Post-tonsillectomy hemorrhage rates in children compared by surgical technique

Safety of Tonsillectomy and/or Adenoidectomy in Pediatric Patients with Prolonged Activated Partial Thromboplastin Time and Factor XII Deficiency

Objective

To evaluate the safety and feasibility of tonsillectomy and/or adenoidectomy (T&A) in pediatric patients with prolonged activated partial thromboplastin time (APTT) and coagulation factor deficiency.

Methods

A prospective study was admitted to the children undergoing T&A at our institution between October 2019 and January 2020, specifically focusing on preoperative coagulation function. Within this group, we identified 5 patients exhibiting prolonged APTT and coagulation factor deficiencies, constituting the experimental group, and 10 patients matched by gender and age with normal blood coagulation function were selected as the control group. Comparative analyses between the two groups were conducted, focusing on surgical duration, intraoperative bleeding volume, duration of hospital stay, and postoperative complications such as active bleeding across the groups. At the six-month postoperative mark, a reassessment of coagulation functions and factor assays was conducted within the experimental group.

Results

No statistically significant differences were discovered in terms of surgical duration or bleeding volume when comparing the experimental subgroups with their respective control counterparts. Furthermore, there were no incidences of postoperative active bleeding observed in any of the groups. Notably, postoperative APTT values (32.7 ± 1.7s) exhibited a significant disparity compared to preoperative levels (43.7 ± 1.8s, p < 0.01). Coagulation factors demonstrated normalization, evidenced by a significant difference in postoperative Factor XII levels (40.2 ± 5.4%) compared to preoperative levels (63.1 ± 5.9%, p < 0.01).

Conclusion

Prolonged APTT with FXII factor deficiency does not show a significant bleeding tendency and is not a contraindication for T&A surgery. Post T&A surgery, children with abnormal coagulation function and deficient clotting factors show significant improvement compared to pre-surgery. It is important to consider that chronic inflammation in adenoids and tonsils may contribute to the prolongation of APTT and the manifestation of Factor XII deficiency.

A comparison of coblation and modified monopolar tonsillectomy in adults

OBJECTIVE

To compare the intraoperative records and postoperative clinical outcomes of adults who underwent coblation and modified monopolar tonsillectomy tonsillectomies.

MATERIALS AND METHODS

Adult patients with tonsillectomy were randomly divided into the coblation and modified monopolar tonsillectomy groups. The estimated blood loss, postoperative pain score, operation time, post-tonsillectomy hemorrhage (PTH), and cost of disposable equipment were compared.

RESULTS

Pain intensity in the coblation and monopolar groups was similar on postoperative days 3 and 7. However, the mean maximum pain score in the monopolar group was significantly higher compared to the coblation group on postoperative days 1 (P < 0.01) and 2 (P < 0.05).Secondary PTH occurred in 7.1% (23/326) of patients in the coblation group and 2.8% (9/327) of patients in the monopolar group (P < 0.05).

CONCLUSION

Although pain was significantly increased on postoperative days 1 and 2 in the modified monopolar tonsillectomy group, the operation time, secondary PTH, and medical costs were significantly decreased compared to the coblation technique group.

Estimated Probability Distribution of Bleeding After Pediatric Tonsillectomy: A Retrospective National Cohort Study of US Children

Importance

The American Academy of Otolaryngology-Head and Neck Surgery Foundation has recommended yearly surgeon self-monitoring of posttonsillectomy bleeding rates. However, the predicted distribution of rates to guide this monitoring remain unexplored.

Objective

To use a national cohort of children to estimate the probability of bleeding after pediatric tonsillectomy to guide surgeons in self-monitoring of this event.

Design, Settings, and Participants

This retrospective cohort study used data from the Pediatric Health Information System for all pediatric (<18 years old) patients who underwent tonsillectomy with or without adenoidectomy in a children's hospital in the US from January 1, 2016, through August 31, 2021, and were discharged home. Predicted probabilities of return visits for bleeding within 30 days were calculated to estimate quantiles for bleeding rates. A secondary analysis included logistic regression of bleeding risk by demographic characteristics and associated conditions. Data analyses were conducted from August 7, 2022 to January 28, 2023.

Main Outcomes and Measures

Revisits to the emergency department or hospital (inpatient/observation) for bleeding (primary/secondary diagnosis) within 30 days after index discharge after tonsillectomy.

