Indicaciones de Adenoidectomía y Amigdalectomía: Documento de Consenso entre la Sociedad Española de Otorrinolaringología y Patología Cervicofacial y la Asociación Española de Pediatría

Effectiveness of Adenoidectomy as a Standalone Procedure in Improving the Quality of Life of Children with Obstructive Sleep Apnea

Adenoid hypertrophy (AH) and its sequel like nasal obstruction, obstructive sleep apnoea (OSA), recurrent rhinitis and middle ear disorders are common diseases of pediatric age group, forming the major bulk of pediatric outpatient visits. The recommended approach to treating OSA in children is through adenotonsillectomy. Adenoidectomy is the surgical procedure of removal of hypertrophied adenoid tissues, which is the most common surgery performed by Ear, Nose, and Throat (ENT) surgeons. Given that adenoidectomy alone might lead to reduced instances of adverse outcomes, decreased risk of complications, and lower expenses, our objective was to explore the viability and suitability of adenoidectomy as a standalone treatment for pediatric OSA and to learn the significant effect of adenoidectomy on the quality of life (QOL) of children. Multicentric prospective study conducted in Department of ENT, Head and Neck Oncosurgery, Smita Memorial Hospital, Thodupuzha & Department of ENT, Head and Neck surgery, MCS Hospital, Muvattupuzha, Kerala, India from June 2022 to June 2023. Children between the age group of 5-10 years, who underwent adenoidectomy during the study period, satisfying the inclusion criteria were subjected for the study. Adenoidectomy was done for them using endoscope assisted coblation technique. Postoperative improvement in symptoms and change in quality of life were analyzed using obstructive sleep disorders-6 (OSD-6) questionnaire at the end of 3 months follow up. The surgeon observed a statistically significant improvement in all domains of OSD-6; and there by improvement in QOL in all patients, who underwent adenoidectomy in a course of three months. Adenoid hypertrophy is the most common cause of nasal obstruction in pediatric population and is creating a significant negative impact on the quality of life of children. Adenoidectomy is a safe and simple procedure which can provide significant improvement in quality of life of kids. Adenoidectomy in isolation could be a valid and recommended surgical choice for selected population of children displaying symptoms of pediatric OSA.

Rhinomanometry with and without decongestant used to select children for adenoidectomy: a cohort study

OBJECTIVE

Adenoid hypertrophy may coexist, and often does, with rhinitis. Therefore, in some cases, adenoidectomy alone, despite the fact that it reduces nasal resistance, may be insufficient to restore nasal breathing. Juliusson et al. suggested using rhinomanometry with and without nasal decongestant as a method for selecting patients for adenoidectomy. In this study, we aim to assess whether the decongestant test, when using normative data, is useful to select children for adenoidectomy.

METHODS

Children between 4 and 15 years old undergoing adenoidectomy were selected from two tertiary referral university hospitals. Participants underwent anterior active rhinomanometry with and without nasal decongestant before and after surgery. Parents fill in the sinus and nasal quality-of-life survey (SN5).

RESULTS

47 participants were included, and mean age 6.5 ± 2.15. 2 cohorts were defined according to the result of the nasal decongestant test (> 40% improvement in nasal resistance or not). There is a statistically significant difference between groups, with a higher improvement in nasal resistance and airflow after adenoidectomy in the group with less than 40% improvement in nasal resistance.

CONCLUSIONS

In conclusion, this study supports the use of the decongestant test with rhinomanometry to select children for adenoidectomy; especially as it has proven to be a simple technique, harmless, fast, and easily performed on collaborative children.

Revisiting systematic geographical variations in tonsils surgery in children in the Spanish National Health System: spatiotemporal ecological study on hospital administrative data

OBJECTIVE

To provide new evidence on how tonsils surgery in children has geographically varied over time in the context of the Spanish National Health System.

DESIGN

Observational ecological spatiotemporal study on geographical variations in medical practice, using linked administrative datasets, including virtually all surgeries performed from 2003 to 2015.

SETTING

The Spanish National Health System, a quasi-federal structure with 17 autonomous communities (ACs), and 203 healthcare areas (HCAs).

PARTICIPANTS

Patients aged 19 and younger residing in the HCAs and ACs.

