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Kattimani V, Panneerselvam E, Tiwari R, Panga GSK, Sreeram RR. An Overview of Systematic Reviews on the Surgical Management of Obstructive Sleep Apnoea. J Maxillofac Oral Surg 2023; 22:781-793. [PMID: 38105854 PMCID: PMC10719205 DOI: 10.1007/s12663-023-02051-x] [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: 08/24/2023] [Accepted: 10/21/2023] [Indexed: 12/19/2023] Open
Abstract
Background Obstructive Sleep Apnoea (OSA) is a common sleep disorder marked by partial or total obstruction of the upper airway while a person is asleep leading to breathing difficulty, reduced oxygenation and frequent awakenings. This condition affects the general health significantly compromising quality of life. The objective of this overview is to thoroughly assess the systematic reviews on current surgical therapies for the management of OSA in terms of patient outcomes. Methods A thorough literature search was performed from inception till 31st December 2022 using PubMed, and Cochrane databases. Studies evaluating the effectiveness and safety of different surgical techniques for the management of OSA were considered. The quality of articles was assessed using AMSTAR (A MeaSurement Tool to Assess systematic Reviews) and Glenny et al. checklist. Results Out of eighteen studies, only seven studies met the inclusion and exclusion criteria. Results showed that the majority of studies were in the pediatric age group except one systematic review which assessed the adult age group. Conclusion None of the published articles had compared all surgical procedures based on the standard evaluating procedure nor followed all reporting guidelines in the primary studies. For better implementation, further multi center studies are warranted with unique reporting criteria and guidelines about pre- as well as post-operative phases. Future research should concentrate on contrasting strategies, combination therapies, and evaluating long-term effects. Supplementary Information The online version contains supplementary material available at 10.1007/s12663-023-02051-x.
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Affiliation(s)
- Vivekanand Kattimani
- SIBAR Institute of Dental Sciences, Takkellapadu, Guntur, Andhra Pradesh 522509 India
| | | | - Rahul Tiwari
- Narsinhbhai Patel Dental College and Hospital, Sankalchand Patel University, Visnagar, Gujarat India
| | | | - Roopa Rani Sreeram
- SIBAR Institute of Dental Sciences, Takkellapadu, Guntur, Andhra Pradesh 522509 India
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Sjöblom HM, Timgren JM, Piitulainen JM, Jero J. Patient injuries from tonsil and adenoid surgery in Finland. Laryngoscope Investig Otolaryngol 2022; 7:1773-1779. [PMID: 36544943 PMCID: PMC9764750 DOI: 10.1002/lio2.954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 08/11/2022] [Accepted: 10/01/2022] [Indexed: 11/06/2022] Open
Abstract
Objectives The aims of this national register-based study were to examine patient injury claims related to tonsil and adenoid surgery injuries and to compare the frequency of claims between tonsillectomies and tonsillotomies in Finland. Methods We analyzed the complaints related to tonsil and adenoid surgery received by the Finnish Patient Insurance Center (PIC) between the years 2000 and 2019. One hundred seventy-two cases were included in the analysis. The annual surgery rates between the years 2000 and 2018 were acquired from the Finnish Institute for Health and Welfare. Results During the years 2000 to 2018, a total of 292,679 patients had tonsil and/or adenoid surgery nationwide. For tonsil or adenoid surgeries, the national average was 5.3 cases and 1.8 cases per 10,000, respectively, resulting in patient injury claims and compensations. A total of 33.1% of the claims regarding tonsil or adenoid surgery processed by the PIC were compensated. Most of the claims were made after a tonsillectomy (87.8%), and few were made after a tonsillotomy (1.7%). Seven deaths were recorded. Conclusion Patient injuries from tonsil and adenoid surgeries were mostly related to traditional extracapsular tonsillectomies. Most surgeries, along with most complications, involved specialists, who performed routine operations in high-volume centers. Surgeries for acute or recurrent infections resulted in more claims. Severe complications arising from tonsil and adenoid surgeries were rare. Level of Evidence 4.
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Affiliation(s)
- Henrik M. Sjöblom
- Division of Surgery and Cancer Diseases, Department of Otorhinolaryngology – Head and Neck SurgeryTurku University HospitalTurkuFinland,Department of MedicineUniversity of TurkuTurkuFinland
| | | | - Jaakko M. Piitulainen
- Division of Surgery and Cancer Diseases, Department of Otorhinolaryngology – Head and Neck SurgeryTurku University HospitalTurkuFinland,Department of MedicineUniversity of TurkuTurkuFinland
| | - Jussi Jero
- Department of MedicineUniversity of HelsinkiHelsinkiFinland
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Piitulainen JM, Uusitalo T, Sjöblom HM, Ivaska LE, Jegoroff H, Kauko T, Kokki H, Kytö E, Mansikka I, Ylikoski J, Jero J. Intracapsular tonsillectomy in the treatment of recurrent and chronic tonsillitis in adults: a protocol of a prospective, single-blinded, randomised study with a 5-year follow-up (the FINITE trial). BMJ Open 2022; 12:e062722. [PMID: 36104143 PMCID: PMC9476145 DOI: 10.1136/bmjopen-2022-062722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 08/25/2022] [Indexed: 12/04/2022] Open
Abstract
INTRODUCTION The standard surgical treatment for recurrent or chronic tonsillitis is extracapsular tonsillectomy. Recent studies show that intracapsular tonsillectomy has the potential to reduce the postoperative morbidity of patients undergoing tonsil surgery. The Finnish Intracapsular Tonsillectomy (FINITE) trial aims to provide level I evidence to support the hypothesis that the recovery time from tonsil surgery can be reduced with intracapsular tonsillectomy. Additionally, from this trial, major benefits in quality of life, reduction of postoperative complications, treatment costs and throat symptoms might be gained. METHODS AND ANALYSIS The FINITE trial is a prospective, randomised, controlled, patient-blinded, three-arm clinical trial. It is designed to compare three different surgical methods being extracapsular monopolar tonsillectomy versus intracapsular microdebrider tonsillectomy versus intracapsular coblation tonsillectomy in the treatment of adult patients (16-65 years) suffering from recurrent or chronic tonsillitis. The study started in September 2019, and patients will be enrolled until a maximum of 200 patients are randomised. Currently, we are in the middle of the study with 125 patients enrolled as of 28 February 2022 and data collection is scheduled to be completed totally by December 2027. The primary endpoint of the study will be the recovery time from surgery. Secondary endpoints will be the postoperative pain scores and the use of analgesics during the first 3 weeks of recovery, postoperative haemorrhage, quality of life, tonsillar remnants, need for revision surgery, throat symptoms, treatment costs and sick leave. A follow-up by a questionnaire at 1-21 days and at 1, 6, 24 and 60 months will be conducted with a follow-up visit at the 6-month time point. ETHICS AND DISSEMINATION Ethical approval was obtained from the Medical Ethics Committee of the Hospital District of Southwest Finland (reference number 29/1801/2019). Results will be made publicly available in peer-reviewed scientific journals. TRIAL REGISTRATION NUMBER NCT03654742.
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Affiliation(s)
- Jaakko Matias Piitulainen
- Department of Otorhinolaryngology - Head and Neck Surgery, Turku University Hospital, Turku, Finland
- Otorhinolaryngology, Faculty of Medicine, University of Turku, Turku, Finland
| | - Tapani Uusitalo
- Department of Otorhinolaryngology - Head and Neck Surgery, Turku University Hospital, Turku, Finland
- Otorhinolaryngology, Faculty of Medicine, University of Turku, Turku, Finland
| | - Henrik M Sjöblom
- Department of Otorhinolaryngology - Head and Neck Surgery, Turku University Hospital, Turku, Finland
- Otorhinolaryngology, Faculty of Medicine, University of Turku, Turku, Finland
| | - Lotta E Ivaska
- Department of Otorhinolaryngology - Head and Neck Surgery, Turku University Hospital, Turku, Finland
- Otorhinolaryngology, Faculty of Medicine, University of Turku, Turku, Finland
| | - Henri Jegoroff
- Otorhinolaryngology, Faculty of Medicine, University of Turku, Turku, Finland
| | - Tommi Kauko
- Department of Otorhinolaryngology - Head and Neck Surgery, Turku University Hospital, Turku, Finland
| | - Hannu Kokki
- School of Medicine, University of Eastern Finland, Joensuu, Finland
| | - Eero Kytö
- Department of Otorhinolaryngology - Head and Neck Surgery, Turku University Hospital, Turku, Finland
- Otorhinolaryngology, Faculty of Medicine, University of Turku, Turku, Finland
| | - Iisa Mansikka
- Department of Otorhinolaryngology - Head and Neck Surgery, Turku University Hospital, Turku, Finland
- Otorhinolaryngology, Faculty of Medicine, University of Turku, Turku, Finland
| | - Jenni Ylikoski
- Department of Otorhinolaryngology - Head and Neck Surgery, Turku University Hospital, Turku, Finland
- Otorhinolaryngology, Faculty of Medicine, University of Turku, Turku, Finland
| | - Jussi Jero
- Faculty of Medicine, University of Helsinki, Helsinki, Finland
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Stalfors J, Ovesen T, Bertelsen JB, Bugten V, Wennberg S, Sunnergren O. Comparison of clinical practice of tonsil surgery from quality register data from Sweden and Norway and one clinic in Denmark. BMJ Open 2022; 12:e056551. [PMID: 35477880 PMCID: PMC9047789 DOI: 10.1136/bmjopen-2021-056551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 03/16/2022] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVES To compare the application of indications, demographics, surgical and haemostatic techniques in tonsil surgery in three countries. DESIGN Non-randomised, prospective, observational cohort. SETTING All patients registered in the National Tonsil Surgery Quality Registers in Sweden, Norway and West Jutland, Denmark. PARTICIPANTS Data were retrieved from 2017 to 2019; registered surgeries: Sweden: 20 833; Norway: 10 294 and West Jutland, Denmark: 505. RESULTS Tonsil surgery for obstruction was twice as common in Sweden (62.2%) compared with Norway (31%) and Denmark (27.7%). Recurrent tonsillitis was registered twice as frequently in Norway (35.7%) and Denmark (39%) compared with Sweden (16.7%). Chronic tonsillitis was registered more frequently in Norway (29.8%) than in Sweden (13.8%) and Denmark (12.7%). Day surgery (>76%) was comparable. The higher frequency of obstruction in Sweden affected age and gender distributions: Sweden (7 years, 50.4% boys), Norway (17 y, 42.1%) and Denmark (19 y, 38.4%). For obstructive disorders, tonsillotomy with adenoidectomy was used in a majority of Swedish children (72%), whereas tonsillectomy with or without adenoidectomy dominated in Norway (53.5%) and Denmark (57.9%). Cold steel was the technique of choice for tonsillectomy in all three countries. For tonsillotomy, hot dissection techniques dominated in all countries. Disparities were observed with regard to haemostatic techniques. Bipolar diathermy was commonly used in all countries. Monopolar diathermy was practically only used in Sweden. Infiltration with epinephrine in the tonsillar bed was registered in Sweden and Norway but not at all in Denmark. Combined cold surgical and cold haemostatic techniques were more commonly used in Sweden (22.7%) than in Norway (10.4%) and Denmark (6.2%). CONCLUSIONS This study demonstrates disparities among the Nordic countries in tonsil surgery in terms of indications plus surgical and haemostatic techniques. Increased coverage and further monitoring of outcomes is needed to identify best practices and ideal guidelines for improved care.