Results

Of the 96 415 children (mean [SD] age, 5.3 [3.9] years; 41 284 [42.8%] female; 46 954 [48.7%] non-Hispanic White individuals) who had undergone tonsillectomy, 2100 (2.18%) returned to the emergency department or hospital with postoperative bleeding. The predicted 5th, 50th, and 95th quantiles for bleeding were 1.17%, 1.97%, and 4.75%, respectively. Variables associated with bleeding after tonsillectomy were Hispanic ethnicity (OR, 1.19; 99% CI, 1.01-1.40), very high residential Opportunity Index (OR, 1.28; 99% CI, 1.05-1.56), gastrointestinal disease (OR, 1.33; 99% CI, 1.01-1.77), obstructive sleep apnea (OR, 0.85; 99% CI, 0.75-0.96), obesity (OR,1.24; 99% CI, 1.04-1.48), and being more than 12 years old (OR, 2.48; 99% CI, 2.12-2.91). The adjusted 99th percentile for bleeding after tonsillectomy was approximately 6.39%.

Conclusions and Relevance

This retrospective national cohort study predicted 50th and 95th percentiles for posttonsillectomy bleeding of 1.97% and 4.75%. This probability model may be a useful tool for future quality initiatives and surgeons who are self-monitoring bleeding rates after pediatric tonsillectomy.

Examining the life-cycle of the Coblator II device: Increases in paediatric post-tonsillectomy haemorrhage after six years of use

All paediatric tonsillectomies were examined from 2012 – 2019 at a single tertiary-referral institution, and all were performed by one of two paediatric otolaryngologists. One exclusively used the diathermy, the other exclusively used the Coblator II. Two Coblator units were purchased simultaneously in 2012 and not replaced. There was no significant difference in number of tonsillectomies performed (1298 via diathermy, 1221 via Coblator), nor in postoperative day of bleed, patient age, indication for procedure, and no patient had an underlying coagulopathy. The most common indication for tonsillectomy in both groups was sleep-disordered breathing. There was no significant difference in postoperative haemorrhage rates between groups for the first six years of the study (0%-1.4%/year). Years 7 and 8 saw the Coblator group haemorrhage rate significantly increase (0%-0.6% diathermy group vs 2%-3% Coblator group), though still fell within accepted rate of postoperative haemorrhage. The devices were then replaced, and the differences in haemorrhage disappeared. There appears to be a significant increase in paediatric post-tonsillectomy haemorrhage when using a Coblator device greater than six years old. This may suggest a useful lifespan for the Coblator II device.

Effect of ibuprofen on severity of surgically-managed pediatric post-tonsillectomy hemorrhage

OBJECTIVES

The association between ibuprofen use and severity of post-tonsillectomy hemorrhage (PTH) remains unclear. We aimed to compare PTH severity in patients who did or did not receive ibuprofen.

METHODS

A retrospective cohort study of pediatric patients requiring operative control of PTH at a tertiary children's hospital between 2015 and 2019 was performed. PTH severity was assessed using pre-tonsillectomy and post-hemorrhage hemoglobin and hematocrit values, estimated intraoperative blood loss, estimated hemorrhage flow rate, and need for transfusion. Differences in hemorrhage severity markers between the two cohorts were compared.

RESULTS

A total of 168 consecutive patients were included in this study. The mean age was 8.8 years, and 55.4% of patients were male. Sixty-five patients (38.7%) received ibuprofen postoperatively. There was no statistically significant difference in the mean change in hemoglobin (1.1 vs. 1.1, P = 0.85) or hematocrit (3.1 vs. 3.2, P = 0.97) between patients who received ibuprofen compared to those who did not. Similarly, there were no significant differences in need for transfusion (3.1% vs. 3.9%, P = 1.00) or occurrence of high-flow (arterial) blood loss (33.8% vs. 40.8%, P = 0.42) between the two groups.

CONCLUSION

Postoperative ibuprofen use does not appear to significantly increase PTH severity, as measured by change in hemoglobin and hematocrit values, need for transfusion, or presence of high-flow blood loss. This study introduces previously unexplored markers to assess PTH severity and supports further prospective studies to determine the effect of ibuprofen on PTH severity.