INTERVENTIONS

Tonsillectomy with adenoidectomy (T&A); and tonsillectomies alone (T). MAIN ENDPOINTS: (1) Evolution of T&A and T rates; (2) spatiotemporal variation in the risk of receiving T&A or T surgery at regional level (ACs) and HCAs; and (3) the fraction of the variation (FV) attributed to each of the components of variation-ACs, HCAs, year and interaction ACs year.

RESULTS

T&A age-sex standardised rates increased over the period of analysis from 15.2 to 20.9 (5.7 points per 10 000 inhabitants). T alone remained relatively lower than T&A rates, evolving from 3.6 in 2003 to 3.9 in 2015 (0.3 points per 10 000 inhabitants). Most of the risk variation was captured at the HCAs level in both procedures (FV: 55.3% in T&A and 72.5% in T). The ACs level explained 27.6% of the FV in the risk in T&A versus 8% in T. The interaction ACs year was similar in both procedures (FV: 15.5% in T&A and 17.5% in T). The average trend hardly explained 1.46% and 1.83% of the variation, respectively.

CONCLUSION

Our study showed wide persistent variations with a steady increase in rates and risk of T&A and a stagnation of T alone, where most of the variation risk was explained at HCA level.

Assessing the ability of children and parents to rate their nasal patency. A cross sectional study

OBJECTIVE

Nasal obstruction is a common complaint in pediatric otolaryngology. There are several concerns about how nasal obstruction should be measured. This debate is even more important in children, as they can experience difficulties in being sensitive to their symptoms or even expressing them. In this research we aim to explore the ability of children (and their parents) to assess their nasal obstruction.

PARTICIPANTS

AND METHODS: An observational cross-sectional study was performed. Four cohorts of children were consecutively selected from a third level referral Hospital. Cohort A (children suffering solely turbinate enlargement), B (adenoid enlargement only), and C (adenoid and turbinate enlargement), while cohort D were healthy controls. Children and parents were asked to rate nasal patency through a Likert scale from 0 (no patency, complete obstruction of the nose) to 10 (complete patency, it is easy to breathe through the nose). All participants underwent rhinomanometry. Results of nasal resistance were relativized according to pediatric reference values per each age subgroup.

RESULTS

146 participants were included. Cohort A (54), B (40), C (28), D (24). There is a poor but significant correlation between parents' assessment and nasal resistance (rho = -0.28; p = 0.004). In children, there is no significant correlation with nasal resistance (rho = -0.14; p = 0.17). Stratified by severity, only children (and their parents) with good nasal breathing demonstrated good correlation values with the visual analogue score (VAS). Stratified by age, the correlation is only significant for parents of children older than 12 years old.

CONCLUSIONS

This study has demonstrated a good ability to rate nasal patency by healthy children and their parents, but a poor ability for children suffering from impaired nasal breathing. We suggest combining subjective assessment of nasal patency with objective measurements such as rhinomanometry in children.

Pediatric turbinate radiofrequency ablation improves quality of life and rhinomanometric values. A prospective study

OBJECTIVE

turbinate surgery in pediatric patients is gradually increasing in popularity amongst pediatric otolaryngologists. However, despite this, there is scarce information regarding this surgical procedure in children. The present research is designed with the aim of assessing changes in nasal resistance, nasal airflow and quality of life in pediatric patients undergoing turbinate radiofrequency ablation.

METHODS

A prospective uncontrolled intervention clinical trial design was followed. Children between 4 and 15 years old undergoing turbinate radiodiofrequency ablation (TRA) were consecutively selected. Children were examined preoperatively and 1, 3, 6 and 12 months after turbinate surgery. Anterior active rhinomanometry with and without nasal decongestant and examination of the turbinates and adenoid size were carried out in each follow-up visit. The SN5 quality of live survey was answered by parents.

RESULTS

81 children were included, 28 with associated adenoidectomy. A significant improvement in quality of life was demonstrated since the first month after TRA. Regarding nasal resistance, there was an improvement 1 month after surgery, but it only reached statistical significance for the whole sample (p < 0.001)) and for the cohort of isolated turbinate surgery (p < 0.001) at 3 months, while the values for the cohort of children who underwent adenoidectomy reached significance at 6 months after surgery (p = 0.04). The difference in nasal resistance before and after decongestant was compared to the change in nasal resistance after surgery. It demonstrated a strong correlation with the change in nasal resistance at 1 month (R = 0.985; p < 0.001), 3 months (R = 0.995; p < 0.001), 6 months (R = 0.98; p < 0.001) and 12 months (R = 0.98; p < 0.001) after surgery.

