Gastroesophageal reflux as a predictor of complications after adenotonsillectomy in young children

Supplemental oxygen requirement after tonsillectomy in children >3 years of age

INTRODUCTION

The indications for postoperative admission after tonsillectomy in children >3 years of age are less well defined than for children <3 years old, and typically include severe obstructive sleep apnea (OSA), obesity, comorbidities, or behavioral factors. Inpatient care after tonsillectomy typically consists of respiratory monitoring and support, as respiratory compromise is the most common complication after pediatric tonsillectomy. We aim to evaluate risk factors associated with postoperative oxygen supplementation and to identify high risk populations within the admitted population who use additional resources or require additional interventions.

METHODS

Retrospective chart review of patients between the ages of 3 and 18 years old who underwent tonsillectomy by four surgeons at a tertiary care children's hospital was performed. Data including demographics, comorbidities, surgical intervention, pre- and postoperative AHI, admission, postoperative oxygen requirement, and postoperative complications was collected and analyzed.

RESULTS

There were 401 patients included in the analysis. Of the patients in this study, 65.59% were male, 43.39% were Latino, and 53.87% were ages 3 to 7. Of the 397 patients with a record for supplemental oxygen, 36 (9.07%) received supplemental oxygen. The LASSO regression odds ratios (OR) found to be important for modeling supplemental oxygen use (in decreasing order of magnitude) are BMI ≥35 (OR = 2.30), pre-op AHI >30 (OR = 2.28), gastrointestinal comorbidities (OR = 2.20), musculoskeletal comorbidities (OR = 1.91), cardiac comorbidities (OR = 1.20), pulmonary comorbidities (OR = 1.14), and BMI 30 to <35 (OR = 1.07). Female gender was found to be negatively associated with risk of supplemental oxygen use (OR = 0.84). Age, race, AHI ≥15-30, neurologic comorbidities, syndromic patients, admission reason, and undergoing other procedures concomitantly were not found to be associated with increased postoperative oxygen requirement.

CONCLUSION

BMI ≥30, pre-op AHI >30, male gender, and gastrointestinal, musculoskeletal, cardiac, and pulmonary comorbidities are all associated with postoperative supplemental oxygen use. Age, race, AHI ≥15-30, neurologic comorbidities, syndromic patients, admission reason, and undergoing other procedures concomitantly were not found to be associated with increased postoperative oxygen requirement.

Role of laryngopharyngeal reflux (LPR) in complications after tonsillectomy in adult patients

BACKGROUND

Tonsillectomy and tonsillectomy with adenoidectomy are among the most common surgical procedures in otolaryngology practice, but the complications, especially the postoperative bleeding, are seriously troubling surgeons. Some authors had identified that gastroesophageal reflux and LPR are both risk factors for complications in tonsillectomy of children patients.

AIMS/OBJECTIVES

Therefore, we designed this prospective study to assess the role of LPR in the development of complications following tonsillectomy in adult patients. We want to provide a basis for future clinical practice.

MATERIAL AND METHODS

We recruited a totally of 150 adult patients (18-60 years old) who had an indication of tonsillectomy because of recurrent tonsillitis and divided them into two groups, the laryngopharyngeal reflux (LPR) group and the control group identified by the results of Reflux Symptom Index (RSI) and Reflux Finding Score (RFS). The complications that were observed and evaluated were pain, hemorrhage, fever, infection, and pulmonary problems.

RESULT

All the patients complained of pain after surgery. The duration of the pain in the LPR group was much longer than that of the control group. In the LPR group, patients had a similar pain level on the first day after surgery. However, on the 7th day and 14th day after surgery, the pain level was obviously higher than that of the control group. We found that the body temperature mildly rose on the 1st day after surgery and gradually fell to normal level in both groups. No cases had bleeding within 24 h after surgery. There were nine cases of bleeding in the LPR group, while only one case of bleeding occurred in the control group. There were no cases of infection or pulmonary complications in either group.

CONCLUSIONS AND SIGNIFICANCE

LPR is closely related to the complications followed by tonsillectomy and we also suggest that high dosages of proton pump inhibitors (PPI), alkaline water, and alginates should be prescribed to the patients with LPR during the perioperative period.

Predictive Pediatric Characteristics for Revision Tonsillectomy After Intracapsular Tonsillectomy

OBJECTIVES

There is little research on the rate and risk factors for revision tonsillectomy after primary intracapsular tonsillectomy. Our study aimed to determine the revision rate following intracapsular tonsillectomy, identify patient characteristics that may increase the probability of revision surgery, and report the tonsillar hemorrhage rate after revision.