Role of Octreotide in Conservative Management of Chyle Leak Post Neck Dissection in Cases of Head Neck Cancer: A Retrospective Analysis

Chyle leak is a dreadful complication in patients undergoing neck dissections. Octreotide has been used in the management of chyle leak post neck dissections in head and neck cancer patients. Currently there is no consensus and practice guidelines on the same. (1) To study the role of octreotide in early cessation of post neck dissection chyle leak. (2) To study incidence of intra-operative and post-operative CL, its relation to the extent of nodal disease and neck dissection, prior radiotherapy. Retrospective analysis of 16 patients out of 529 neck dissection over a period of 03 years between Jan 2016 and Dec 2019 who developed post-operative chyle leak. All patients who had post-operative chyle leak were administered octreotide. Time taken for chyle leak to stop was primary outcome. Secondary outcomes were duration of hospitalization post-operatively, incidence of intra-operative and post-operative chyle leak, its relation to the extent of nodal disease, prior radiotherapy and type of neck dissection. 59 of 529 neck dissections (11.15%) were noted to have intra-operative chyle leak. 16 of 529 neck dissections (3.02%) developed post-operative chyle leak. On applying chi square test, prior multimodality and N plus neck were found to be significant risk factors in developing postoperative chyle leak. Considering only RT versus no RT in prior multimodality treated group, the difference was insignificant. Onset of chyle leak varied from 1 to 5 post-op day (mean 2.68 days). 15 (93.75%) patients responded to octreotide. Chyle leak resolved between 3 and 10 days (mean 5.18 days) and octreotide was given for 5-12 days (mean-7.18 days). Overall duration of hospitalization ranged from 09 to 18 days (mean 12.18 days). 01 patient (6.25%) had to be re-explored due to high volume leak despite using octreotide. Adverse effects of octreotide were minimal and tolerable. Octreotide is effective in reducing the duration of chyle leak, hospital stay and need for surgical intervention. It may be considered as suitable adjunct to conservative measures in the management for post-operative chyle leak.

The Effect of Desmopressin Intraoperatively on Hemorrhage During the Rhinoplasty Surgery

This clinical trial discusses the efficacy of premedication with desmopressin in the management of bleeding and clears the surgical field during rhinoplasty surgery. This study is a randomized, double-blinded placebo-control clinical trial. Seventy patients were enrolled in this study and divided into two equal intervention-control groups. Thirty minutes before surgery, the intervention group received 500 ml of normal saline containing 0.1 μg/kg desmopressin and, the control group received 500 ml of normal saline. According to the surgeon's opinion, the local distribution of bleeding was dramatically different in both groups. While DDAVP receivers had grade 1 or 2 bleeding (according to the FROMME-BOEZAART grading score), the control group had grade 3 or 4 bleeding, and this difference was statistically meaningful. It seems that intravenous DDAVP can reduce bleeding and clear the surgical field during rhinoplasty surgery, but further studies are needed to determine the exact role and dose of the DDAVP.

Preoperative thromboelastography in the prediction of post-tonsillectomy hemorrhage by coblation tonsillectomy: a post-hoc analysis

BACKGROUND

Post-tonsillectomy hemorrhage (PTH) affects around 4% of patients after tonsillectomy. We hypothesized that preoperative thromboelastography (TEG) might identify patients at higher risk of PTH.

OBJECTIVE

Investigate whether evaluation of coagulation function by preoperative TEG might help to predict PTH after tonsillectomy by coblation tonsillectomy (TE).

DESIGN

Post-hoc analysis of randomized controlled study.

SETTING

Otolaryngology Department between January 2017 and August 2019.

PATIENTS AND METHODS

This post-hoc analysis included adults who underwent coblation TE for benign tonsillar disorders. Routine blood tests and TEG were performed preoperatively. The TEG parameters evaluated included coagulation reaction time (R) and maximum thrombus amplitude (MA).

MAIN OUTCOME MEASURES

The main outcome was PTH during the 4-week postoperative period.

SAMPLE SIZE AND CHARACTERISTICS

284 RESULTS: The 19 patients (6.7%) that experienced PTH had a higher prevalence of diabetes mellitus, lower use of intraoperative suturing, fewer patients with grade I and II tonsillar enlargement, a higher white blood cell count, lower platelet count, lower fibrinogen level, lower R value, and a lower MA value than patients without PTH (all P<.05). Multivariate logistic regression revealed that diabetes mellitus (P<.053), fibrinogen level ≤2.735 g/L (P<.027), R≤6.55 min (P<.011) and MA≤59.15 mm (P<.012) were independently associated with PTH. A regression model incorporating these four factors predicted PTH with a sensitivity of 73.7% and specificity of 83.8%.

CONCLUSION

Preoperative evaluation of diabetes mellitus history, fibrinogen level, and TEG parameters might help to identify patients at higher risk of PTH after coblation TE.