CONCLUSIONS

turbinate surgery in pediatric patients seems to be a safe procedure which objectively and subjectively improves the symptoms of children suffering from nasal obstruction.

What is the relationship between the size of the adenoids and nasal obstruction? A systematic review

OBJECTIVE

adenoidectomy is one of the most common surgical procedure in pediatric otolaryngology practice. Clinical guidelines (such as the Spanish or American) suggest adenoidectomy when the enlargement of the adenoids is associated with nasal obstruction. Nasal endoscopy and cephalograms are adequate methods to estimate the size of the adenoids. However, they do not measure nasal patency. This systematic review is designed with the objective of exploring the relationship between adenoid size and nasal ventilation through rhinomanometry.

REVIEW METHODS

3 authors members of the YO-IFOS rhinology study group independently analyzed the data sources (Pubmed, the Cochrane Library, EMBASE, SciELO) for papers assessing both nasal resistance and/or nasal airflow in rhinomanometry and adenoid size by any method (endoscopy, cephalogram, direct examination).

RESULTS

A total of 10 studies with a total population of 969 participants met the inclusion criteria. 5 authors explored the size of the adenoids through endoscopy. 4 authors explored the adenoids through lateral cephalograms. Finally, a further 2 authors explored adenoid size studying the resected tissue. Five studies explored the correlation between adenoid size and nasal resistance in rhinomanometry, which ranged from 0.20 to 0.84. Finally, 5 studies used nasal decongestant. It was found higher sensitivity and specificity, a higher area under the curve for the receiver operating characteristic curve, and higher correlation with adenoid size for rhinomanometry under nasal decongestion.

CONCLUSION

Up to now, there is no ideal diagnostic method for adenoid hypertrophy. Therefore, it seems prudent to use a combination of all currently available tools, as they provide complementary, rather than supplementary information. Available evidence suggests that rhinomanometry combined with nasal decongestant could help to elucidate the existence of nasal obstruction in intermediate cases of adenoid hypertrophy, as well as throw light on other possible causes for nasal obstruction, mainly turbinate hypertrophy.

Assessing the effect of adenoidectomy on nasal resistance and airflow. A systematic review and meta-analysis

OBJECTIVE

Clinical guidelines suggest adenoidectomy when enlarged adenoids are associated with nasal obstruction and other symptoms. Given that nasal obstruction is the leading symptom of adenoid hypertrophy, it should be thoroughly explored. However, there is no consensus regarding what could be the best approach. This systematic review is designed with the objective of exploring the extent to which adenoidectomy can decrease nasal resistance through rhinomanometry.

REVIEW METHODS

3 authors members of the YO-IFOS rhinology study group independently analyzed the data sources (Pubmed, the Cochrane Library, EMBASE, SciELO) for papers assessing the change in nasal resistance and/or nasal airflow in rhinomanometry after adenoidectomy in pediatric patients.

RESULTS

A total of 9 studies with a total population of 423 participants (323 patients excluding healthy controls) met the inclusion criteria. All of them found decreased nasal resistance after adenoidectomy. 5 studies could be combined in a metanalysis, which revealed a statistically significant difference of 0.52 Pa in basal conditions, and 0.64 Pa in rhinomanometry under nasal decongestion. 4 authors explored changes in nasal airflow. All of them found a statistically significant increase in nasal airflow after adenoidectomy. However, their results could not be merged in a meta-analysis.

CONCLUSION

This systematic review and meta-analysis demonstrated the existence of a systematic decrease in nasal resistance and increase in nasal airflow with and without nasal decongestant after adenoidectomy. The available evidence suggests that rhinomanometry with nasal decongestant could help in intermediate cases of adenoid hypertrophy, in order to identify the presence of nasal obstruction and, when present, the possibility of other causes for it rather than enlarged adenoids, mainly turbinate hypertrophy.

Radiofrequency ablation turbinoplasty improves the sense of smell in pediatric patients: A prospective study

INTRODUCTION

The olfactory sense is of paramount importance for the adequate development of a child. Olfactory loss in children might have different origins. One of the most common is conductive, when nasal obstruction prevents odorants from reaching the olfactory epithelium. Rhinitis and turbinate enlargement have been proven to diminish the sense of smell in pediatric patients. A common treatment for resistant rhinitis in these patients is turbinate radiofrequency ablation (TRA). However, despite an increasing research effort in this field, there are no studies instrumentally assessing olfaction in children undergoing turbinate surgery to date. This study was designed with the aim of assessing changes in olfaction through validated instrumental tools in pediatric patients undergoing TRA for the first time.