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Affiliation(s)
- Joacim Stalfors
- Department of Otolaryngology, Sahlgrenska Academy, Goteborg, Sweden
| | - Therese Ovesen
- Institute of Clinical Medicine, Aarhus Universitet, Aarhus, Denmark
| | | | - Vegard Bugten
- Department of Otorhinolaryngology - Head and Neck Surgery, St Olavs Hospital Trondheim University Hospital, Trondheim, Norway
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, Trondheim, Norway
| | - Siri Wennberg
- Department of Medical Quality Registries, St Olavs Hospital Trondheim University Hospital, Trondheim, Trøndelag, Norway
| | - Ola Sunnergren
- Department of Clinical and Experimental Medicine, Linköpings universitet Hälsouniversitetet, Linkoping, Sweden
- Department of Otorhinolaryngology, Region Jönköping County, Jonkoping, Sweden
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Cavaliere M, De Luca P, De Bonis E, Maurizi R, Cassandro C, Ralli M, Cassandro E, Scarpa A. Partial intracapsular tonsillectomy in the treatment of pediatric obstructive sleep apnea/hypopnea syndrome: a prospective study with 5-year follow-up. Eur Arch Otorhinolaryngol 2021; 279:3089-3093. [PMID: 34628549 PMCID: PMC9072457 DOI: 10.1007/s00405-021-07119-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 07/23/2021] [Indexed: 11/14/2022]
Abstract
Objective To assess efficacy and safety of tonsil reduction with bipolar forceps electrocautery as treatment of paediatric obstructive sleep apnea/hypopnea syndrome (OSAHS). Study design Prospective interventional study. Methods Two hundred and sixty-three children aged 4–10 years with OSAHS and an apnea hypopnea index (AHI) > 3 were enrolled from March 2013 to January 2016. Pre-operative evaluation included oropharyngeal clinical examination with fiberoptic nasopharyngoscopy, OSA-18 questionnaire and overnight sleep study. All children were treated with adenoidectomy and tonsillotomy with bipolar forceps. OSA-18 questionnaire and overnight sleep study were performed 30 days after surgery. Results Pre-operative average of the OSA-18 questionnaires was of 70.3 (SD = 9.7); 30-day post-operative score was 23.15 (SD = 8.2; p = 0.045). Pre-operative average Apnea Hypopnea Index (AHI) score was 9.41 (SD = 4.1); 30-day post-operative average of AHI score was of 1.75 (SD = 0.8; p = 0.012). Oxygen Desaturation Index (ODI) rate changed from 7.39 (SD = 4) to 1.34 (30-day post-operative) (SD = 4.7; p = 0.085). NADIR rate changed from 79% (SD = 6.32) to 90% (30-day post-operative) (SD = 5.18; p = 0.00012). Peri- and post-operative complications in our sample were mainly pain (average 75 doses of paracetamol), while bleeding did not occur (0%). All patients received a follow-up examination 5 years after surgery to evaluate tonsil size; at this time-point, a reduction in tonsil size from 3.6 (3–4; SD = 4.2) to 1.3 (1–2; SD = 5.5) was found, while tonsil regrowth was observed in five children (2%). Conclusion This study showed that partial tonsillotomy with bipolar forceps electrocautery associated to adenoidectomy is an effective technique in treating OSAHS symptoms in children and ensures less complications in terms of hemorrhage, postoperative pain and infections compared to traditional adenotonsillectomy. The very low tonsillar regrowth rate reported in this study may support the routine use of this technique.
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Affiliation(s)
- Matteo Cavaliere
- Department of Medicine, Surgery and Dentistry, University of Salerno, Salerno, Italy
| | - Pietro De Luca
- Department of Medicine, Surgery and Dentistry, University of Salerno, Salerno, Italy.
| | - Egidio De Bonis
- Department of Medicine, Surgery and Dentistry, University of Salerno, Salerno, Italy
| | - Riccardo Maurizi
- Department of Clinical Sciences and Translational Medicine, Otorhinolaryngology Unit, Tor Vergata University of Rome, Rome, Italy
| | | | - Massimo Ralli
- Department of Surgical Sciences, Sapienza University of Rome, Rome, Italy
| | - Ettore Cassandro
- Department of Medicine, Surgery and Dentistry, University of Salerno, Salerno, Italy
| | - Alfonso Scarpa
- Department of Medicine, Surgery and Dentistry, University of Salerno, Salerno, Italy
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Sakki AJ, Mäkinen LK, Kanerva M, Nokso-Koivisto J. Monopolar tonsillotomy versus cold dissection tonsillectomy in children: Prospective study on postoperative recovery. Int J Pediatr Otorhinolaryngol 2021; 141:110513. [PMID: 33234329 DOI: 10.1016/j.ijporl.2020.110513] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 11/17/2020] [Accepted: 11/17/2020] [Indexed: 12/27/2022]
Abstract
OBJECTIVES To compare postoperative self-reported recovery results with monopolar tonsillotomy and cold dissection tonsillectomy in children. To evaluate the feasibility of the monopolar technique in tonsillotomy. METHODS Children <12 years undergoing tonsillotomy or tonsillectomy between April 2018 and March 2020 who (with a caregiver) were willing to participate in a two-week follow-up formed the study group. They filled in a questionnaire about pain-related outcomes, return to normal activities, weight changes, complications, and length of home care. RESULTS Altogether 166 patients were recruited; 103 (62%) returned the questionnaire. The first pain-free day with tonsillotomy was day 5 and with tonsillectomy day 11. After tonsillotomy, patients returned to normal activities faster, e.g. they were able to eat normally 6.5 days earlier than tonsillectomy patients. During the first postoperative week weight dropped after tonsillectomy, but not after tonsillotomy. The length of home care was 6 days with tonsillotomy and 10 days with tonsillectomy. The incidence of postoperative hemorrhage (including minor bleedings at home) was 14% after tonsillotomy and 32% after tonsillectomy. Hemorrhages needing interventions were 0% with tonsillotomy and 2% with tonsillectomy. CONCLUSION Children operated on with monopolar tonsillotomy recovered faster and had less postoperative hemorrhage than those undergoing tonsillectomy. They were able to return earlier to daycare/school and their caregivers back to work. Recovery results with monopolar tonsillotomy were equal to other tonsillotomy techniques reported in the literature, hence the monopolar technique can be considered an alternative method to perform tonsillotomy.
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Affiliation(s)
- Anniina J Sakki
- Department of Otorhinolaryngology - Head and Neck Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland.
| | - Laura K Mäkinen
- Department of Otorhinolaryngology - Head and Neck Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Mervi Kanerva
- Department of Otorhinolaryngology - Head and Neck Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Johanna Nokso-Koivisto
- Department of Otorhinolaryngology - Head and Neck Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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Blackshaw H, Springford LR, Zhang LY, Wang B, Venekamp RP, Schilder AG. Tonsillectomy versus tonsillotomy for obstructive sleep-disordered breathing in children. Cochrane Database Syst Rev 2020; 4:CD011365. [PMID: 32347984 PMCID: PMC7193676 DOI: 10.1002/14651858.cd011365.pub2] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Obstructive sleep-disordered breathing (oSDB) is a condition encompassing breathing problems when asleep due to upper airway obstruction. In children, hypertrophy of the tonsils and/or adenoids is thought to be the commonest cause. As such, (adeno)tonsillectomy has long been the treatment of choice. A rise in partial removal of the tonsils over the last decade is due to the hypothesis that tonsillotomy is associated with lower postoperative morbidity and fewer complications. OBJECTIVES To assess whether partial removal of the tonsils (intracapsular tonsillotomy) is as effective as total removal of the tonsils (extracapsular tonsillectomy) in relieving signs and symptoms of oSDB in children, and has lower postoperative morbidity and fewer complications. SEARCH METHODS We searched the Cochrane ENT Trials Register; Central Register of Controlled Trials (CENTRAL); MEDLINE; EMBASE; CINAHL; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The search date was 22 July 2019. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing the effectiveness of (adeno)tonsillectomy with (adeno)tonsillotomy in children aged 2 to 16 years with oSDB. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods and assessed the certainty of the evidence for our pre-defined outcomes using GRADE. Our primary outcomes were disease-specific quality of life, peri-operative blood loss and the proportion of children requiring postoperative medical intervention (with or without hospitalisation). Secondary outcomes included postoperative pain, return to normal activity, recurrence of oSDB symptoms as a result of tonsil regrowth and reoperation rates. MAIN RESULTS We included 22 studies (1984 children), with predominantly unclear or high risk of bias. Three studies used polysomnography as part of their inclusion criteria. Follow-up duration ranged from six days to six years. Although 19 studies reported on some of our outcomes, we could only pool the results from a few due both to the variety of outcomes and the measurement instruments used, and an absence of combinable data. Disease-specific quality of life Four studies (540 children; 484 (90%) analysed) reported this outcome; data could not be pooled due to the different outcome measurement instruments used. It is very uncertain whether there is any difference in disease-specific quality of life between the two surgical procedures in the short (0 to 6 months; 3 studies, 410 children), medium (7 to 13 months; 2 studies, 117 children) and long term (13 to 24 months; 1 study, 67 children) (very low-certainty evidence). Peri-operative blood loss We are uncertain whether tonsillotomy reduces peri-operative blood loss by a clinically meaningful amount (mean difference (MD) 14.06 mL, 95% CI 1.91 to 26.21 mL; 8 studies, 610 children; very low-certainty evidence). In sensitivity analysis (restricted to three studies with low risk of bias) there was no evidence of a difference between the groups. Postoperative complications requiring medical intervention (with or without hospitalisation) The risk of postoperative complications in the first week after surgery was probably lower in children who underwent tonsillotomy (4.9% versus 2.6%, risk ratio (RR) 1.75, 95% CI 1.06 to 2.91; 16 studies, 1416 children; moderate-certainty evidence). Postoperative pain Eleven studies (1017 children) reported this outcome. Pain was measured using various scales and scored by either children, parents, clinicians or study personnel. When considering postoperative pain there was little or no difference between tonsillectomy and tonsillotomy at 24 hours (10-point scale) (MD 1.09, 95% CI 0.88 to 1.29; 4 studies, 368 children); at two to three days (MD 0.93, 95% CI -0.14 to 2.00; 3 studies, 301 children); or at four to seven days (MD 1.07, 95% CI -0.40 to 2.53; 4 studies, 370 children) (all very low-certainty evidence). In sensitivity analysis (restricted to studies with low risk of bias), we found no evidence of a difference in mean pain scores between groups. Return to normal activity Tonsillotomy probably results in a faster return to normal activity. Children who underwent tonsillotomy were able to return to normal activity four days earlier (MD 3.84 days, 95% CI 0.23 to 7.44; 3 studies, 248 children; moderate-certainty evidence). Recurrence of oSDB and reoperation rates We are uncertain whether there is a difference between the groups in the short (RR 0.26, 95% CI 0.03 to 2.22; 3 studies, 186 children), medium (RR 0.35, 95% CI 0.04 to 3.23; 4 studies, 206 children) or long term (RR 0.21 95% CI 0.01 to 4.13; 1 study, 65 children) (all very low-certainty evidence). AUTHORS' CONCLUSIONS For children with oSDB selected for tonsil surgery, tonsillotomy probably results in a faster return to normal activity (four days) and in a slight reduction in postoperative complications requiring medical intervention in the first week after surgery. This should be balanced against the clinical effectiveness of one operation over the other. However, this is not possible to determine in this review as data on the long-term effects of the two operations on oSDB symptoms, quality of life, oSDB recurrence and need for reoperation are limited and the evidence is of very low quality leading to a high degree of uncertainty about the results. More robust data from high-quality cohort studies, which may be more appropriate for detecting differences in less common events in the long term, are required to inform guidance on which tonsil surgery technique is best for children with oSDB requiring surgery.