LIMITATIONS

Single-center study with a small sample size; possibly underpowered statistically. TEG measurements might not accurately reflect coagulation function, and a validation cohort was unavailable.

CONFLICT OF INTEREST

None. CHINESE CLINICAL TRIAL REGISTRY NUMBER OF STUDY USED IN THIS ANALYSIS: ChiCTR2000032171. http://www.chictr.org.cn/showprojen.aspx?proj=52553.

Can intraoperative suturing reduce the incidence of posttonsillectomy hemorrhage? A systematic review and meta-analysis

Objective

This study was to compare tonsillectomy with intraoperative suturing (TIS) and tonsillectomy without intraoperative suturing (TsIS) in preventing postoperative tonsillectomy hemorrhage (PTH).

Methods

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was followed. Articles compare TIS and TsIS in preventing PTH were included. The quality of eligible studies was assessed with the Newcastle-Ottawa Scale (NOS) by two independent investigators. Random effect models were used to determine odds ratio (OR) with 95% CIs.

Results

A total of 15 studies were analyzed. The pooled results showed the PTH rate was lower in the TIS group (OR = 0.64; 95% CI, 0.47-0.88). The TIS group had a lower primary and secondary PTH rate than the TsIS group with OR values of 0.44 (95% CI, 0.30-0.64) and 0.70 (95% CI, 0.54-0.90), respectively. However, suturing did not show an advantage in reducing the risk of returning to the operation room for hemostasis (OR = 0.57; 95% CI, 0.13-2.47). Adults might benefit from the intraoperative suturing procedure (OR = 0.31; 95% CI, 0.16-0.60). Patients with more than three stitches on each side had a lower PTH rate (OR: 0.44; 95% CI, 0.32-0.60). Suturing the tonsillar fossa and pillars simultaneously could reduce the PTH rate (OR = 0.47; 95% CI, 0.34-0.64).

Conclusions

Intraoperative suturing is a good strategy for preventing PTH. More multicenter randomized controlled studies should be conducted to demonstrate the efficacy of this procedure.

Level of Evidence

5.

A single center retrospective comparison of post-tonsillectomy hemorrhage between BiZact and Coblator

INTRODUCTION

Over 550,000 tonsillectomies are performed every year. While post-tonsillectomy hemorrhage (PTH) has been studied in the coblator, bovie, and cold steel technique, there is a dearth of studies examining the post-tonsillectomy outcome using BiZact. This study examines the rate of BiZact PTH requiring control of hemorrhage in the OR and assess resident comfort using the device.

METHODS

Retrospective chart review for all tonsillectomies performed between January 2018 and December 2020 were performed. Rates of PTH were analyzed. In addition, a 7-question BiZact resident experience survey was administered to 25 otolaryngology residents.

RESULTS

1384 patients were included in this study; 444 (32%) Bizact and 940 (68%) Coblation. 11 (2.48%) BiZact patients had PTH requiring OR for control of hemorrhage, compared to 44 (4.68%) Coblation patients. There were no patient deaths because of PTH. The mean age of patients with PTH was 7.44 (SD 4.07) years old. 22 (88%) residents responded to the survey. 17 (77.27%) felt more confident with Coblator while performing tonsillectomy most commonly reported for ease of use, followed by BiZact 4 (18.18%), most commonly reported for improved surgical plane.

CONCLUSION

BiZact is a safe and effective addition. At our institution, the rate of secondary PTH requiring OR intervention for BiZact is comparable to the national average for other tonsillectomy devices. The rate of BiZact PTH requiring OR intervention in our experience was nearly half of those done with Coblator. Overall residents at SCHC preferred Coblator over BiZact mainly attributed to Coblator's versatility and ability to control intraoperative tonsil bleeding without additional instruments despite BiZact's shorter operative time.

Predictive Pediatric Characteristics for Revision Tonsillectomy After Intracapsular Tonsillectomy

OBJECTIVES

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

STUDY DESIGN

Level III, retrospective case-control study.

SETTING

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

METHODS

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

RESULTS

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

CONCLUSION

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

Primary and secondary postoperative hemorrhage in pediatric tonsillectomy

BACKGROUND

Tonsillectomy is the most common procedure for treatment of pediatric recurrent acute tonsillitis and tonsillar enlargement that contributes to obstructive sleep apnea hypopnea syndrome. Postoperative hemorrhage of tonsillectomy is a life-threatening complication.

AIM

To identify the risk factors that may contribute to primary and secondary post-operative hemorrhage in pediatric tonsillectomy.