METHODS

A prospective uncontrolled intervention clinical trial design was conducted. Two cohorts of children ranging 4-15 years old were consecutively selected from a third level referral Hospital and subjected to the universal sniff test (U-Sniff), alcohol sniff test (AST), and sniffin sticks threshold test (SST) before and 1, 3 and 6 months after surgery. Cohort A consisted of children solely undergoing TRA. Cohort B consisted of children on whom adenoidectomy and TRA had been performed. Additionally, a cohort of Spanish healthy controls, paired by sex and age, were asked to perform the U-Sniff.

RESULTS

A total of 81 participants with a mean age of 10.31 ± 2.56 years were included. Fifty-three patients underwent TRA exclusively and 28 were subjected to associated adenoidectomy. Despite a tendency toward improvement in the U-sniff scores, there were no statistically significant differences after surgery. However, statistically significant differences were obtained for threshold tasks measured with SST and AST, revealing differences at 1, 3 and 6 months after surgery compared to preoperative scores.

CONCLUSIONS

In summary, this research demonstrated adequate levels in the sense of smell regarding identification tasks, but decreased olfactory threshold scores in pediatric patients suffering from TE. TRA, alone or with adenoidectomy, improved smell threshold scores, but had no significant effect on identification tasks.

Comparison of two specific quality of life questionnaires in a paediatric population with adenotonsillar disease

INTRODUCTION AND OBJECTIVE

T-14 and TAHSI are validated and reliable specific questionnaires which measure the quality of life in paediatric patients with adenotonsillar disease. The present study aims to compare the adapted and validated versions in Spanish of these two questionnaires (T-14-s and s-TAHSI) in order to assess the preferential use of either of them in our environment.

MATERIAL AND METHODS

A multicentre prospective cross-sectional study was carried out between November 2015 and April 2016, to determine the possible correlation between these two instruments. Subjects aged from 2 to 16 years with indication for adenotonsillar surgery and healthy controls, were consecutively included. Parents or caregivers of these children completed T-14-s and s-TAHSI questionnaires initially, after 2-6 weeks and at 6 months after surgery. T-14-s and s-TAHSI scores of the entire sample were compared globally, patient and control subgroups were compared separately and finally, compared in the group of patients at 6 months from surgery, using Pearson correlation coefficient. The proportion of variability shared between both tests was calculated.

RESULTS

A hundred subjects (50 cases and 50 controls) were studied. The overall correlation presented by both questionnaires was very high (0.97) with a significance level of p < .01. The proportion of shared variability was 94%, very high. The results were maintained when comparing the questionnaires in the subpopulations of cases and controls, as well as the postoperative questionnaires.

CONCLUSION

Quality of life questionnaires for paediatric patients with adenotonsillar pathology, T-14-s and s-TAHSI, showed high correlation and allows the equivalent use of both in our environment.

Impact of adenotonsillectomy on the evolution of inflammatory markers

BACKGROUND

Tonsils are first-line host defence organs against pathogenic agents and participate in local and systemic immunity. Persistent increases in systemic inflammatory responses may contribute to associated morbidity. The aim of this study was to verify the short- and long-term impact of adenotonsillectomy on the evolution of inflammatory markers in 3- to 9-year-old children.

METHODS

A prospective and longitudinal study was conducted over 1 year in 29 children who underwent tonsillectomy due to either chronic tonsillitis or adenotonsillar hypertrophy. Measurements of high-sensitivity C-reactive protein (hs-CRP) levels were taken. Levels of Th1-type cytokines [interleukin-1, interferon-γ, and tumor necrosis factor-α (TNF-α)] and anti-inflammatory Th2-type cytokines [interleukin-4, -5, -6, -10 and -13] were measured. Levels of transforming growth factor-beta (TGF-β) and intercellular adhesion molecule-1 (ICAM-1) were also determined. The results were compared to those of 29 control children.