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Affiliation(s)
- Helen Blackshaw
- evidENT, Ear Institute, University College London, London, UK
- National Institute of Health Research, University College London Hospitals Biomedical Research Centre, London, UK
| | - Laurie R Springford
- evidENT, Ear Institute, University College London, London, UK
- National Institute of Health Research, University College London Hospitals Biomedical Research Centre, London, UK
| | - Lai-Ying Zhang
- School of Medicine, The University of Queensland, Brisbane, Australia
| | - Betty Wang
- School of Medicine, The University of Queensland, Brisbane, Australia
| | - Roderick P Venekamp
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Anne Gm Schilder
- evidENT, Ear Institute, University College London, London, UK
- National Institute of Health Research, University College London Hospitals Biomedical Research Centre, London, UK
- Julius Center for Health Sciences and Primary Care & Department of Otorhinolaryngology, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
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Amin N, Lakhani R. Intracapsular versus extracapsular dissection tonsillectomy for adults: A systematic review. Laryngoscope 2019; 130:2325-2335. [PMID: 31782813 DOI: 10.1002/lary.28435] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 11/04/2019] [Accepted: 11/07/2019] [Indexed: 12/24/2022]
Abstract
OBJECTIVES Tonsillectomy is an extremely common ENT surgical procedure. There is a growing interest in the role of intracapsular dissection tonsillectomy (ICDT) due to reported reduced perioperative complications. We aim to compare the outcomes associated with ICDT versus traditional extracapsular dissection tonsillectomy (ECDT) in the adult population. METHODS Systematic review of all randomized controlled trials (RCTs) comparing ICDT and ECDT for all indications in the adult population. Electronic searches performed through CENTRAL, PubMed, Ovid EMBASE, Web of Science, ClinicalTrials.gov, and WHO ICTRP. Review Manager 5.3 (RevMan 2014) was used to carry out the meta-analysis. RESULTS Nine RCTs were included with a total of 11 reports with mean age of 23.9 years including 181 patients who received ICDT compared to 176 patients receiving ECDT. We found statistically significant reduced postoperative pain and analgesia requirement as well as a reduced rate of secondary postoperative bleeding in patients undergoing ICDT versus ECDT. There appears to be no significant difference in controlling recurrent tonsillitis between the ICDT and ECDT groups. CONCLUSION Across the recorded outcomes we noted no clear benefit to performing ECDT over ICDT and evidence suggests high patient satisfaction with ICDT. Laryngoscope, 130:2325-2335, 2020.
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Affiliation(s)
- Nikul Amin
- ENT Department, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Raj Lakhani
- ENT Department, St George's University Hospital and Epsom Hospital, London, United Kingdom
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9
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Borgström A, Nerfeldt P, Friberg D. Postoperative pain and bleeding after adenotonsillectomy versus adenotonsillotomy in pediatric obstructive sleep apnea: an RCT. Eur Arch Otorhinolaryngol 2019; 276:3231-3238. [PMID: 31377901 PMCID: PMC6811389 DOI: 10.1007/s00405-019-05571-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 07/16/2019] [Indexed: 11/27/2022]
Abstract
Purpose Our previous randomized controlled trial (RCT) of children with obstructive sleep apnea (OSA) showed no significant differences between adenotonsillectomy (ATE) and adenotonsillomy (ATE) in improving nocturnal respiration and symptoms after one year. This is the continuous report with the evaluation of postoperative morbidity concerning bleeding and pain. Methods A double-blinded RCT including 79 children, aged 2–6 years, with moderate to severe OSA, randomized to either ATE (n = 40) or ATT (n = 39). From one to ten days postoperatively, parents filled in a logbook with six pain-related outcomes (parent and child grading pain at different levels, days of analgesic use and return to normal diet). Peri- and postoperative bleeding were also registered. Results 63 patients (80%) returned the logbook. There were significant differences between groups in only two of the six pain-related outcomes in favor of the ATT group; first day when the children graded themselves as pain free (p = 0.021, Log Rank Test), and first day the caregiver estimated pain VAS ≤ 5 (p = 0.007, Log Rank Test). Two (5%) cases of postoperative bleeding occurred in the ATE group, one of which needed a return to theatre. No case of postoperative bleeding was seen in the ATT group. Conclusions The results from this RCT are in line with previous comparative studies between ATT and ATE. Children operated with ATT had significantly less postoperative pain in one-third of the outcomes, and less bleeding than ATE. However, as the differences in morbidity between the surgical methods were minor the clinical significance is uncertain. Trial registration This study was approved by the Swedish Regional Ethics Board in Stockholm, Sweden (Dnr 2011/925-32 and 2013/2274-32) and registered at ClinicalTrials.gov (Trial registration number NCT01676181).
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Affiliation(s)
- Anna Borgström
- , Hägersten, Sweden. .,Department of Clinical Science, Intervention and Technology, CLINTEC, Karolinska Institutet, Stockholm, Sweden.
| | - Pia Nerfeldt
- Department of Otorhinolaryngology, Karolinska University Hospital, CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | - Danielle Friberg
- Department of Surgical Sciences, Otorhinolaryngology and Head and Neck Surgery, Akademiska Hospital, Uppsala University, Uppsala, Sweden
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10
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Changing trends in pediatric tonsil surgery. Int J Pediatr Otorhinolaryngol 2019; 118:84-89. [PMID: 30594099 DOI: 10.1016/j.ijporl.2018.12.028] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Revised: 12/18/2018] [Accepted: 12/19/2018] [Indexed: 12/14/2022]
Abstract
OBJECTIVES We analyzed trends in tonsil surgery over a 10-year period in a single tertiary care hospital and evaluated the effects of these changes on use of hospital services and healthcare costs. METHODS This was a retrospective cohort study based on data from databases at the Department of Otorhinolaryngology, Helsinki University Hospital, Helsinki, Finland. Children under 16 years of age with tonsillectomy (TE) or tonsillotomy (TT) performed during 2007-2016 were included in the study. RESULTS In 10 years, 4979 tonsil surgeries were performed on 4951 children: TE in 3170 (64%) and TT in 1781 (36%) children. The total number of tonsil surgeries stayed nearly constant. TT operations commenced in the study hospital in 2009 and from 2012 onwards have been more common than TE procedures. Altogether 279 patients visited the emergency department because of complications; TE patients had 9.0 visits/100 surgeries and TT patients 1.8 visits/100 surgeries. The most common complication was postoperative hemorrhage: 200 cases (6.3%) in the TE group and 11 cases (0.6%) in the TT group. During the two-year follow-up after tonsil surgery the total costs of healthcare services were significantly lower in the TT group than in the TE group. CONCLUSION Considerable changes have occurred in tonsil surgery in children during the 10-year study period; TT is today performed more often than TE. As a consequence, complications, readmissions to hospital, and number of patients treated in the operating room because of postoperative hemorrhage have decreased, lowering the costs of healthcare.
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11
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Kassab AN, Ahmed MR, Saber M, Mekawy S. Comparative intraindividual ablative tissue effects of diode laser 980 nm versus radiofrequency in tonsillar hypertrophy management. ACTA ACUST UNITED AC 2019; 39:150-155. [PMID: 30745591 PMCID: PMC6536027 DOI: 10.14639/0392-100x-1909] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Accepted: 02/18/2018] [Indexed: 11/23/2022]
Abstract
Tonsillotomy (tonsillar ablation) using diode laser and radiofrequency has been introduced for management of tonsillar hypertrophy as it is associated with fewer hazards to deep structures. We compared tissue volume and histological changes in the tonsils following radiofrequency tonsillotomy versus diode laser tonsillotomy in tonsillar hypertrophy. 40 tonsils excised from 20 patients were included in this study. Twenty tonsils were subjected to radiofrequency tonsillotomy (RFT) group 1, and the other 20 tonsils were subjected to diode laser 980 nm tonsillotomy (DLT) group 2. Both procedures were followed by cold dissection tonsillectomy for macroscopic and histological examination of tonsils. Tonsillar volume reduction was evident in both groups with a non-significant difference between groups. Histological changes were evident in both groups. In our study, both radiofrequency and diode laser were effective in tonsillar ablation in terms of volume reduction and keeping the histological pattern intact.
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Affiliation(s)
- A N Kassab
- Medical Department, National Institute of Laser Enhanced Sciences, Cairo University, Egypt
| | - M R Ahmed
- Department of Otorhinolaryngology, Faculty of Medicine Suez Canal University, Ismailia, Egypt
| | - M Saber
- Medical Department, National Institute of Laser Enhanced Sciences, Cairo University, Egypt
| | - S Mekawy
- Faculty of Medicine, Department of Pathology, Cairo University, Egypt
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12
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Kumar S, Padiyar B, Rai A. Cold Dissection Tonsillectomy and Radiofrequency Tonsil Ablation: A Prospective Comparative Study. DUBAI MEDICAL JOURNAL 2018. [DOI: 10.1159/000493513] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
<b><i>Background:</i></b> Over the last few years, various techniques have been proposed for performing tonsillectomy in an attempt to lower the morbidity of this surgery. However, controversy still exists regarding the optimal technique involving the least postoperative morbidity. More recently, temperature-controlled radiofrequency has been introduced as a much more effective and safe device for tonsil reduction. <b><i>Objective:</i></b> To compare the effectiveness of conventional tonsillectomy versus radiofrequency tonsil ablation with respect to duration of surgery, amount of intraoperative bleeding, recovery time, and postsurgical pain. <b><i>Materials and Methods:</i></b> 60 patients were randomly divided into two groups. One group underwent conventional cold ablation tonsillectomy while radiofrequency tonsillectomy was performed in the second group. Duration of surgery, amount of intraoperative bleeding, recovery time, and postsurgical pain (using the Wong-Baker FACES Pain Rating Scale®) were measured. All patients were followed for 24 months. <b><i>Results:</i></b> Comparing the radiofrequency tonsillectomy group to the cold dissection tonsillectomy group, the mean duration of surgery was 6.92 versus 18 min, the amount of intraoperative bleeding was 2.75 versus 39.88 mL, and the difference on the postoperative pain scale between the two groups was statistically significant (<i>p</i> < 0.005). There was no recurrence of tonsillitis episodes in either of the 2 groups during the 2-year follow-up period. <b><i>Conclusion:</i></b> After adequate training, the radiofrequency technique is beneficial to both the surgeon and the patient, including the possibility to excise tissue and coagulate bleeding vessels with the same device. Postoperative morbidity and complications are lower as compared to the conventional cold dissection technique.
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Effect of Suturation Plus Surgicel Application on Post-Tonsillectomy Bleeding and Pain. J Craniofac Surg 2018; 28:e672-e675. [PMID: 28857996 DOI: 10.1097/scs.0000000000003827] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE The aim of this study was to evaluate the effect of suturation (tonsillary fossa closure) plus Surgicel application on postoperative bleeding and pain after tonsillectomies performed using a classical dissection method. STUDY DESIGN A prospective, randomized, double-blind, clinical trial was performed on 760 patients undergoing tonsillectomy or adenotonsillectomy during a 5-year period. METHODS After excluding patients with hemorrhagic disorder, chronic disease, and peritonsillar abscess, both tonsils were removed via classic dissection technique (cold knife or blunt dissection) and then electrocauterized for hemostasis. The tonsillar fossa randomly assigned to the treatment protocol (Group 1) was closed by sutures, following Surgicel application. The other side was unaltered and acted as the control (Group 2). Pain was evaluated every day for 10 days postoperatively, and bleeding was reported at any time. RESULTS A total of 760 patients (393 males, 367 females) between the ages of 4 and 35 years (mean age 13.46 ± 7.98) were included in the study. Bleeding was observed in 31 patients: 8 from Group 1; and 23 from Group 2 (95% confidence interval [CI], P < 0.05). The average pain score was greater in Group 1 than in Group 2 on each postoperative day (95% CI, P < 0.05). CONCLUSION Suturation plus Surgicel application increased pain levels while decreasing bleeding incidence during the postoperative period.
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14
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Differences in postoperative maladaptive behavioral changes between partial and total tonsillectomy patients. Int J Pediatr Otorhinolaryngol 2018; 106:55-58. [PMID: 29447892 DOI: 10.1016/j.ijporl.2017.12.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Revised: 12/28/2017] [Accepted: 12/29/2017] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Behavioral difficulties associated with sleep-disordered breathing (SDB) improve after tonsillectomy, but surgery may lead to the development of short-term postoperative maladaptive behavioral changes (PMBCs). These PMBCs have not been compared between total and partial tonsillectomy patients. METHODS SDB patients aged 1-6 years undergoing tonsillectomy were recruited. Parent phone surveys were conducted at 48-72 hours and 1-2 weeks postoperatively. Parents identified PMBCs using the Post-Hospital Behavior Questionnaire (PHBQ), scoring changes in behavior compared to baseline. PMBCs were defined by PHBQ scores >0 and compared by one-tailed t-test. Postoperative pain was categorized as mild, moderate, and severe pain using the Parents' Postoperative Pain Measure (PPPM). Differences in pain levels were analyzed by Chi-squared test. A p-value <0.05 was deemed statistically significant. RESULTS Seventy-eight children completed the study, with 29 total tonsillectomy and 49 partial tonsillectomy patients. At both time points after surgery, PHBQ scores were higher in total tonsillectomy patients than in partial tonsillectomy patients (3.41 ± 3.53 versus 1.94 ± 2.25 at 2-3 days, p = .013). PMBCs were also more frequent in total than partial tonsillectomy patients (76% versus 59% at 2-3 days; 28% versus 7% at 1-2 weeks). Meanwhile, distribution of pain levels was similar between both partial and total tonsillectomy patients. CONCLUSIONS Our study indicates that total tonsillectomy patients more frequently experience PMBCs than do partial tonsillectomy patients despite similar distributions in pain levels postoperatively. This difference in PHBQ scores between total and partial tonsillectomy patients should be further explored.