METHODS

The clinical data from 5015 children, 3443 males and 1572 females, aged 1.92-17.08 years, with recurrent tonsillitis and/or tonsil hypertrophy who underwent tonsillectomy in our hospital from January 2009 to December 2018 were retrospectively collected. The variables including sex, age, time of onset, diagnosis, method of tonsillectomy, experience of surgeon, time when the surgery started and monthly average air temperature were abstracted. The patients with postoperative hemorrhage were classified into two groups, the primary bleeding group and the secondary bleeding group, and their characteristics were compared with those of the nonbleeding group separately. Statistical analysis was performed by chi-square test with SPSS 20.

RESULTS

Ninety-two patients had post-tonsillectomy hemorrhage, and the incidence rate of post-tonsillectomy hemorrhage was 1.83%. The mean age was 5.75 years. Cases of primary hemorrhage accounted for approximately 33.70% (31/92), and cases of secondary hemorrhage occurred in 66.30% (61/92). The rate of reoperation for bleeding was 0.92%, and the rate of rehospitalization for bleeding was 0.88% in all patients. Multiple hemostasis surgery was performed in 6.52% (3/46) of patients. The method of tonsillectomy (coblation tonsillectomy) and experience of the surgeon (junior surgeon with less than 5 years of experience) were significantly associated with primary hemorrhage (χ² = 5.830, P = 0.016, χ²= 6.621, P = 0.010, respectively). Age (over 6 years old) and time of onset (more than a 1-year history) were significantly associated with secondary hemorrhage (χ²= 15.242, P = 0.000, χ²=4.293, P = 0.038, respectively). There was no significant difference in sex, diagnosis, time when the surgery started or monthly average air temperature. There was a significant difference in the intervention measures between the primary bleeding group and the secondary bleeding group (χ²= 10.947, P = 0.001). The lower pole and middle portion were the common bleeding sites, followed by the upper pole and palatoglossal arch.

CONCLUSION

The incidence rate of post-tonsillectomy hemorrhage is low. Coblation tonsillectomy and less than 5 years’ experience of surgeon contribute to the tendency for primary hemorrhage. Age and time of onset are responsible for secondary hemorrhage.

Octreotide versus oral dietary modification for the treatment of chylous fistula following neck dissection: A systematic review and meta-analysis

AIMS

Chylous fistula following neck surgery is a rare, but significant complication. Currently, there is no standardised treatment, which may comprise pressure dressings, oral dietary modification (ODM), surgery or a combination of such measures. Octreotide is a somatostatin analogue that has gained popularity in the management of cervical chyle leaks. The effectiveness of octreotide compared with ODM is unclear. We provide a comprehensive, systematic review of the literature pertaining to the management of chylous fistulae, comparing both treatment strategies.

METHODS

The bibliographic databases MEDLINE, Cochrane, PubMed, EMBASE and Google Scholar were searched from inception to October 2019. Search terms included (chyle [title/abstract]) OR (chylous [title/abstract]) AND (fistula [title/abstract]) OR (fistulae [title/abstract]) OR (leak [title/abstract]) AND (neck [title/abstract]) OR (dissection [title/abstract]). The study was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Risk of bias was assessed using guidelines from the Joanna Briggs Institute. Outcome measures included the proportion of chylous fistulae that spontaneously resolved without the need for surgery and time taken until resolution, for both DM and octreotide, respectively.

RESULTS

The primary search identified 20 articles for review, comprising 313 patients. Two studies were suitable for pooled analysis. There was no statistically significant difference in the time taken for chylous fistula to resolve between groups (octreotide 10.0 days; ODM 12.0 days; P = .38). The overall rate of resolution was 89.6% and 81.5%, respectively (P = .25). Surgery was highly effective in cases failing to resolve following intervention with either method (96% [53/55] patients).

CONCLUSION

The use of octreotide for chylous fistula following neck dissection surgery is associated with a high rate of spontaneous resolution. However, significant heterogeneity, bias and concurrent use of ODM/TPN for patients in studies investigating octreotide precludes universal recommendation at this time. Further research in the form of randomised controlled trials is required to establish an independent treatment effect.

Pediatric Obstructive Sleep Apnea and Neurocognition

Pediatric obstructive sleep apnea affects a large number of children and has multiple end-organ sequelae. Although many of these have been demonstrated to be reversible, the effects on some of the organ systems, including the brain, have not shown easy reversibility. Progress in this area has been hampered by lack of a preclinical model to study the disease. Therefore, perioperative and sleep physicians are tasked with making a number of difficult decisions, including optimal surgical timing to prevent disease evolution, but also to keep the perioperative morbidity in a safe range for these patients.

