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Jacobson A, Mack D, Herrera G, Bowe SN, Highland KB, Patzkowski MS. Incidence of Surgically Managed Post-Tonsillectomy Hemorrhage Associated With NSAID Prescribing for Postoperative Pain Management. Mil Med 2024; 189:e1955-e1959. [PMID: 38758073 DOI: 10.1093/milmed/usae194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 12/28/2023] [Accepted: 04/03/2024] [Indexed: 05/18/2024] Open
Abstract
INTRODUCTION Tonsillectomy ranks high among the most common pediatric surgical procedures in the United States. Non-Steroidal Anti-Inflammatory Drugs (NSAIDs), such as ibuprofen, are routinely prescribed to manage post-tonsillectomy pain, but may carry the risk of hemorrhage. MATERIALS AND METHODS This retrospective, longitudinal, secondary-data analysis study compared the incidence of surgically managed post-tonsillectomy hemorrhage (sPTH) in pediatric patients prescribed ibuprofen at Brooke Army Medical Center (BAMC) after tonsillectomy compared to a similar cohort of pediatric patients at the Children's Hospital of Philadelphia (CHOP) not prescribed ibuprofen. Additional regression analysis examined predictors of sPTH at BAMC. RESULTS The odds of sPTH was lower in patients who were prescribed ibuprofen at BAMC, relative to patients who were not at CHOP (OR 0.57, 95% CI, 0.37, 0.87; P < 0.01). In a generalized linear model evaluating BAMC patient data, there was a lack of a relationship between reason for tonsillectomy (tonsillitis versus tonsillar obstruction), primary procedure (tonsillectomy-only versus tonsillectomy with adenoidectomy), and presence of a co-occurring procedure. CONCLUSIONS Post-tonsillectomy ibuprofen prescribing practices were not associated with an elevated risk of sPTH, relative to patients at CHOP not exposed to ibuprofen.
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Affiliation(s)
- Andrew Jacobson
- Department of Anesthesia, Brooke Army Medical Center, JBSA Fort Sam Houston, TX 78234-6200, USA
| | - Douglas Mack
- Department of Otolaryngology-Head and Neck Surgery, San Antonio Uniformed Services Health Education Consortium, JBSA Fort Sam Houston, TX 78234-6200, USA
| | - Germaine Herrera
- Department of Anesthesiology, Uniformed Services University, Bethesda, MD 20814, USA
- Henry M. Jackson Foundation, Inc., Rockville, MD 20852, USA
- Defense and Veterans Center for Integrative Pain Management, Bethesda, MD 20814, USA
| | - Sarah N Bowe
- Department of Otolaryngology-Head and Neck Surgery, San Antonio Uniformed Services Health Education Consortium, JBSA Fort Sam Houston, TX 78234-6200, USA
| | - Krista B Highland
- Department of Anesthesiology, Uniformed Services University, Bethesda, MD 20814, USA
| | - Michael S Patzkowski
- Department of Anesthesia, Brooke Army Medical Center, JBSA Fort Sam Houston, TX 78234-6200, USA
- Department of Anesthesiology, Uniformed Services University, Bethesda, MD 20814, USA
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So V, Radhakrishnan D, MacCormick J, Webster RJ, Tsampalieros A, Zitikyte G, Ripley A, Murto K. Does Celecoxib Prescription for Pain Management Affect Post-tonsillectomy Hemorrhage Requiring Surgery? A Retrospective Observational Cohort Study. Anesthesiology 2024; 141:313-325. [PMID: 38684054 DOI: 10.1097/aln.0000000000005032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2024]
Abstract
BACKGROUND Adenotonsillectomy and tonsillectomy (referred to as tonsillectomy hereafter) are common pediatric surgeries. Postoperative complications include hemorrhage requiring surgery (2 to 3% of cases) and pain. Although nonsteroidal anti-inflammatory drugs are commonly administered for postsurgical pain, controversy exists regarding bleeding risk with cyclooxygenase-1 inhibition and associated platelet dysfunction. Preliminary evidence suggests selective cyclooxygenase-2 inhibitors, for example celecoxib, effectively manage pain without adverse events including bleeding. Given the paucity of data for routine celecoxib use after tonsillectomy, this study was designed to investigate the association between postoperative celecoxib prescription and post-tonsillectomy hemorrhage requiring surgery using chart-review data from the Children's Hospital of Eastern