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Zhang LY, Zhong L, David M, Cervin A. Tonsillectomy or tonsillotomy? A systematic review for paediatric sleep-disordered breathing. Int J Pediatr Otorhinolaryngol 2017; 103:41-50. [PMID: 29224763 DOI: 10.1016/j.ijporl.2017.10.008] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2017] [Revised: 09/27/2017] [Accepted: 10/03/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Recent evidence has challenged the practice of tonsillectomy in children with sleep-disordered breathing. Tonsillotomy (subtotal/partial/intracapsular tonsillectomy) has been proposed as an alternative with equivalent effectiveness and decreased post-operative morbidity, thus improving cost-effectiveness. OBJECTIVE To systematically review the literature comparing clinical efficacy, post-operative morbidity, and cost-effectiveness of tonsillotomy and tonsillectomy in paediatric (<16yo) patients with sleep-disordered breathing. DATA SOURCES A systematic search of MEDLINE, EMBASE, and CENTRAL (1984-July 2014) was conducted. Papers in English directly comparing post-operative outcomes in tonsillectomy and tonsillotomy in children undergoing surgery for sleep-disordered breathing were included. REVIEW METHODS Two authors independently assessed abstracts for relevance, with disagreements resolved by a third author. Selected studies were independently assessed regarding inclusion and exclusion criteria. RESULTS Thirty-two studies satisfied inclusion and exclusion criteria (19 randomised, 13 non-randomised). Patient satisfaction, quality-of-life, and polysomnographic improvement post-surgery did not vary between tonsillotomy and tonsillectomy. Tonsillotomy reduced the odds of a secondary haemorrhage by 79% (OR 0.21, 95% CI 0.17-0.27, p < 0.01), decreased post-operative pain and reduced return to normal oral intake by 2.8 days (95% CI 1.08-4.52, p < 0.01). The odds of readmission were decreased by 62% (OR 0.38, 95% CI 0.23-0.60, p < 0.01). Tonsillotomy had a slightly higher rate of symptom recurrence (4.51%) than tonsillectomy (2.55%), the long-term impact of which was unclear. CONCLUSION Current evidence supports tonsillotomy in children with obstructive surgical indications. It is likely to reduce post-operative haemorrhage, pain, and facilitate a faster return to normal diet and activity. Healthcare burden is decreased due to fewer post-operative complications and reduced need for medical re-contact. More research is necessary to assess the risk of recurrence, and further classification of secondary haemorrhage severity is required to fully clarify the clinical benefit of tonsillotomy.
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Affiliation(s)
| | | | - Michael David
- School of Population Health, University of Queensland, Brisbane, QLD, Australia
| | - Anders Cervin
- Faculty of Medicine and Biomedical Sciences, University of Queensland, Brisbane, QLD, Australia
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Lee HS, Yoon HY, Jin HJ, Hwang SH. The safety and efficacy of powered intracapsular tonsillectomy in children: A meta-analysis. Laryngoscope 2017; 128:732-744. [DOI: 10.1002/lary.26886] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/07/2017] [Indexed: 11/11/2022]
Affiliation(s)
- Ho Seok Lee
- Department of Otolaryngology-Head and Neck Surgery, College of Medicine; The Catholic University of Korea; Seoul South Korea
| | - Ho Young Yoon
- Department of Otolaryngology-Head and Neck Surgery, College of Medicine; The Catholic University of Korea; Seoul South Korea
| | - Ho Joon Jin
- Department of Otolaryngology-Head and Neck Surgery, College of Medicine; The Catholic University of Korea; Seoul South Korea
| | - Se Hwan Hwang
- Department of Otolaryngology-Head and Neck Surgery, College of Medicine; The Catholic University of Korea; Seoul South Korea
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17
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Gudnadottir G, Tennvall GR, Stalfors J, Hellgren J. Indirect costs related to caregivers' absence from work after paediatric tonsil surgery. Eur Arch Otorhinolaryngol 2017; 274:2629-2636. [PMID: 28289832 DOI: 10.1007/s0045-017-4526-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Accepted: 03/03/2017] [Indexed: 05/23/2023]
Abstract
Tonsillotomy has gradually replaced tonsillectomy as the surgical method of choice in children with upper airway obstruction during sleep, because of less postoperative pain and a shorter recovery time. The aim of this study was to examine the costs related to caregivers' absenteeism from work after tonsillectomy (TE) and tonsillotomy (TT). All tonsillectomies and tonsillotomies in Sweden due to upper airway obstruction during 1 year, reported to the National Tonsil Surgery Register in children aged 1-11 were included, n = 4534. The number of days the child needed analgesics after surgery was used as a proxy to estimate the number of work days lost for the caregiver. Data from the Social Insurance Agency (Försäkringskassan) regarding the days the parents received temporary parental benefits in the month following surgery were also analysed. The indirect costs due to the caregivers' absenteeism after tonsillectomy vs tonsillotomy were calculated, using the human capital method. The patient-reported use of postoperative analgesic use was 77% (n = 3510). Data from the Social Insurance Agency were gathered for all 4534 children. The mean duration of analgesic treatment was 4.6 days (indirect cost of EUR 747). The mean number of days with parental benefits was 2.9 (EUR 667). The indirect cost of tonsillectomy was 61% higher than that of tonsillotomy (EUR 1010 vs EUR 629). The results show that the choice of surgical method affects the indirect costs, favouring the use of tonsillotomy over tonsillectomy for the treatment of children with SDB, due to less postoperative pain.
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Affiliation(s)
- Gunnhildur Gudnadottir
- Department of Otorhinolaryngology, Sahlgrenska University Hospital, Sahlgrenska Academy, Gothenburg University, Gröna stråket 9, 413 46, Gothenburg, Sweden.
| | | | - J Stalfors
- Department of Otorhinolaryngology, Sahlgrenska University Hospital, Sahlgrenska Academy, Gothenburg University, Gröna stråket 9, 413 46, Gothenburg, Sweden
| | - J Hellgren
- Department of Otorhinolaryngology, Sahlgrenska University Hospital, Sahlgrenska Academy, Gothenburg University, Gröna stråket 9, 413 46, Gothenburg, Sweden
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18
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Kim JS, Kwon SH, Lee EJ, Yoon YJ. Can Intracapsular Tonsillectomy Be an Alternative to Classical Tonsillectomy? A Meta-analysis. Otolaryngol Head Neck Surg 2017; 157:178-189. [DOI: 10.1177/0194599817700374] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Objective Tonsillectomy is the most common operation performed in the otolaryngologic fields. Efforts have been made to reduce postoperative complications, and one of these is intracapsular tonsillectomy and adenoidectomy (ICTA), which leaves the tonsillar tissue with tonsillar capsule. This study aimed to evaluate intracapsular tonsillectomy compared with classical extracapsular tonsillectomy in terms of efficacy of the technique for managing obstructive sleep apnea (OSA) and reducing postoperative complications. Data Sources We performed a literature search using PubMed, EMBASE, and the Cochrane Library through December 2016. Review Methods Summarized risk ratio (RR), risk differences (RDs), and standardized mean differences (SMDs) with 95% confidence intervals (CIs) were estimated by summarizing the risk estimates of each study using random-effects models that considered both within- and between-study variations. Results Our search included 15 randomized controlled studies. The RRs for postoperative bleeding and residual tonsils were, respectively, 0.44 ( P = .01) and 6.02 ( P = .0002). There were significant differences in postoperative pain ( P = .0022), need for analgesics ( P < .0001), days to normal diet ( P = .006), and days to normal activity ( P < .00001) between intracapsular tonsillectomy and extracapsular tonsillectomy. Conclusions Intracapsular tonsillectomy can effectively reduce postoperative pain and bleeding, which shortens the time required to return to normal life. There was no difference between microdebrider and coblator in intracapsular tonsillectomy regarding postoperative pain and bleeding. It can increase the risk of remnant tonsils; however, it does not increase the risk of recurrent infection.
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Affiliation(s)
- Jong Seung Kim
- Department of Otorhinolaryngology–Head and Neck Surgery, College of Medicine, Chonbuk National University, Jeonju, Republic of Korea
- Research Institute of Clinical Medicine of Chonbuk National University, Biomedical Research Institute of Chonbuk National University Hospital, Jeonju, Republic of Korea
| | - Sam Hyun Kwon
- Department of Otorhinolaryngology–Head and Neck Surgery, College of Medicine, Chonbuk National University, Jeonju, Republic of Korea
- Research Institute of Clinical Medicine of Chonbuk National University, Biomedical Research Institute of Chonbuk National University Hospital, Jeonju, Republic of Korea
| | - Eun Jung Lee
- Department of Otorhinolaryngology–Head and Neck Surgery, College of Medicine, Chonbuk National University, Jeonju, Republic of Korea
- Research Institute of Clinical Medicine of Chonbuk National University, Biomedical Research Institute of Chonbuk National University Hospital, Jeonju, Republic of Korea
| | - Yong Joo Yoon
- Department of Otorhinolaryngology–Head and Neck Surgery, College of Medicine, Chonbuk National University, Jeonju, Republic of Korea
- Research Institute of Clinical Medicine of Chonbuk National University, Biomedical Research Institute of Chonbuk National University Hospital, Jeonju, Republic of Korea
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19
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Borgström A, Nerfeldt P, Friberg D. Adenotonsillotomy Versus Adenotonsillectomy in Pediatric Obstructive Sleep Apnea: An RCT. Pediatrics 2017; 139:peds.2016-3314. [PMID: 28320866 DOI: 10.1542/peds.2016-3314] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/12/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Adenotonsillectomy (ATE) is a well-established and effective treatment of pediatric obstructive sleep apnea (OSA). In recent years, a more conservative method, adenotonsillotomy (ATT), has gained popularity because it is associated with less postoperative morbidity. Yet no previous randomized study has compared these 2 methods regarding their effectiveness in treating pediatric OSA in terms of polysomnographic data, which was the primary aim of this study. The hypothesis was that ATT is noninferior to ATE after 1 year. METHODS Seventy-nine children, aged 2 to 6 years, with OSA (Apnea-Hypopnea Index [AHI] 5-30) were randomized to ATT (n = 40) or ATE (n = 39). Polysomnography (PSG) and questionnaire OSA-18 were assessed at baseline and 1 year postsurgery. RESULTS Mean difference between groups in the primary outcome, change in AHI, was 0.83, 95% confidence interval -3.2 to 4.9, not exceeding the noninferiority margin of 5. After ATE, AHI decreased from median 12.7 (interquartile range 8.3-19.1) to 2.0 (1.2-3.1) and after ATT from 15.8 (8.5-21.2) to 4.0 (1.2-5.1). For both groups, significant improvements of PSG and OSA-18 questionnaire outcomes were observed, with no significant differences between groups. Five children (13%) in the ATT group needed repeated surgery for tonsil regrowth and recurrence of OSA. CONCLUSIONS The results suggest that ATT is noninferior to ATE in treating pediatric OSA regarding PSG outcomes after 1 year. ATT could be considered an alternative to ATE for treatment of pediatric OSA. However, after ATT, there is a nonnegligible risk of recurrence of OSA, and this should be taken into account when selecting surgical method.