Conventional Lymphangiography (CL) in the Management of Postoperative Lymphatic Leakage (PLL): A Systematic Review

BACKGROUND

 Postoperative lymphatic leakage (PLL) is usually managed by conservative and/or surgical treatments but these procedures can be challenging to perform and potentially clinically ineffective. Therefore, conventional lymphangiography (CL) has emerged as an important alternative. The aim of this review is to present the available outcome data on CL in the management of PLL.

METHOD

 A systematic literature search (PubMed) using the MeSH term "lymphangiography" was performed and the search was restricted to literature published between January 2007 and August 2019. Identification, screening, and assessment for eligibility and inclusion were conducted in accordance with PRISMA.

RESULTS

 From the initially obtained 1006 articles (identification), 28 articles with a total of 201 patients were finally included (inclusion). The methodological quality of all included articles corresponds to level 4 (Oxford Centre for Evidence-based Medicine - Levels of Evidence, March 2009). PLL occurs after oncological and non-oncological surgery in the form of chylothorax, chylous ascites, and cervical, thoracic, abdominal and peripheral lymph fistula and/or lymphocele. The technical success rate of CL is 75-100 %. Access for CL is transpedal (176 patients) or intranodal (25 patients). Lipiodol is used as the contrast material in all articles, with a maximum amount of 20 ml for transpedal CL and 30 ml for intranodal CL. The X-ray imaging modalities used for CL are fluoroscopy, radiography and/or CT. Two articles report CL-associated major complications and CL-associated morbidity and mortality. The PLL cure rate is 51-70 % for transpedal CL (time to PLL cure: 2-29 days) and 33-100 % for intranodal CL (time to PLL cure: 2-< 30 days). Bailout procedures in the case of clinically ineffective CL include a range of treatments.

CONCLUSION

 CL is feasible, safe, and effective in the management of PLL. Lipiodol as the contrast material is essential in CL because the highly viscous iodinated poppy-seed oil has not only diagnostic but therapeutic effects. Guidelines and randomized controlled trials are further steps towards defining the ultimate value of CL.

KEY POINTS

  · PLL is a difficult-to-treat and potentially life-threatening surgical complication.. · CL has emerged as an alternative to conservative/surgical treatment of PLL.. · CL is feasible, safe, and effective in the management of PLL. · Lipiodol-based CL can be regarded as a therapeutic procedure.. · Guidelines and randomized controlled trials are further important steps..

CITATION FORMAT

· Sommer CM, Pieper CC, Itkin M et al. Conventional Lymphangiography (CL) in the Management of Postoperative Lymphatic Leakage (PLL): A Systematic Review. Fortschr Röntgenstr 2020; 192: 1025 - 1035.

Finger-pressing: a simple and efficient way to stop chyle leak post neck dissection

PURPOSE

Postoperative chyle leak (CL) is a rare but severe complication after neck dissection. Conservative first-line treatments, such as total parenteral nutrition (TPN), octreotide and pressure dressing, can significantly prolong the hospital stay. Efficient and well-tolerated conservative treatment options are still lacking.

METHODS

We have developed a new maneuver to treat CL called "finger-pressing." A thumb is pressed against the point of leakage between the two muscle heads of the sternocleidomastoid. Finger-pressing continues for about 24 h until CL stops. We used this maneuver to treat six CL patients. Drainage output and duration of hospital stay were compared with another six CL patients treated using the traditional pressure dressing.

RESULTS

The finger-pressing maneuver cured all six CL patients. Most CLs (5/6) could be controlled after about 24 h pressing. Only one high-output CL required 72 h of finger-pressing to stop the leak. All patients had their drainage tubes removed within 3 days after pressing started and all patients tolerated the treatment well. In the control group, the traditional pressure dressing time varied from 2 to 5 days, until the patient was no longer able to cooperate. Three patients underwent a second operation that cured the CL in two cases. The average hospital stay was significantly longer than that in the finger-pressing group (20 vs 9 days, p = 0.037).

CONCLUSIONS

Finger-pressing is an efficient and well-tolerated method for treating CL post neck dissection. This maneuver could be a useful adjuvant therapy to traditional methods in treating CL.