RESULTS

At baseline, children with surgery indications presented with higher levels of hs-CRP, interleukin-1 and -10, interferon-γ, TNF-α and ICAM-1, whereas values of interleukin-4 were significantly lower than in control children. Children with severe tonsillar obstruction had higher values of interleukin-1, -4, and -5 and lower values of interleukin-10 compared with children with recurrent tonsillitis. One year after surgery, the levels except IL-4 did not show a significant difference from those obtained in the control group. The levels of hs-CRP and TNF-α decreased significantly in the first month.

CONCLUSION

Children with chronic tonsillitis and/or adenotonsillar hypertrophy have significantly elevated levels of proinflammatory cytokines. Adenotonsillectomy restores the normal values of these parameters 1 year after surgery.

Histological analysis of tonsillectomies: relationship with surgical technique, post-operative pain and haemorrhage

Objectives:

There is no consensus on the optimal technique to decrease post-tonsillectomy morbidity. Histopathological analysis can estimate collateral tissue damage. This study compared histological findings for tonsils removed by cold or electrocautery dissection and their relationship with post-operative complications.

Methods:

Two adult out-patient groups were included in the study: 37 who underwent cold dissection and 37 who underwent electrocautery dissection. Histological analysis was used to assess tissue damage.

Results:

Tissue damage was significantly higher in the electrocautery dissection group (p = 0.002), as were the number of emergency department visits (p = 0.01) and the need for supplemental analgesia (p = 0.013). Patients in the cold dissection group experienced less pain (p = 0.001) and fewer secondary haemorrhage episodes.

Conclusion:

Cold dissection produces less tissue damage, which is associated with lower incidence of complications. This study suggests that cold dissection is the technique of choice for tonsillectomy.

Basiespinal Cerebrospinal Fluid Leak as a Complication After Adenoidectomy: Case Report and Literature Review

BACKGROUND

Adenoidectomy is one of the most common procedures in the field of pediatric otolaryngology. Postoperative bleeding is one of the most frequent complications (0.4%). In turn, cerebrospinal fluid fistula is a very uncommon but critical complication in this type of surgery.

METHODS

We report the case of a 3-year-old patient who underwent adenoidectomy and presented a cerebrospinal fluid leak associated with pneumocephalus and meningitis.

RESULTS

The solution provided was a suture in layers of the fistula tract, reinforced with basipharyngeal vascularized and rotation random flap of mucosa, and a free graft of muscle, through a transoral endoscopic approach.

CONCLUSIONS

Cerebrospinal fluid leak as a complication after adenoidectomy is exceedingly rare. These pharyngospinal fistulae are determined by the anatomic features associated with intraoperative hemorrhagic complications, and it is essential that we take them into account when facing postoperative complications in the follow-up. The use of vascularized flaps based on the irrigation of the ascending pharyngeal artery with endoscopic techniques offers low-morbidity solutions, which are more efficient than traditional methods.

[Ischemic stroke in childhood. A complication of tonsillectomy]

Tonsillectomy is one of the most frequently performed otorhinolaryngological procedures on children. The postoperative complications are classified into primary or intermediate, which generally appear within 24h, and as secondary or delayed, after 48 h. We present the case of an ischemic stroke after performing a tonsillectomy on a 3 year-old boy, which was diagnosed in the immediate postoperative period. Using brain echo-doppler and angio-CT, an intraluminal clot was observed in the left internal carotid artery, probably as a result of direct vessel injury during arterial ligature for hemostasis.

[Recommendations for management of acute pharyngitis in adults]

La faringoamigdalitis aguda (FAA) en el adulto es una de las enfermedades infecciosas más comunes en la consulta del médico de familia. La etiología más frecuente es viral. Dentro de la etiología bacteriana, el principal agente responsable es Streptococcus pyogenes o estreptococo β-hemolítico del grupo A (EBHGA), causante del 5-30% de los casos. En el manejo diagnóstico, las escalas de valoración clínica para predecir la posible etiología bacteriana, son una buena ayuda para seleccionar a qué pacientes se deben practicar las técnicas de detección rápida de antígeno estreptocócico. Es conocido que, en general, sin estas técnicas se tiende al sobrediagnóstico de FAA estreptocócica, con la consiguiente prescripción innecesaria de antibióticos, muchas veces de amplio espectro. Así, con el manejo de las escalas y la técnica de diagnóstico rápido, elaboramos los algoritmos de manejo de la FAA. Los objetivos del tratamiento son acelerar la resolución de los síntomas, reducir el tiempo de contagio y prevenir las complicaciones supurativas locales y no supurativas. Los antibióticos de elección para el tratamiento de la FAA estreptocócica son penicilina y amoxicilina. La asociación de amoxicilina y clavulánico no está indicada en el tratamiento inicial en la infección aguda. Los macrólidos tampoco son un tratamiento de primera elección; su uso debe reservarse para pacientes con alergia a la penicilina. Es importante en nuestro país adecuar tanto el diagnóstico de la FAA bacteriana y la prescripción de antibióticos a la evidencia científica disponible. La implantación de protocolos de actuación en las farmacias comunitarias puede ser de utilidad para identificar y cribar los casos que no requieran tratamiento antibiótico.