STUDY DESIGN

Level III, retrospective case-control study.

SETTING

A tertiary care pediatric center (Alfred I. duPont Hospital for Children, Wilmington, Delaware).

METHODS

A case-control study of pediatric patients who underwent intracapsular tonsillectomy between January 1, 2004, and December 31, 2018, was performed. Patients aged 2 to 20 years were analyzed and compared with matched controls who underwent intracapsular tonsillectomy within 7 days of the same surgeon's case. In total, 169 revision procedures were included with 169 matched controls.

RESULTS

A 1.39% revision rate was observed among a total of 12,145 intracapsular tonsillectomies. Among the 169 patients who underwent a revision procedure, the mean time between cases was 3.5 years. Tonsillitis was the most common diagnosis prompting revision tonsillectomy. Four (2.4%) patients underwent operative control of a postoperative tonsillar hemorrhage after revision surgery. Younger patients (P < .001) and patients with a history of gastroesophageal reflux disease (P = .006) were more likely to undergo revision tonsillectomy.

CONCLUSION

Patients below age 4 years and patients with gastroesophageal reflux disease may be at increased risk of undergoing revision tonsillectomy after primary intracapsular tonsillectomy. These factors should be considered when selecting an intracapsular technique for primary tonsillectomy in pediatric patients.

Reflux as a Risk Factor for Morbidity after Pediatric Tonsillectomy: A National Cohort of Inpatients

OBJECTIVE

Gastroesophageal reflux (GER) has been identified as a risk factor for complications following pediatric tonsillectomy. The primary objective of this study was to examine outcomes after tonsillectomy among children with GER using a nationwide database. Secondary objectives included analyzing duration of hospitalization and total charges after admission.

METHODS

A cross-sectional review of the Healthcare Cost and Utilization Project (HCUP) Kids' Inpatient Databases (KID) from 2012 and 2016.

RESULTS

A total of 21,232 children had a tonsillectomy with or without adenoidectomy, with 1683 (7.9%) diagnosed with GER. Average age for patients with reflux was 4.4 years and for those without was 5.6 years (P < .001). The rate of primary hemorrhage was not statistically different between groups (P = .87). Patients with reflux were more likely to have respiratory complications (P = .03), aspiration pneumonitis (P < .001), and hypoxemia (P < .001) during their hospital course. Noninvasive ventilation and reintubation also occurred more frequently in this population (P < .001). Children with reflux had a longer duration of postoperative admission (3.8 vs. 2.3 days, P < .001) and higher total hospital charges ($47,129 vs. $27,584, P < .001). Multivariable regression analysis determined that reflux remained a statistically significant indicator of aspiration pneumonitis, hypoxemia, invasive and non-invasive ventilation, as well as length of admission.

CONCLUSION

Children with GER were significantly more likely to experience inpatient complications following tonsillectomy. Further, length of admission was higher compared to children without reflux. These results suggest that children with GER experience poorer outcomes after tonsillectomy and highlight the role for appropriate preoperative counseling and planning in this patient population. Laryngoscope, 131:907-910, 2021.

Outcomes intensive care unit placement following pediatric adenotonsillectomy

INTRODUCTION

Adenotonsillectomy (AT) is the most common surgical procedure for the treatment of sleep related breathing issues in children. While overnight observation in the hospital setting is utilized frequently in children after a AT, ICU setting is commonly used for patients with sleep apnea. This objective of this study is to examine factors associated with the preoperative decision to admit patients to PICU following AT as well as co-morbidities that may justify necessity for higher level of care.

METHODS

This is a retrospective chart review from the years of 2009-2016. All patients who underwent AT for known sleep-related breathing issues at Nationwide Children's Hospital were eligible for inclusion. A complication was defined as an adverse event such as pulmonary edema, re-intubation, or a bleeding event. Respiratory support was defined as utilizing supplementary oxygen for more than one day, positive pressure ventilation, or intubation. Proportions and medians were used to describe the overall rate of complications/complexities in care, and bivariate statistics were used to evaluate the relationship between patient characteristics and outcomes. Similar methods were used to evaluate factors associated with preoperative referral to the PICU.