Intra-capsular complete tonsillectomy, a modification of surgical technique to eliminate delayed post-operative bleeding

Pediatric tonsillectomy is a frequently performed procedure using a variety of surgical techniques. Despite decades of modern surgical experience and advances in tools and techniques, a consensus on which technique is superior for minimizing complications has not been established. In a 2014 study, the authors examined differing surgical techniques and devices to determine if there was a significant difference in the bleed rates based on technique and device [1]. In that study 7024 children were evaluated, of which a total of 1.4% (n = 99) of children experienced a postoperative hemorrhage that required a second surgery. There was no significant difference found between the four different techniques that were evaluated. Although the combined rates of post-operative hemorrhage requiring a second surgery was lower compared to many other published reports, we hypothesized that continued improvement in surgical techniques could eliminate post-operative hemorrhage completely. As follow up to that study, we decided on a collective change in technique, and subsequent analysis of our post-operative results with respect to only one outcome, post-operative hemorrhage requiring a second surgery. With a new standardized technique in place, we retrospectively evaluated one year of surgical outcomes. These procedures were performed using the technique of a modified and complete, intra-capsular Coblator tonsillectomy. Of the 783 tonsillectomies done in 12 months, we found there were 0 patients that had experienced a postoperative hemorrhage requiring a second surgery. Based on our previous study with a rate of 1.4% post-operative hemorrhage we would have expected to have 11 episodes of post-operative hemorrhage requiring a second surgery.

Pseudomonas aeruginosa-mannose sensitive hemagglutinin injection therapy for the treatment of chyle fistula following neck dissection

BACKGROUND

The efficacy of Pseudomonas aeruginosa-mannose sensitive hemagglutinin (PA-MSHA) injection therapy in the treatment of chyle fistula following neck dissection is unclear.

METHODS

This prospective study enrolled 26 patients who developed chyle fistula after neck dissection. Patients were divided into high-output (>500 mL) and low-output groups (≤500 mL) and were initially treated conservatively for 5 days in the high-output group or 7 days in the low-output group. When conservative treatment failed, topical PA-MSHA therapy was applied.

RESULTS

Twelve of 26 patients were cured with conservative treatment, and the remaining 14 patients were all successfully resolved by PA-MSHA therapy. Chyle fistula got resolved in the low-output and high-output groups after the initiation of therapy were at a median 1 days and 6 days, respectively. Among them, 12 (85.7%) patients experienced fever and 11 (78.6%) patients experienced neck pain.

CONCLUSIONS

Topical PA-MSHA injection therapy could effectively manage chyle fistula following neck dissection.

Pilot study to explore the prophylactic efficacy of oral probiotic Streptococcus salivarius K12 in preventing recurrent pharyngo-tonsillar episodes in pediatric patients

Background: In the pediatric population, acute pharyngo-tonsillitis represents one of the most frequent causes of access to outpatient treatment and use of antibiotics. In frequent tonsillitis, the pharmacological approach is no longer effective, and, therefore, surgery becomes the treatment of choice.

Methods: This study compares the prophylactic efficacy of Streptococcus salivarius K12 (Bactoblis^®) in children with recurrent pharyngo-tonsillitis treated vs untreated, with a 12 -month follow-up. The primary objectives are: The incidence of recurrence of pharyngo-tonsillar episodes and the concomitant use of other drugs. Secondary objectives are: tolerability of the treatment, the effectiveness in terms of clinical improvement, days of absence from school, reduction of the use of standard therapies, and cancellation from the surgical planning list.

Results: Patients belonging to group A (treated with K12 for 90 days) were 24 males and 26 females, mean age 6.6 years (SD=1.57), those belonging to group B (untreated) were 23 males and 27 females, average age 6.8 years (SD=1.72). In the follow-up, group A reported 26 inflammatory pharyngo-tonsillary episodes in the first trimester, unlike group B, who reported 72 in the second trimester. This has shown a lower incidence (3.38%) of the disease compared to group B (6.66%), for a total of 169 inflammatory pharyngo-tonsillary episodes in group A against 333 in group B. A reduction in days of school absence of 429 days in group A and 927 days in the control group (P<0.01) was also noted. Finally, 14 children of group A (28%) underwent adenotonsillectomy, against the whole group B. No adverse events were reported.

Conclusion: The efficacy of K12 on the prevention of pharyngo-tonsillar infections, the decrease in the use of antibiotics and the improvement of the overall quality-of-life was confirmed, with a decreased number of absences from school and fewer patients undergoing surgery.