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Affiliation(s)
- Anna Borgström
- Department of Otorhinolaryngology, Karolinska University Hospital, and Department of Clinical Science, Intervention and Technology, CLINTEC, Karolinska Institute, Stockholm, Sweden
| | - Pia Nerfeldt
- Department of Otorhinolaryngology, Karolinska University Hospital, and Department of Clinical Science, Intervention and Technology, CLINTEC, Karolinska Institute, Stockholm, Sweden
| | - Danielle Friberg
- Department of Otorhinolaryngology, Karolinska University Hospital, and Department of Clinical Science, Intervention and Technology, CLINTEC, Karolinska Institute, Stockholm, Sweden
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20
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Gudnadottir G, Tennvall GR, Stalfors J, Hellgren J. Indirect costs related to caregivers' absence from work after paediatric tonsil surgery. Eur Arch Otorhinolaryngol 2017; 274:2629-2636. [PMID: 28289832 PMCID: PMC5419997 DOI: 10.1007/s00405-017-4526-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Accepted: 03/03/2017] [Indexed: 12/19/2022]
Abstract
Tonsillotomy has gradually replaced tonsillectomy as the surgical method of choice in children with upper airway obstruction during sleep, because of less postoperative pain and a shorter recovery time. The aim of this study was to examine the costs related to caregivers' absenteeism from work after tonsillectomy (TE) and tonsillotomy (TT). All tonsillectomies and tonsillotomies in Sweden due to upper airway obstruction during 1 year, reported to the National Tonsil Surgery Register in children aged 1-11 were included, n = 4534. The number of days the child needed analgesics after surgery was used as a proxy to estimate the number of work days lost for the caregiver. Data from the Social Insurance Agency (Försäkringskassan) regarding the days the parents received temporary parental benefits in the month following surgery were also analysed. The indirect costs due to the caregivers' absenteeism after tonsillectomy vs tonsillotomy were calculated, using the human capital method. The patient-reported use of postoperative analgesic use was 77% (n = 3510). Data from the Social Insurance Agency were gathered for all 4534 children. The mean duration of analgesic treatment was 4.6 days (indirect cost of EUR 747). The mean number of days with parental benefits was 2.9 (EUR 667). The indirect cost of tonsillectomy was 61% higher than that of tonsillotomy (EUR 1010 vs EUR 629). The results show that the choice of surgical method affects the indirect costs, favouring the use of tonsillotomy over tonsillectomy for the treatment of children with SDB, due to less postoperative pain.
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Affiliation(s)
- Gunnhildur Gudnadottir
- Department of Otorhinolaryngology, Sahlgrenska University Hospital, Sahlgrenska Academy, Gothenburg University, Gröna stråket 9, 413 46, Gothenburg, Sweden.
| | | | - J Stalfors
- Department of Otorhinolaryngology, Sahlgrenska University Hospital, Sahlgrenska Academy, Gothenburg University, Gröna stråket 9, 413 46, Gothenburg, Sweden
| | - J Hellgren
- Department of Otorhinolaryngology, Sahlgrenska University Hospital, Sahlgrenska Academy, Gothenburg University, Gröna stråket 9, 413 46, Gothenburg, Sweden
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21
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Rubinstein BJ, Derkay CS. Rethinking surgical technique and priorities for pediatric tonsillectomy. Am J Otolaryngol 2017; 38:233-236. [PMID: 28117117 DOI: 10.1016/j.amjoto.2017.01.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2016] [Accepted: 01/17/2017] [Indexed: 11/29/2022]
Abstract
The past 100years have witnessed dramatic shifts in the concept of ideal surgical goals and operative technique in tonsil surgery. Surgeons are reviving a technique of intracapsular tonsillectomy with increasing precision thanks to modern technology. With intracapsular tonsillectomy, pediatric patients recover faster, use less pain medication, and have a lower risk of dehydration and hemorrhage. Various considerations will dictate the adoption of this technology in the coming years. This current review explores concepts and controversies surrounding tonsillectomy with a focus on quality improvement.
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Affiliation(s)
- Benjamin J Rubinstein
- Department of Otolaryngology-Head and Neck Surgery, Eastern Virginia Medical School, 600 Gresham Drive Suite 1100, Norfolk, Virginia 23507, USA.
| | - Craig S Derkay
- Department of Otolaryngology-Head and Neck Surgery, Eastern Virginia Medical School, 600 Gresham Drive Suite 1100, Norfolk, Virginia 23507, USA.
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Papaspyrou G, Linxweiler M, Knöbber D, Schick B, Al Kadah B. Laser CO 2 tonsillotomy versus argon plasma coagulation (APC) tonsillotomy: A retrospective study with 10-year follow-up. Int J Pediatr Otorhinolaryngol 2017; 92:56-60. [PMID: 28012534 DOI: 10.1016/j.ijporl.2016.11.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Revised: 11/04/2016] [Accepted: 11/07/2016] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Tonsillotomy is increasingly gaining acceptance as the treatment for tonsillar hyperplasia resulting in obstructive symptoms. The aim of this study was to compare the long-term results of CO2 laser tonsillotomy with those of argon plasma coagulation (APC) tonsillotomy. METHODS The data of 64 children, aged 2-10 years (mean 4.7 years), treated in the Department of Otolaryngology, Head and Neck Surgery, in Homburg, Germany with APC (36 patients) or CO2 laser (28 patients) for tonsillar hyperplasia between June 2004 and December 2004 were available for analysis. RESULTS Forty-five (APC: 26 patients, CO2: 19 patients) of the 64 patients (70.3%) could be contacted and were available for follow-up in a telephone survey conducted 10 years after surgery. The mean operation time was 17 min (range 10-25 min) in the APC group and 23 min (range 13-32 min) in the CO2 group (p = 0.0003). No case of intra- or postoperative bleeding was documented. One minor intraoperative complication in the form of a superficial lip burn was documented in the APC group. During the minimum 10 years of follow-up, 1 patient treated with APC underwent a surgical revision because of tonsillar regrowth, whereas in the group of patients treated with CO2, no surgical revision was needed. Regarding the parents' assessment of their children's symptoms, 89.4% of the parents of the CO2 laser group and 84.6% of the parents of the APC group reported that the overall long-term operation results of their children to be "very satisfying." Regarding complications, the need for secondary tonsillectomy, and parents' satisfaction, no statistically significant differences were found. CONCLUSIONS Both CO2 laser tonsillotomy and APC tonsillotomy are safe procedures leading to very satisfying results with respect to intra- and postoperative complications.
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Affiliation(s)
- Giorgos Papaspyrou
- Department of Otorhinolaryngology, University Medical Centre, Homburg, Saar, Germany.
| | - Maximilian Linxweiler
- Department of Otorhinolaryngology, University Medical Centre, Homburg, Saar, Germany
| | - Dirk Knöbber
- Department of Otorhinolaryngology, University Medical Centre, Homburg, Saar, Germany
| | - Bernhard Schick
- Department of Otorhinolaryngology, University Medical Centre, Homburg, Saar, Germany
| | - Basel Al Kadah
- Department of Otorhinolaryngology, University Medical Centre, Homburg, Saar, Germany
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23
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Windfuhr JP. Indications for tonsillectomy stratified by the level of evidence. GMS CURRENT TOPICS IN OTORHINOLARYNGOLOGY, HEAD AND NECK SURGERY 2016; 15:Doc09. [PMID: 28025609 PMCID: PMC5169082 DOI: 10.3205/cto000136] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Background: One of the most significant clinical trials, demonstrating the efficacy of tonsillectomy (TE) for recurrent throat infection in severely affected children, was published in 1984. This systematic review was undertaken to compile various indications for TE as suggested in the literature after 1984 and to stratify the papers according to the current concept of evidence-based medicine. Material and methods: A systematic Medline research was performed using the key word of "tonsillectomy" in combination with different filters such as "systematic reviews", "meta-analysis", "English", "German", and "from 1984/01/01 to 2015/05/31". Further research was performed in the Cochrane Database of Systematic Reviews, National Guideline Clearinghouse, Guidelines International Network and BMJ Clinical Evidence using the same key word. Finally, data from the "Trip Database" were researched for "tonsillectomy" and "indication" and "from: 1984 to: 2015" in combination with either "systematic review" or "meta-analysis" or "metaanalysis". Results: A total of 237 papers were retrieved but only 57 matched our inclusion criteria covering the following topics: peritonsillar abscess (3), guidelines (5), otitis media with effusion (5), psoriasis (3), PFAPA syndrome (6), evidence-based indications (5), renal diseases (7), sleep-related breathing disorders (11), and tonsillitis/pharyngitis (12), respectively. Conclusions: 1) The literature suggests, that TE is not indicated to treat otitis media with effusion. 2) It has been shown, that the PFAPA syndrome is self-limiting and responds well to steroid administration, at least in a considerable amount of children. The indication for TE therefore appears to be imbalanced but further research is required to clarify the value of surgery. 3) Abscesstonsillectomy as a routine is not justified and indicated only for cases not responding to other measures of treatment, evident complications, or with a significant history of tonsillitis. In particular, interval-tonsillectomy is not justified as a routine. 4) TE, with or without adenoidectomy, is efficacious to resolve sleep-related breathing disorders resulting from (adeno)tonsillar hypertrophy in children. However, the benefit is reduced by co-morbidities, such as obesity, and further research is required to identify prognostic factors for this subgroup of patients. Further research is indicated to clarify selection criteria not only for this subpopulation that may benefit from less invasive procedures such as tonsillotomy in the long-term. 5) Further trials are also indicated to evaluate the efficacy of TE on the clinical course in children with psoriasis guttata as well as on psoriasis vulgaris in adults, not responding to first-line therapy. 6) Conflicting results were reported concerning the role of TE in the concert to treat Ig-A nephropathy, mandating further clinical research. 7) Most importantly, randomized-controlled clinical trials with an adequate long-term follow-up are desirable to clarify the benefit of TE in patients with recurrent episodes of tonsillitis, with or without pharyngitis. Factors like age, spontaneous healing rate and postoperative quality of life have to be included when comparing TE with antibiotic therapy.
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Affiliation(s)
- Jochen P. Windfuhr
- Department of Otolaryngology, Head & Neck Surgery, Allergology, Kliniken Maria Hilf, Mönchengladbach, Germany
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Kordeluk S, Goldbart A, Novack L, Kaplan DM, El-Saied S, Alwalidi M, Shapira-Parra A, Segal N, Slovik Y, Max P, Joshua BZ. Randomized study comparing inflammatory response after tonsillectomy versus tonsillotomy. Eur Arch Otorhinolaryngol 2016; 273:3993-4001. [PMID: 27216303 DOI: 10.1007/s00405-016-4083-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Accepted: 05/03/2016] [Indexed: 11/26/2022]
Abstract
To determine if there was a difference in the inflammatory reaction after tonsil surgery with "traditional" techniques (tonsillectomy and adenoidectomy or TA) compared to partial intracapsular tonsillectomy and adenoidectomy (PITA). DESIGN Randomized, double-blind study. SETTING tertiary care academic hospital. Children under the age of 16 years with a diagnosis of obstructive sleep disordered breathing were randomly allocated into three study groups: TA with electrocautery (n = 34), PITA with CO2 laser (n = 30) and PITA with debrider (n = 28). All of the children underwent adenoidectomy with a current at the same surgical procedure. MAIN OUTCOME MEASURE c-reactive protein level (CRP) was the primary endpoint. In addition, the following were assessed: white blood cells (WBC), neutrophils (NEU), interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-α). Pre- and post-procedure measurements were compared between the groups. Parents filled out a questionnaire daily during the first postoperative week assessing pain, swallowing and snoring. CRP levels ascended higher in the PITA groups after surgery (p = 0.023), WBC and NEU showed the same pattern, IL-6 levels were higher in PITA group and there was no difference in TNF-alpha levels between the two types of procedures. Postoperative pain and postoperative hemorrhage were significantly lower in the PITA groups as compared to the TA group (p = 0.01 and 0.048). PITA in comparison to TA is associated with lower morbidity; however, the inflammatory response does not differ significantly in the first 24 h after surgery. Additional long-term studies assessing efficacy of PITA are warranted. LEVEL OF EVIDENCE Level 1, prospective randomized controlled trial.