[Recommendations for management of acute pharyngitis in adults]

Acute pharyngitis in adults is one of the most common infectious diseases seen in general practitioners' consultations. Viral aetiology is the most common. Among bacterial causes, the main agent is Streptococcus pyogenes or group A β-haemolytic streptococcus (GABHS), which causes 5%-30% of the episodes. In the diagnostic process, clinical assessment scales can help clinicians to better predict suspected bacterial aetiology by selecting patients who should undergo a rapid antigen detection test. If these techniques are not performed, an overdiagnosis of streptococcal pharyngitis often occurs, resulting in unnecessary prescriptions of antibiotics, most of which are broad spectrum. Consequently, management algorithms that include the use of predictive clinical rules and rapid tests have been set up. The aim of the treatment is speeding up symptom resolution, reducing the contagious time span and preventing local suppurative and non-suppurative complications. Penicillin and amoxicillin are the antibiotics of choice for the treatment of pharyngitis. The association of amoxicillin and clavulanate is not indicated as the initial treatment of acute infection. Neither are macrolides indicated as first-line therapy; they should be reserved for patients allergic to penicillin. The appropriate diagnosis of bacterial pharyngitis and proper use of antibiotics based on the scientific evidence available are crucial. Using management algorithms can be helpful in identifying and screening the cases that do not require antibiotic therapy.

[Recommendations for management of acute pharyngitis in adults]

La faringoamigdalitis aguda (FAA) en el adulto es una de las enfermedades infecciosas más comunes en la consulta del médico de familia. La etiología más frecuente es viral. Dentro de la etiología bacteriana, el principal agente responsable es Streptococcus pyogenes o estreptococo β-hemolítico del grupo A (EBHGA), causante del 5-30% de los casos. En el manejo diagnóstico, las escalas de valoración clínica para predecir la posible etiología bacteriana, son una buena ayuda para seleccionar a qué pacientes se deben practicar las técnicas de detección rápida de antígeno estreptocócico. Es conocido que, en general, sin estas técnicas se tiende al sobrediagnóstico de FAA estreptocócica, con la consiguiente prescripción innecesaria de antibióticos, muchas veces de amplio espectro. Así, con el manejo de las escalas y la técnica de diagnóstico rápido, elaboramos los algoritmos de manejo de la FAA. Los objetivos del tratamiento son acelerar la resolución de los síntomas, reducir el tiempo de contagio y prevenir las complicaciones supurativas locales y no supurativas. Los antibióticos de elección para el tratamiento de la FAA estreptocócica son penicilina y amoxicilina. La asociación de amoxicilina y clavulánico no está indicada en el tratamiento inicial en la infección aguda. Los macrólidos tampoco son un tratamiento de primera elección; su uso debe reservarse para pacientes con alergia a la penicilina. Es importante en nuestro país adecuar tanto el diagnóstico de la FAA bacteriana y la prescripción de antibióticos a la evidencia científica disponible. La implantación de protocolos de actuación en las farmacias comunitarias puede ser de utilidad para identificar y cribar los casos que no requieran tratamiento antibiótico.

Recommendations for management of acute pharyngitis in adults

Acute pharyngitis in adults is one of the most common infectious diseases seen in general practitioners' consultations. Viral aetiology is the most common. Among bacterial causes, the main agent is Streptococcus pyogenes or group A β-haemolytic streptococcus (GABHS), which causes 5%-30% of the episodes. In the diagnostic process, clinical assessment scales can help clinicians to better predict suspected bacterial aetiology by selecting patients who should undergo a rapid antigen detection test. If these techniques are not performed, an overdiagnosis of streptococcal pharyngitis often occurs, resulting in unnecessary prescriptions of antibiotics, most of which are broad spectrum. Consequently, management algorithms that include the use of predictive clinical rules and rapid tests have been set up. The aim of the treatment is speeding up symptom resolution, reducing the contagious time span and preventing local suppurative and non-suppurative complications. Penicillin and amoxicillin are the antibiotics of choice for the treatment of pharyngitis. The association of amoxicillin and clavulanate is not indicated as the initial treatment of acute infection. Neither are macrolides indicated as first-line therapy; they should be reserved for patients allergic to penicillin. The appropriate diagnosis of bacterial pharyngitis and proper use of antibiotics based on the scientific evidence available are crucial. Using management algorithms can be helpful in identifying and screening the cases that do not require antibiotic therapy.

