22
|
Stevenson AN, Myer CM, Shuler MD, Singer PS. Complications and legal outcomes of tonsillectomy malpractice claims. Laryngoscope 2011; 122:71-4. [DOI: 10.1002/lary.22438] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2011] [Revised: 09/09/2011] [Accepted: 09/16/2011] [Indexed: 12/14/2022]
|