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Affiliation(s)
- Sofia Kordeluk
- Department of Otolaryngology-Head and Neck Surgery, Soroka University Medical Center, Box 151, 84101, Beersheva, Israel.
| | - Aviv Goldbart
- Department of Pediatrics and Sleep-Wake Disorders Unit, Soroka University Medical Center, Beersheva, Israel
| | - Lena Novack
- Department of Public Health, Faculty of Medical Sciences, Ben-Gurion University in the Negev, Beersheva, Israel
| | - Daniel Michael Kaplan
- Department of Otolaryngology-Head and Neck Surgery, Soroka University Medical Center, Box 151, 84101, Beersheva, Israel
| | - Sabri El-Saied
- Department of Otolaryngology-Head and Neck Surgery, Soroka University Medical Center, Box 151, 84101, Beersheva, Israel
| | - Musa Alwalidi
- Department of Otolaryngology-Head and Neck Surgery, Soroka University Medical Center, Box 151, 84101, Beersheva, Israel
| | - Angelica Shapira-Parra
- Department of Otolaryngology-Head and Neck Surgery, Soroka University Medical Center, Box 151, 84101, Beersheva, Israel
| | - Nili Segal
- Department of Otolaryngology-Head and Neck Surgery, Soroka University Medical Center, Box 151, 84101, Beersheva, Israel
| | - Yuval Slovik
- Department of Otolaryngology-Head and Neck Surgery, Soroka University Medical Center, Box 151, 84101, Beersheva, Israel
| | - Puterman Max
- Department of Otolaryngology-Head and Neck Surgery, Soroka University Medical Center, Box 151, 84101, Beersheva, Israel
| | - Ben-Zion Joshua
- Department of Otolaryngology-Head and Neck Surgery, Soroka University Medical Center, Box 151, 84101, Beersheva, Israel
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Clinical practice guideline: tonsillitis II. Surgical management. Eur Arch Otorhinolaryngol 2016; 273:989-1009. [DOI: 10.1007/s00405-016-3904-x] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2015] [Accepted: 01/13/2016] [Indexed: 12/25/2022]
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Lim J, McKean MC, Hearne BJ. WITHDRAWN: Adenotonsillectomy for obstructive sleep apnoea in children. Cochrane Database Syst Rev 2015; 2015:CD003136. [PMID: 26418217 PMCID: PMC10687504 DOI: 10.1002/14651858.cd003136.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
This review has been withdrawn because it has been split into the following reviews: '(Adeno)tonsillectomy versus non‐surgical management of obstructive sleep apnoea syndrome (OSAS) in children' (Schilder 2015) and 'Tonsillectomy versus tonsillotomy in children with sleep‐disordered breathing (including obstructive sleep apnoea)' (protocol) (Blackshaw 2014). The editorial group responsible for this previously published document have withdrawn it from publication.
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Affiliation(s)
- Jerome Lim
- Medway Maritime HospitalEar, Nose and Throat DepartmentWindmill RoadGillinghamKentUKME7 5NY
| | - Michael C McKean
- Newcastle upon Tyne NHS TrustPaediatrics3 rd Floor, Doctors Residence, Royal Victoria InfirmaryQueen Victoria RoadNewcastle upon TyneTyne and WearUKNE1 4LP
| | - Benjamin J Hearne
- Faculty of Brain Sciences, University College LondonevidENT, Ear InstituteLondonUK
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Abstract
The editorial titled "Gizmos" in the April issue of Otolaryngology-Head and Neck Surgery was unfortunate. Intracapsular tonsillectomy is a rational surgical option for managing tonsillar hypertrophy causing obstructive sleep apnea in selected children. It is performed routinely by surgeons across the globe and has become the standard of care across northern Europe due to the high safety profile of the operation. The semirigid, dartlike design of the sinuplasty devices suggested the idea for an airway-specific set of high-pressure balloons. We began working on these in 2007 and had FDA approval in 2009. They are in wide use by many airway surgeons. Lingual tonsils are a frequent cause of obstructive sleep apnea, and there is no tool that manages this as effectively as endoscopic plasma ablation. We are all engaged in an honorable effort to improve care; surgical and creative skills are as important as analytical skills. Both are necessary for the continuous improvement of our work. Both are worthy of respect.
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Bender B, Blassnigg EC, Bechthold J, Kral F, Riccabona U, Steinbichler T, Riechelmann H. Microdebrider-assisted intracapsular tonsillectomy in adults with chronic or recurrent tonsillitis. Laryngoscope 2015; 125:2284-90. [PMID: 25876886 DOI: 10.1002/lary.25265] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Revised: 01/26/2015] [Accepted: 02/23/2015] [Indexed: 12/21/2022]
Abstract
OBJECTIVES/HYPOTHESIS We compared the effectiveness and morbidity of microdebrider-assisted total intracapsular tonsillectomy (ICTE) with conventional extracapsular tonsillectomy (ECTE) in adults with chronic or recurrent tonsillitis. STUDY DESIGN Prospective randomized surgical trial. METHODS Adult patients with recurrent or chronic tonsillitis who underwent tonsillectomy between July 2010 and July 2012 in the Department of Otorhinolaryngology-Head and Neck Surgery, Medical University Innsbruck, Innsbruck, Austria, were consecutively included. Patients were randomized to receive either ICTE or ECTE. Patients and examiners were blinded to the surgical procedure. Effectiveness was assessed with the Tonsil and Adenoid Health Status Instrument (TAHSI). Various parameters of perioperative morbidity and the occurrence of tonsillar remnants were recorded. RESULTS In the 104 randomized patients, the average TAHSI score was 34.6 ± 11.7 before and 2.2 ± 5.7 after 6 months following tonsillectomy (P < 0.001). TAHSI scores improved equally in patients receiving conventional ECTE (33.6 points; 95% confidence interval (CI), 29.5 to 37.6) and in patients with ICTE (31.8 points; 95% CI, 27.7 to 35.9; between groups P = 0.6). Posttonsillectomy hemorrhage was more frequent following conventional ECTE (P = 0.03). Following ECTE, patients required more pain medication then following ICTE (P < 0.05). Tonsillar remnants were significantly more frequent after ICTE (P < 0,001). However, presence of tonsillar remnants had no influence on postoperative THASI scores (P > 0.5). CONCLUSION Tonsillectomy reduced symptoms of chronic or recurrent tonsillitis in adults with remarkable effectiveness. Microdebrider-assisted ICTE reduced symptoms as effectively as conventional ECTE. ICTE was associated with lower morbidity, but residual tonsils occurred in almost half of patients, costs were higher, and the intracapsular approach was more intricate and time-consuming. LEVEL OF EVIDENCE 1b.
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Affiliation(s)
- Birte Bender
- Department of Otorhinolaryngology, Medical University Innsbruck, Innsbruck, Austria
| | | | - Jana Bechthold
- Department of Otorhinolaryngology, Medical University Innsbruck, Innsbruck, Austria
| | - Florian Kral
- Department of Otorhinolaryngology, Medical University Innsbruck, Innsbruck, Austria
| | - Ursula Riccabona
- Department of Anesthesiology and Critical Care Medicine, Medical University Innsbruck, Innsbruck, Austria
| | - Teresa Steinbichler
- Department of Otorhinolaryngology, Medical University Innsbruck, Innsbruck, Austria
| | - Herbert Riechelmann
- Department of Otorhinolaryngology, Medical University Innsbruck, Innsbruck, Austria
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Wang H, Fu Y, Feng Y, Guan J, Yin S. Tonsillectomy versus tonsillotomy for sleep-disordered breathing in children: a meta analysis. PLoS One 2015; 10:e0121500. [PMID: 25807322 PMCID: PMC4373680 DOI: 10.1371/journal.pone.0121500] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2014] [Accepted: 02/01/2015] [Indexed: 11/20/2022] Open
Abstract
Objectives Tonsillotomy has gained popular acceptance as an alternative to the traditional tonsillectomy in the management of sleep-disordered breathing in children. Many studies have evaluated the outcomes of the two techniques, but uncertainty remains with regard to the efficacy and complications of tonsillotomy versus a traditional tonsillectomy. This study was designed to investigate the efficacy and complications of tonsillotomy versus tonsillectomy, in terms of the short- and long-term results. Methods We collected data from electronic databases including MEDLINE, EMBASE, and the Cochrane Library. The following inclusion criteria were applied: English language, children, and prospective studies that directly compared tonsillotomy and tonsillectomy in the management of sleep disordered breathing. Subgroup analysis was then performed. Results In total, 10 eligible studies with 1029 participants were included. Tonsillotomy was shown to be advantageous over tonsillectomy in short-term measures, such as a lower hemorrhage rate, shorter operation time, and faster pain relief. In long-term follow-up, there was no significant difference in resolution of upper-airway obstructive symptoms, the quality of life, or postoperative immune function between the tonsillotomy and tonsillectomy groups. The risk ratio of SDB recurrence was 3.33 (95% confidence interval = 1.62 6.82, P = 0.001), favoring tonsillectomy at an average follow-up of 31 months. Conclusions Tonsillotomy may be advantageous over tonsillectomy in the short term measures and there are no significant difference of resolving obstructive symptoms, quality of life and postoperative immune function. For the long run, the dominance of tonsillotomy may be less than tonsillectomy with regard to the rate of sleep-disordered breathing recurrence.
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Affiliation(s)
- Hui Wang
- Department of Otolaryngology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China, 200233
| | - Yangyang Fu
- Department of Otolaryngology, Dalian Municipal Central Hospital, 826 Xinan Road, Dalian, 116033 China
| | - Yanmei Feng
- Department of Otolaryngology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China, 200233
| | - Jian Guan
- Department of Otolaryngology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China, 200233
| | - Shankai Yin
- Department of Otolaryngology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China, 200233
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Tonsillectomy versus tonsillotomy: a study of parental preference. Int J Pediatr Otorhinolaryngol 2015; 79:359-62. [PMID: 25604258 DOI: 10.1016/j.ijporl.2014.12.026] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2014] [Accepted: 12/22/2014] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To directly sample the preference of representative parents who would be hypothetically considering tonsillotomy versus tonsillectomy for their child and assess the role of parental age, educational level, and risk aversion in making this choice. METHODS Parents in a pediatric otolaryngology waiting room were asked to complete an anonymous survey which presented hypothetical scenarios for their child and described the specifics of tonsillectomy and tonsillotomy in terms of post-operative recovery, tonsil regrowth rates, and future strep throat risk. Other questions gathered parental demographic data and assessed risk tolerance. RESULTS Two hundred and thirty-four parents completed the survey. A large majority of parents (201 of 234, 85.9%) preferred tonsillectomy over tonsillotomy for their child. Parental education and age were not associated with procedural preference. An increasing self-reported risk aversion score (p=0.003, Fisher's exact test) and a classification as risk averse using validated questions (p=0.034) were both associated with a preference for tonsillectomy over tonsillotomy. CONCLUSION Parents of pediatric Otolaryngology patients strongly prefer tonsillectomy over tonsillotomy when described in general terms. This parental choice appears to correlate with risk aversion of the possible long-term complications of tonsillotomy including the need for future treatment of streptococcal pharyngitis and/or regrowth of the tonsils and subsequent revision tonsil surgery.