Protocol for post-tonsillectomy pain control in outpatient adults

INTRODUCTION

Even though notable advances in anaesthetic and surgical techniques have appeared in recent years, morbidity, and especially pain, associated with tonsillectomy is still an important clinical problem.

OBJECTIVES

Assess the influence of a specific protocol for the control of postoperative pain and compare the frequency of complications in patients with and without it.

METHODS

This was a descriptive, observational and prospective study on adult tonsillectomy patients in outpatient surgery. There were 2 groups: group 1, with 65 patients to whom a variable analgesic treatment was given; and group 2, with 50 patients with analgesic protocol and preoperative nursing interview. For the evaluation of pain, a numerical scale from 0 to 10 was used. The surgical techniques used were cold dissection or electric dissection.

RESULTS

On the 4(th) day, group 1 (without protocol) presented a mean pain of 4.8 points on a numerical scale from 0 to 10, while group 2 (with protocol) presented mean of 3 (P=.0002). From group 1, 22 patients (36%) had to go to the emergency service, while 8 (16%) in group 2 did so (P=.019). On the 4(th) day, patients operated with cold dissection presented 3.7 points, as opposed to those operated with electric dissection, who presented 4.4 points.

CONCLUSIONS

A specific protocol applied to adult tonsillectomy patients in outpatient surgery is useful to obtain less pain and fewer complications.

Electrodissection tonsillectomy with laryngeal mask

INTRODUCTION

The Colorado® microdissection needle has been used for 30 years as an alternative to cold dissection. Alexander was the first to publish the results of laryngeal mask in otorhinolaryngology and maxillofacial surgery. Later on it was introduced as a standard anaesthetic technique in our speciality. Objective The objective of this study was to compare the results of using laryngeal mask combined with Colorado® microdissection needle in tonsillectomies. The benefits of each of these 2 techniques are already known. Methods We present a prospective observational study of 107 paediatric tonsillectomies associated or not to adenoidectomy. Variables analysed are pain (Brodman scale), analgesia, bleeding, uvula oedema and days up to the restoration of diet and normal life. Surgical, anaesthetic and total surgery room times are also discussed. Results The Colorado® electrodissection technique minimised intraoperative bleeding and the need for haemostasis. However, uvula oedema and local pain increased compared with cold dissection. There were no clinical variations in the recovery of normal life. Combining the Colorado® microdissection needle and laryngeal mask reduced intraoperative, anaesthetic and total surgery room times. Conclusions The combination of these two techniques is a secure, quick and effective method that derives benefits from the advantages of both of them, without increasing surgical or anaesthetic risks.

[Consensus document on the diagnosis and treatment of acute tonsillopharyngitis]

Acute tonsillopharyngitis is one of the most common childhood diseases. Viruses are the most frequent origin. Group A Streptococcus (Streptococcus pyogenes) is the main bacterial cause. A culture or a rapid antigen-detection test of a throat-swab specimen should only be done on the basis of clinical scores, in order to avoid over-diagnosis of bacterial origin and unnecessary antibiotic prescription. The objectives of treatment are: the reduction of symptoms, reduce the contagious period, and prevent local suppurative and systemic complications. Ideally, only confirmed cases should receive antibiotics. If there is no possibility to perform a rapid antigen-detection test, or in some cases if the result is negative, it is recommended to perform a culture and, if there is high suspicious index, to prescribe antibiotics. Penicillin is the treatment of choice, although amoxicillin is also accepted as the first option. Amoxicillin/clavulanate is not indicated in any case as empirical treatment. Macrolides are not a first choice antibiotic, and should be reserved for those patients with immediate penicillin allergy reaction or for the treatment of streptococcal carriers. It is of primordial importance to adapt the prescribing of antibiotics to the scientific evidence.