RESULTS

There were 180 patients admitted to hospital in non-ICU setting and 158 patients with a planned PICU stay. The patients with planned PICU stays had higher rates of technological dependence (13% vs. 3%; p = 0.0006), perioperative sleep studies (80% vs. 29%; p < 0.0001), and more severe classifications of OSA (p < 0.0001). Patients with planned ICU placement also had higher rates of apneas, hypopneas, respiratory disturbance indexes, apnea hypopnea indexes, lower oxygen saturation nadirs, and a longer time spent below 90% oxygenation in sleep studies (p < 0.0001). Nearly 45% of the patients with planned ICU stays required respiratory support compared to just 8% of non-PICU patients. Additionally, 32% of the patients with planned ICU stays experienced complications compared to just 8% of the floor population. Complications were associated with younger ages, gastrointestinal comorbidities, technological dependence, viral infections, and a history of reflux. Interestingly, there were no differences in the complication rate by sleep studies findings. Similarly, there were no population level differences between patients who required respiratory support in the ICU and those that did not. Unplanned PICU placement was a rare but significant adverse event (n = 24). None of the hypothesized risk factors were associated with unplanned PICU placement.

CONCLUSIONS

This study suggest that while our pre-operative referral program for PICU placement is effective in identifying patients needing higher levels of care, the program places many patients in the PICU who did not utilize respiratory support or suffer from complications. We observed some misalignment between characteristics associated with planned ICU stays and actual complications. This suggests that patients with specific clinical histories, not findings on their sleep studies, should be prepared to receive higher levels of care.

Pharyngeal dysfunction associated with early and late onset sleep disordered breathing in children

OBJECTIVE

To compare the frequency and type of diagnoses associated with pharyngeal dysfunction (PD) in children presenting with early versus late onset sleep disordered breathing (SDB).

METHODS

This was a retrospective, cross-sectional study. A consecutive series of children ≤3 years old who underwent management for SDB were retrospectively identified from a prospectively kept surgical database. The early onset group was compared with two separate late onset (≥4years old) groups. Diagnoses associated with PD included gastroesophageal reflux disease (GERD), swallowing dysfunction, prematurity, asthma, and obesity. Distribution of PD diagnoses, airway lesions, syndromic conditions, pulse oximetry scores, and endoscopic pattern of airway obstruction were compared.

RESULTS

73 patients with early onset SDB were identified (51 boys, mean age 2.25 ± 0.64 years, range 1.75-3 years) and compared with two groups of later onset SDB consisting of 75 and 72 patients with mean ages of 7.58 ± 2.40 years and 8.04 ± 3.34 years respectively (range 4-16 years). The early onset SDB group had a higher prevalence of PD diagnoses compared to the later onset group with 35 of 73 patients being diagnosed compared to 41 of 147 children (p = 0.01). Early onset SDB patients were more likely to have GERD or swallowing dysfunction (p < 0.01) while later onset patients more commonly presented with associated asthma or obesity (p < 0.01). There was no statistically significant difference in airway lesions between groups.

CONCLUSION

Early-onset SDB is associated with conditions causing PD more often than later-onset SDB. Identifying these conditions and optimizing their management may impact outcomes in treating pediatric SDB.

Role of Laryngopharyngeal Reflux in Complications of Tonsillectomy in Pediatric Patients

Tonsillectomy and tonsillectomy with adenoidectomy are among the most common surgical procedures in otolaryngology practice. Gastroesophageal reflux was identified as a risk factor for complications in tonsillectomy. This prospective study was designed to assess the role of reflux in the development of complications following tonsillectomy in pediatric patients. Children (n = 60) who underwent tonsillectomy with adenoidectomy were divided into two groups, i.e., the laryngopharyngeal reflux (LPR) group and control group. Patients with LPR were identified by reflux symptom index and reflux finding score. Pain, hemorrhage, fever, nausea, vomiting, fever, dehydration, infection, and pulmonary problems were evaluated post operatively. The mean lengths of hospital stay were 2.11 days in the reflux group and 1.05 days in the control group. The difference was statistically significant. Visual analogue scores of both groups were similar on day 1 but it was significantly higher on day 7 and 14 in LPR group. Nausea and vomiting rates were 11.1 and 9.5 % for the patients in the LPR group and the controls, respectively. The difference between the two groups was not significant. The mean fever was 37.6 °C in the reflux group and 37.3 °C in the controls, which were not significantly different. 19 % of the controls and 22 % of the LPR group patients were readmitted. This difference was not statistically significant. There were two cases of bleeding in the reflux group, while no bleeding occurred in the control group. This difference was significant statistically. LPR is a risk factor for complications following tonsillectomy.