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Stelter K. Tonsillitis and sore throat in children. GMS CURRENT TOPICS IN OTORHINOLARYNGOLOGY, HEAD AND NECK SURGERY 2014; 13:Doc07. [PMID: 25587367 PMCID: PMC4273168 DOI: 10.3205/cto000110] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Surgery of the tonsils is still one of the most frequent procedures during childhood. Due to a series of fatal outcomes after hemorrhage in children in Austria in 2006, the standards and indications for tonsillectomy have slowly changed in Germany. However, no national guidelines exist and the frequency of tonsil surgery varies across the country. In some districts eight times more children were tonsillectomized than in others. A tonsillectomy in children under six years should only be done if the child suffers from recurrent acute bacterially tonsillitis. In all other cases (i.e. hyperplasia of the tonsils) the low risk partial tonsillectomy should be the first line therapy. Postoperative pain and the risk of hemorrhage are much lower in partial tonsillectomy (=tonsillotomy). No matter whether the tonsillotomy is done by laser, radiofrequency, shaver, coblation, bipolar scissor or Colorado needle, as long as the crypts are kept open and some tonsil tissue is left behind. Total extracapsular tonsillectomy is still indicated in severely affected children with recurrent infections of the tonsils, allergy to antibiotics, PFAPA syndrome (periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis) and peritonsillar abscess. With regard to the frequency and seriousness of the recurrent tonsillitis the indication for tonsillectomy in children is justified if 7 or more well-documented, clinically important, adequately treated episodes of throat infection occur in the preceding year, or 5 or more of such episodes occur in each of the 2 preceding years (according to the paradise criteria). Diagnosis of acute tonsillitis is clinical, but sometimes it is hard to distinguish viral from bacterial infections. Rapid antigen testing has a very low sensitivity in the diagnosis of bacterial tonsillitis and swabs are highly sensitive but take a long time. In all microbiological tests the treating physician has to keep in mind, that most of the bacterials, viruses and fungi belong to the healthy flora and do no harm. Ten percent of healthy children even bear strepptococcus pyogenes all the time in the tonsils with no clinical signs. In these children decolonization is not necessary. Therefore, microbiological screening tests in children without symptoms are senseless and do not justify an antibiotic treatment (which is sometimes postulated by the kindergartens). The acute tonsillitis should be treated with steroids (e.g. dexamethasone), NSAIDs (e.g. ibuprofene) and betalactam antibiotics (e.g. penicillin or cefuroxime). With respect to the symptom reduction and primary healing the short-term late-generation antibiotic therapy (azithromycin, clarithromycin or cephalosporine for three to five days) is comparable to the long-term penicilline therapy. There is no difference in the course of healing, recurrence or microbiological resistance between the short-term penicilline therapy and the standard ten days therapy. On the other hand, only the ten days antibiotic therapy has proven to be effective in the prevention of rheumatic fever and glomerulonephritic diseases. The incidence of rheumatic heart disease is currently 0.5 per 100,000 children of school age. The main morbidity after tonsillectomy is pain and the late haemorrhage. Posttonsillectomy bleeding can occur till the whole wound is completely healed, which is normally after three weeks. Life-threatening haemorrhages occur often after smaller bleedings, which can spontaneously cease. That is why every haemorrhage, even the smallest, has to be treated properly and in ward. Patients and parents have to be informed about the correct behaviour in case of haemorrhage with a written consent before the surgery. The handout should contain important addresses, phone numbers and contact persons. Almost all cases of fatal outcome after tonsillectomy were due to false management of haemorrhage. Haemorrhage in small children can be especially life-threatening because of the lower blood volume and the danger of aspiration with asphyxia. A massive haemorrhage is an extreme challenge for every paramedic or emergency doctor because of the difficult airway management. Intubation is only possible with appropriate inflexible suction tubes. All different surgical techniques have the risk of haemorrhage and even the best surgeon will experience a postoperative haemorrhage. The lowest risk of haemorrhage is after cold dissection with ligature or suturing. All "hot" techniques with laser, radiofrequency, coblation, mono- or bipolar forceps have a higher risk of late haemorrhage. Children with a hereditary coagulopathy have a higher risk of haemorrhage. It is possible, that these children were not identified before surgery. Therefore it is recommended by the Society of paediatrics, anaesthesia and ENT, that a standardised questionnaire should be answered by the parents before tonsillectomy and adenoidectomy. This 17-point-checklist questionnaire is more sensitive and easier to perform than a screening with blood tests (e.g. INR and PTT). Unfortunately, a lot of surgeons still screen the children preoperatively by coagulative blood tests, although these tests are inappropriate and incapable of detecting the von Willebrand disease, which is the most frequent coagulopathy in Europe. The preoperative information about the surgery should be done with the child and the parents in a calm and objective atmosphere with a written consent. A copy of the consent with the signature of the surgeon and both custodial parents has to be handed out to the parents.
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Affiliation(s)
- Klaus Stelter
- Dep. of Otorhinolaryngology, Head and Neck Surgery, Grosshadern Medical Centre, University of Munich, Munich, Germany
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Deak L, Saxton D, Johnston K, Benedek P, Katona G. Comparison of Postoperative Pain in Children with Two Intracapsular Tonsillotomy Techniques and a Standard Tonsillectomy: Microdebrider and radiofrequency tonsillotomies versus standard tonsillectomies. Sultan Qaboos Univ Med J 2014; 14:e500-e505. [PMID: 25364553 PMCID: PMC4205062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2014] [Revised: 05/07/2014] [Accepted: 05/28/2014] [Indexed: 06/04/2023] Open
Abstract
OBJECTIVES The aim of this study was to compare the duration and severity of postoperative pain for two different tonsillotomy techniques (radiofrequency [RF] and microdebrider [MD]) with the standard tonsillectomy. METHODS This non-randomised retrospective study, carried out from February 2011 to September 2012, investigated 128 children in two independent centres: Heim Pál Children's Hospital in Budapest, Hungary, and Muscat Private Hospital in Muscat, Oman. Those undergoing conventional tonsillectomies acted as the control group. One centre tested the MD technique (n = 28) while the other centre tested the RF technique (n = 31). RESULTS The pain-free period after the tonsillotomies was similar between the two techniques and ranged up to three days. Other indicators of pain resolution, like the use of a single analgesic, reduced night-time waking and the time taken to resume a normal diet, were also similar for the two groups. However, patients benefited significantly from having a tonsillotomy rather than a tonsillectomy. CONCLUSION The partial resectioning of tonsillar tissue using the MD and RF techniques showed promising outcomes for a better postoperative quality of life when compared to a traditional tonsillectomy. In this study, the results of both the MD and RF tonsillotomy methods were almost identical in terms of the duration of postoperative pain and recovery time.
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Affiliation(s)
- Levente Deak
- Department of Ear, Nose & Throat, Al Zahra Hospital, Dubai, United Arab Emirates
| | - David Saxton
- Department of Ear, Nose & Throat, Al Zahra Hospital, Dubai, United Arab Emirates
| | - Keith Johnston
- Department of Anaesthesia & Critical Care, Muscat Private Hospital, Muscat, Oman
| | - Palma Benedek
- Department of Oto-Rhino-Laryngology & Bronchology, Heim Pál Children’s Hospital, Budapest, Hungary
| | - Gábor Katona
- Department of Oto-Rhino-Laryngology & Bronchology, Heim Pál Children’s Hospital, Budapest, Hungary
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Ericsson E, Graf J, Lundeborg-Hammarstrom I, Hultcrantz E. Tonsillotomy versus tonsillectomy on young children: 2 year post surgery follow-up. J Otolaryngol Head Neck Surg 2014; 43:26. [PMID: 25064139 PMCID: PMC6389138 DOI: 10.1186/s40463-014-0026-6] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2014] [Indexed: 11/24/2022] Open
Abstract
Objectives To study the long-term effect of tonsillotomy and tonsillectomy in young children after two years in comparison to the results after six months. Method Children, age 4-5 with Sleep Disordered Breathing (SDB) and tonsil hyperplasia, were randomized to TE (32) or TT (35). TT was performed ad modum Hultcrantz with radiofrequency technique (Ellman). An adenoidectomy with cold steel was performed in the same session for 80% of cases. The patients were assessed prior to surgery, at six and 24 months postoperatively. Effects of surgery were evaluated clinically, through questionnaire (general health/snoring/ENT-infections), Quality of Life (QoL), survey of pediatric obstructive sleep apnea with OSA-18, and children’s behavior with the Child Behavior Checklist. Results After two years there was still no difference between the groups with respect to snoring and frequency or severity of upper airway infections. Both TT and TE had resulted in large improvement in short and long term QoL and behavior. Three TT-children and one TE child had been re-operated due to recurrence of obstructive problems, the TE-child and one of the TT-children with adenoidectomy and two of the TT-children with tonsillectomy. Three of the TT-children had tonsil tissue protruding slightly out of the tonsil pouch and twelve TE-children had small tonsil remnants within the tonsil pouches, but with no need for surgery. Conclusion Younger children have a small risk of symptom-recurrence requiring re-surgery within two years after TT. For the majority, the positive effect on snoring, infections, behavior and quality of life remain and is similar to TE. Electronic supplementary material The online version of this article (doi:10.1186/s40463-014-0026-6) contains supplementary material, which is available to authorized users.
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Windfuhr JP, Savva K, Dahm JD, Werner JA. Tonsillotomy: facts and fiction. Eur Arch Otorhinolaryngol 2014; 272:949-969. [DOI: 10.1007/s00405-014-3010-x] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2013] [Accepted: 03/13/2014] [Indexed: 11/30/2022]
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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.
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Affiliation(s)
- Jochen P. Windfuhr
- Department of Otorhinolaryngology, Plastic Head and Neck Surgery, Kliniken Maria Hilf, Mönchengladbach, Germany
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Role of subtotal tonsillectomy (‘tonsillotomy’) in children with sleep disordered breathing. The Journal of Laryngology & Otology 2013; 128 Suppl 1:S3-7. [DOI: 10.1017/s0022215113003058] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractIntroduction:Sleep disordered breathing in children causes disturbance in behaviour and also in cardiorespiratory and neurocognitive function. Subtotal tonsillectomy (‘tonsillotomy’) has been performed to treat sleep disordered breathing, with outcomes comparable to established therapies such as total tonsillectomy or adenoidectomy. This review critically assesses the role of subtotal tonsillectomy in a paediatric setting.Method:The Medline database (1966 to October 2012) was electronically searched using key terms including subtotal or intracapsular tonsillectomy, tonsillotomy, tonsillectomy, paediatrics, and sleep disordered breathing.Results:Eighteen papers were identified and reviewed. Subtotal tonsillectomy would appear to have an efficacy equal to that of total tonsillectomy for the treatment of sleep disordered breathing, and has significant benefits in reducing post-operative pain and analgesia use. Subtotal tonsillectomy patients appear to have less frequent post-operative haemorrhage compared with total tonsillectomy patients.Conclusion:In children, subtotal tonsillectomy is associated with fewer post-operative complications whilst having a comparable effect in improving sleep disordered breathing, compared with total tonsillectomy.
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Windfuhr JP, Werner JA. Tonsillotomy: it's time to clarify the facts. Eur Arch Otorhinolaryngol 2013; 270:2985-96. [DOI: 10.1007/s00405-013-2577-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Pre-emptive triple analgesia protocol for tonsillectomy pain control in children: double-blind, randomised, controlled, clinical trial. The Journal of Laryngology & Otology 2013; 127:383-91. [DOI: 10.1017/s0022215113000364] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractIntroduction:This double-blind, controlled, parallel-group study was designed to determine the efficacy of pre-emptive triple analgesia for paediatric post-tonsillectomy pain management.Materials and methods:One hundred and thirty-five children were randomised into two groups: pre-emptive triple analgesia (n = 55) and control (n = 80). Pain was assessed using a visual analogue scale (in hospital) and the Parent's Postoperative Pain Measure (at home), and scores recorded.Results:Visual analogue scale scores on awakening and for 6 hours post-surgery were significantly better in the study group than the control group (p < 0.05). The Parent's Postoperative Pain Measure scores of control group children were significantly higher within the first 3 post-operative days (p = 0.000), with a greater percentage of children experiencing significant pain and requiring more analgesia.Conclusion:The proposed multimodal, pre-emptive analgesia protocol for paediatric post-tonsillectomy pain results in less post-operative pain, both in hospital or at home.
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Paradigm shift in Sweden from tonsillectomy to tonsillotomy for children with upper airway obstructive symptoms due to tonsillar hypertrophy. Eur Arch Otorhinolaryngol 2013; 270:2531-6. [DOI: 10.1007/s00405-013-2374-7] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2012] [Accepted: 01/17/2013] [Indexed: 10/27/2022]
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Cravero JP, Fanciullo GJ, McHugo GJ, Baird JC. The validity of the Computer Face Scale for measuring pediatric pain and mood. Paediatr Anaesth 2013; 23:156-61. [PMID: 23061715 DOI: 10.1111/pan.12036] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/17/2012] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The aim was to assess the validity of the Computer Face Scale. METHODS Forty children (5-13 years old) rated pain and mood prior to and twice following tonsillectomy. The children used the Computer Face Scale to adjust a cartoon face to rate pain and mood. During sessions one and two, the children also chose an expression on the Wong-Baker Faces Scale to rate their pain, and they reported their mood verbally on a seven-point scale. RESULTS On average, the children reported no pain and a positive mood prior to surgery. Soon after surgery, they reported mild pain and a slightly negative mood. An hour later, they reported decreases in pain and return to a positive mood. The differences between presurgery and postsurgery ratings were statistically significant (P ≤ 0.001) for all measures. The correlation between the two mood measures was 0.88 before surgery and 0.78 afterward. The correlation between the two measures of pain was 0.83 after surgery (P's < 0.001). CONCLUSIONS The results support the validity of the Computer Face Scale. The mean ratings of pain and mood followed the expected pattern from pre- to postsurgery, and there was a significant association between ratings obtained by different methods. The Computer Face Scale provides a simple-to-use scale with more resolution and electronic capture, which may provide advantages in numerous clinical and research applications.