Perioperative Desmopressin for Patients Undergoing Otolaryngologic Procedures: A Systematic Review

Objective

Desmopressin (DDAVP) is a hemostatic agent used to manage bleeding in patients with hemostatic disorders, and there is a lack of published data to guide its use during otolaryngology procedures. The objective of this study was to conduct an evidence-based systematic review of the reported uses, efficacy, and adverse effects of DDAVP in the otolaryngology surgical setting.

Data Sources

PubMed, MEDLINE, and EmBase were searched for articles on the use of DDAVP in otolaryngology.

Review Methods

The Methodological Index for Non-Randomized Studies criteria and Cochrane bias tool were used to assess study quality. Patient demographics, DDAVP dosing and route, and outcomes such as bleeding and adverse events were collected. A summary of evidence table was created specifying levels of evidence, benefits, and harm.

Results

Nineteen studies encompassing 440 patients were included. Sixteen studies discussed DDAVP for prophylaxis, and 3 discussed postoperative use. DDAVP effectively prevented bleeding in high-risk patients and successfully facilitated a dry surgical field when necessary. DDAVP had a 100% success rate when used symptomatically. Five studies described adverse effects, including hyponatremia (12.3%), nausea (2.0%), emesis (0.9%), and seizure (0.2%). The aggregate level of evidence for its use was Level B for adenotonsillectomy, septoplasty, and turbinate procedures and Level C for rhinoplasty.

Conclusion

Current literature supports the use of DDAVP in otolaryngology surgical procedures as both a perioperative prophylactic agent and a postoperative symptomatic intervention for bleeding. Both modalities are effective with minimal adverse events. Further well-designed randomized trials are necessary to conclusively formulate guidelines for DDAVP use in otolaryngology.

Paediatric Posttonsillectomy Haemorrhage Rates in Auckland: A Retrospective Case Series

Background

Tonsillectomy is one of the most commonly performed surgical procedures in children. It is performed for sleep-disordered breathing and infective symptoms. Despite advances in instrumentation and perioperative care, posttonsillectomy haemorrhage (PTH) remains a significant complication, which should be audited regularly.

Methods

A retrospective case series of all tonsillectomies performed in patients <15 years old in the Auckland region during 2017 was performed. Demographic, clinical, and surgical data were extracted and analysed. Univariate analysis was performed to compare patients with and without PTH.

Results

A total of 2177 tonsillectomies were performed during the study period, 64% in a public hospital and 36% in a private hospital. The overall PTH rate was 3.6% (0.23% occurring within the first 24 hours (primary) and 3.4% after 24 hours (secondary)). Mean time to PTH was 6.6 ± 3 days (range: 1-16 days). 90% of PTH occurred within the first 10 days and 99% by 14 days. Return to theatre was required in 28% of these cases, representing 1% of all tonsillectomies. There were no deaths or major complications in this cohort. The only differences observed between patients with PTH and those without were that children with PTH had smaller tonsils (p=0.004) and were less likely to have associated OME (p<0.001).

Conclusion

It is important to report institutional tonsillectomy outcomes and associated complications. These results show that PTH rates in Auckland remain within acceptable limits according to the literature.

Revisiting age-related admission following tonsillectomy in the pediatric population

OBJECTIVES/HYPOTHESIS

The objectives of this study were to examine patient outcomes using a 36-month age cutoff as a strict admission criterion following tonsillectomy, and review the safety and determine the plausibility of same-day discharge of children under 3 years old following tonsillectomy.

STUDY DESIGN

Retrospective chart review.

METHODS

A chart review of patients aged 24 to 42 months undergoing tonsillectomy over a 3-year period was conducted. Patients were stratified into <36 months and ≥ 36 months cohorts. Data collected included demographics, medical/sleep history, inpatient records, 30-day emergency department visits, and readmission data. Bivariate comparisons were made using χ² and Wilcoxon tests for categorical and continuous variables.

RESULTS

Between July 2014 and July 2017, 427 patients aged 24 to 42 months underwent tonsillectomy at our institution. Thirty-day emergency department visit, readmission, and greater-than-expected length of stay rates were 3.0% versus 3.7% (P = .75), 1.0 versus 1.8% (P = .61), and 4.7% versus 4.5% (P = 1.00) between the younger and older cohorts, respectively, with no difference in complication rates identified based on age.

CONCLUSIONS

No significant difference in adverse outcomes was appreciated based on a cutoff of 36 months of age at a tertiary center over 3 years. There should continue to be ongoing studies addressing strict age-related admission criteria.

LEVEL OF EVIDENCE

4 Laryngoscope, 129:E389-E394, 2019.