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Affiliation(s)
- Joseph P Cravero
- Department of Anesthesiology, Dartmouth-Hitchcock Medical Center, Lebanon, NH 03756, USA.
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Hultcrantz E, Ericsson E. Factors Influencing the Indication for Tonsillectomy: A Historical Overview and Current Concepts. ACTA ACUST UNITED AC 2013; 75:184-91. [DOI: 10.1159/000342322] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Chaidas KS, Kaditis AG, Papadakis CE, Papandreou N, Koltsidopoulos P, Skoulakis CE. Tonsilloplasty versus tonsillectomy in children with sleep-disordered breathing: short- and long-term outcomes. Laryngoscope 2012; 123:1294-9. [PMID: 23254758 DOI: 10.1002/lary.23860] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2012] [Revised: 09/22/2012] [Accepted: 10/10/2012] [Indexed: 11/07/2022]
Abstract
OBJECTIVES/HYPOTHESIS Adenoidectomy and tonsillectomy (TE) is the standard treatment for obstructive sleep-disordered breathing (SDB) in children with adenotonsillar hypertrophy. Tonsilloplasty (TP) is a new surgical technique that includes partial TE. The purpose of this study was to assess the short- and long-term outcomes of TP compared to TE. STUDY DESIGN A comparison study. METHODS Children with SDB and tonsillar hypertrophy underwent TP or TE. The two groups were compared regarding immediate postoperative course and long-term effects. RESULTS Fifty-one children (age, 6.3 ± 2.5 years) underwent TE, and 50 children (age, 5.9 ± 2.1 years) had TP. The TP group had significantly less intraoperative bleeding compared to the TE group (25.6 ± 8.2 vs. 38.3 ± 12.3 mL, P < .001). Subjects with TP were pain free earlier than children with TE (4.5 ± 0.4 vs. 7.7 ± 0.4 days, P < .001) and returned to a normal diet sooner (3.8 ± 0.2 vs. 7.1 ± 0.3 days, P < .001). By the 3rd to 4th postoperative night, upper airway obstruction was relieved in all participants. Six years postoperatively, 48 of 51 children in the TE group and 43 of 50 children in the TP group participated in a telephone survey. No significant differences were found between the two groups regarding the frequency of recurrent snoring (30.2% in TP vs. 25% in TE), apneas (4.7% vs. 0%), and upper airway infections per year (P > .05). CONCLUSIONS TP is an alternative surgical method for treatment of SDB related to tonsillar hypertrophy with favorable postoperative course and comparable long-term results. LEVEL OF EVIDENCE 2c.
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Affiliation(s)
- Konstantinos S Chaidas
- Department of Otorhinolaryngology-Head and Neck Surgery, General Hospital of Volos, Volos, Greece.
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Sarny S, Habermann W, Ossimitz G, Stammberger H. Significant Post-Tonsillectomy Pain is Associated with Increased Risk of Hemorrhage. Ann Otol Rhinol Laryngol 2012; 121:776-81. [DOI: 10.1177/000348941212101202] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives: In this study, we set out to assess the association of postoperative pain types with the risk of hemorrhage after tonsillectomy. Methods: The questionnaire-based study was conducted on 335 patients who had undergone tonsillectomy. Hemorrhage risk and postoperative pain were evaluated retrospectively with use of a visual analog scale for 5 time periods (day 1, days 2 to 3, days 4 to 7, days 7 to 14, and later). Results: Five pain types were identified by a cluster analysis. The most frequent pain types, I (24.8%; 83 patients) and II (50.8%; 170 patients), show decreasing pain, with pain type II starting on a higher level than pain type I. Pain types III (10.7%; 36 patients) and IV (1.2%; 4 patients) start at a low level with increasing pain for the first few days. In type III, pain decreases after 1 week, whereas type IV consists of a high level of pain for more than 2 weeks. Pain type V (12.5%; 42 patients) involves a very high level of pain from the beginning, which decreases only gradually. Pain type I is associated with a low hemorrhage rate. Patients with increasing pain (types III and IV) and pain type V show a significantly higher hemorrhage risk. Conclusions: Patients who have severe or increasing pain in the first few days after tonsillectomy have a significantly higher risk of hemorrhage.
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Verse T, Pirsig W, Stuck BA, Hörmann K, Maurer JT. Recent Developments in the Treatment of Obstructive Sleep Apnea. ACTA ACUST UNITED AC 2012; 2:157-68. [PMID: 14720014 DOI: 10.1007/bf03256646] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Modern sleep medicine has been in existence for only 20 years and therefore has to be regarded as a comparatively recent field of specialization. For this reason it is not surprising that there are numerous new trends and developments concerning the treatment of sleep-related breathing disorders. This review focuses on developments in the treatment of obstructive sleep apnea (OSA) over the last 5 years.The review is based on a Medline bibliographic search using the key words 'treatment', 'obstructive sleep apnea' and 'sleep-related breathing disorders' and covers papers published since 1997, including references in these articles. In respect to conservative treatments the following important developments were found. Oral devices were shown to be effective in about 50-70% of patients with OSA, but at this stage it is not possible to predict in which patients successful treatment can be expected. As subjective compliance averages only about 50%, thermoplastic devices used as trial devices provide a reasonable alternative to reduce costs. Automatic continuous positive airway pressure (CPAP) units have been shown to cut costs when used for pressure titration in severe sleep apneics during the day or when used in so-called split-night procedures in appropriate cases. Nasal CPAP has proven to be effective in children, showing higher compliance rates than in adults. The development of mouth-pieces provides the possibility of using CPAP orally, e.g. after nasal surgery. Electrical stimulation of the tongue muscles shows promising preliminary results. Nevertheless, further research in this field is necessary. In the field of surgery, the most valuable development has been tissue reduction using radiofrequency energy, which has been shown to be effective and minimally invasive. Other fundamentally new surgical techniques have not been attempted within the last 5 years; instead, development in this area appears to be defined by a combination of previously known methods (so-called multilevel surgery) and optimized methods of patient selection. Such combined surgical procedures has achieved success rates of about 70%. Taking all these developments into account, CPAP therapy remains the gold standard for treatment of patients with OSA; yet the low long-term compliance rates of 60-70% have to be regarded as a major challenge warranting further effort.
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Affiliation(s)
- Thomas Verse
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Mannheim, Mannheim, Germany.
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Palmieri B, Iannitti T, Fistetto G, Rottigni V. The "Swiss-cheese Doppler-guided laser tonsillectomy": a new safe cribriform approach to intracapsular tonsillectomy. Lasers Med Sci 2012; 28:865-9. [PMID: 22855380 PMCID: PMC3637894 DOI: 10.1007/s10103-012-1140-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2012] [Accepted: 06/04/2012] [Indexed: 12/11/2022]
Abstract
Outpatient laser ablation of palatine tonsils is a very interesting procedure that has been recently introduced as a routine in head and neck surgery departments. The aim of this study was to describe a new strategy using a Doppler-guided fibre optic neodymium-yttrium–aluminium–garnet (YAG) laser to remove up to 80 % of tonsillar tissue, as assessed in the long-term postoperative clinical evaluation of the volume of the tonsils at the follow-up, and leaving the capsule in place, thus avoiding any haemorrhagic complication and minimize pain. A total of 20 patients (men, n = 13; women, n = 7), aged between 6 and 63, were recruited for the procedure. They were affected by chronic hypertrophic tonsillitis with a recurrent fever and other symptoms that were related to oral inflammation. Among the 20 patients, no serious adverse events, including haemorrhage-related complications, were observed. Treatment was well tolerated, even in patients displaying an overall low pain threshold. No dropout or uncompleted procedure occurred in the present study. Minor complications included sore throat, moderate oedema, mild acute pharynx inflammation, slight peritonsillar exudate and local burning. The postoperative pain, measured by Scott–Huskisson visual analogue scale, was between 5 and 40 mm and was easily counteracted by means of external ice packages and nonsteroidal anti-inflammatory drugs, according to the individual patient’s need. During the 12–36-month follow-up patients showed improved symptoms (n = 7) and complete recovery (n = 13). A relapse episode was observed in two patients. This study supports fibre optic laser neodymium-YAG tonsil surgery, named “cribriform intracapsular tonsillectomy” or “Swiss-cheese laser tonsillectomy”, as an effective alternative to the traditional cold knife approach or electrosurgery. This approach could become the gold standard for tonsil surgery in the third millennium for safety reasons, acceptable cost–benefit ratio, the precise targeting of the beam across the affected tissues and the short- and long-term recovery.
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Affiliation(s)
- B Palmieri
- Department of General Surgery and Surgical Specialties, University of Modena and Reggio Emilia Medical School, Surgical Clinic, Modena, Italy
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Havel M, Sroka R, Englert E, Stelter K, Leunig A, Betz CS. Intraindividual comparison of 1,470 nm diode laser versus carbon dioxide laser for tonsillotomy: a prospective, randomized, double blind, controlled feasibility trial. Lasers Surg Med 2012; 44:558-63. [PMID: 22837058 DOI: 10.1002/lsm.22053] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/03/2012] [Indexed: 11/12/2022]
Abstract
INTRODUCTION The need for reduction of post-tonsillectomy hemorrhage has led to promotion of tonsillotomy techniques for tonsil tissue reduction in obstructive tonsillar hypertrophy. This trial compares ablative tissue effects using 1,470 nm diode laser and carbon dioxide laser for tonsillotomy in an intraindividual design. METHODS 21 children aged 3-13 years (mean age 6.3 years) underwent laser tonsillotomy for obstructive tonsillar hypertrophy in this double blind, prospective, randomized, clinical feasibility trial. In each of the blinded patients, tonsillotomy was performed using fiber guided 1,470 nm diode laser (contact mode, 15 W power) on the one side and carbon dioxide laser (12 W power) on the other side. An independent, blinded physician documented clinical presentation and patients' symptoms preoperatively and on Days 1, 3, 7, 14, and 21 post-operatively using standardized questionnaire including VAS for each side separately. RESULTS The mean duration of operative treatment was 2.7 min using 1,470 nm laser and 4.9 min using carbon dioxide laser respectively. Intraoperative bleeding and the frequency of bipolar forceps use for intraoperative bleeding control was significantly less using 1,470 nm diode laser system. There was no difference in post-operative pain scores between the carbon dioxide laser treated and the 1,470 nm fiber guided diode laser treated side. No infections, hemorrhages or other complications occurred in the course of the 3 weeks post-operative period. CONCLUSIONS A fiber-guided 1,470 nm diode laser system offers an efficient and safe method for tonsillotomy as treatment of obstructive tonsillar hypertrophy. Compared to our standard practice (carbon dioxide laser), 1,470 nm laser application provides comparable tissue ablation effects with less intraoperative bleeding and shorter operation time.
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Affiliation(s)
- Miriam Havel
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Munich, Marchioninistr. 15, 81377 Munich, Germany.
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Ahlstav Mårtensson U, Erling Hasselqvist N, Boström B. Differences in pain and nausea in children operated on by Tonsillectomy or Tonsillotomy - a prospective follow-up study. J Adv Nurs 2012; 69:782-92. [DOI: 10.1111/j.1365-2648.2012.06060.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Wood JM, Harris PK, Woods CM, McLean SC, Esterman A, Carney AS. Quality of life following surgery for sleep disordered breathing: subtotal reduction adenotonsillectomy versus adenotonsillectomy in Australian children. ANZ J Surg 2011; 81:340-4. [DOI: 10.1111/j.1445-2197.2010.05604.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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