Ontario. METHODS After ethics approval, a retrospective single-center observational cohort study was performed in children less than 18 yr of age undergoing tonsillectomy from January 2007 to December 2017. Cases of adenoidectomy alone were excluded due to low bleed rates. The primary outcome was the proportion of patients with post-tonsillectomy hemorrhage requiring surgery. The association between a celecoxib prescription and post-tonsillectomy hemorrhage requiring surgery was estimated using inverse probability of treatment weighting based on propensity scores and using generalized estimating equations to accommodate clustering by surgeon. RESULTS An initial patient cohort of 6,468 was identified, and 5,846 children with complete data were included in analyses. Median (interquartile range) age was 6.10 (4.40, 9.00) yr, and 46% were female. In the cohort, 28.1% (n = 1,644) were prescribed celecoxib. Among the 4,996 tonsillectomy patients, 1.7% (n = 86) experienced post-tonsillectomy hemorrhage requiring surgery. The proportion with post-tonsillectomy hemorrhage requiring surgery among patients who had a tonsillectomy and were or were not prescribed celecoxib was 1.94% (30 of 1,548; 95% CI, 1.36 to 2.75) and 1.62% (56 of 3,448; 95% CI, 1.25 to 2.10), respectively. Modeling did not identify an association between celecoxib prescription and increased odds of post-tonsillectomy hemorrhage requiring surgery (odds ratio = 1.4; 95% CI, 0.85 to 2.31; P = 0.20). CONCLUSIONS Celecoxib does not significantly increase the odds of post-tonsillectomy hemorrhage requiring surgery, after adjusting for covariates. This large pediatric cohort study of celecoxib administered after tonsillectomy provides compelling evidence for safety but requires confirmation with a multisite randomized controlled trial. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Vincent So
- Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Dhenuka Radhakrishnan
- Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada; Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Johnna MacCormick
- Department of Otolaryngology Head and Neck Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Richard J Webster
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Anne Tsampalieros
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Gabriele Zitikyte
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Allyson Ripley
- University of Western Ontario, Faculty of Medicine, London, Ontario, Canada
| | - Kimmo Murto
- Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, Ontario, Canada; Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
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Cottone C, Vijay A, Chalamgari A, Carr MM. Post-Tonsillectomy Bleeding and Analgesic Use Before and After the FDA Boxed Warning Against Codeine. Laryngoscope 2024. [PMID: 38822691 DOI: 10.1002/lary.31542] [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: 02/14/2024] [Revised: 05/05/2024] [Accepted: 05/08/2024] [Indexed: 06/03/2024]
Abstract
OBJECTIVE The aim of this study was to investigate the trends in post-tonsillectomy analgesic utility and incidence of post-tonsillectomy hemorrhage before and after the 2013 FDA Boxed Warning against codeine use after pediatric tonsillectomy. METHODS A retrospective study was conducted using TriNetX. A search for patients up to 18 years from 2008 to 2022 within the US Collaborative Network identified 15,648,542 subjects. CPT and ICD-10 codes were used to identify children who experienced post-tonsillectomy hemorrhage within 14 days of a tonsillectomy. Analgesics given within 14 days of tonsillectomy were tabulated annually from 2008 to 2022, including codeine, ibuprofen, acetaminophen, oxycodone, ketorolac, and hydrocodone. Bleeding percentage and analgesic utility were grouped into events before and after 2013. RESULTS Mean age at tonsillectomy was 5.6 years (SD = 3.0). Before 2013, the median percentage of children who experienced postoperative bleeding was 1.8% with 0.73% returning to the OR for bleeding control. After 2013, the median percentage of children who experienced postoperative bleeding was 2.4% (p = 0.029), and 0.99% returned to the OR (p = 0.008). Use of post-tonsillectomy codeine fell from 10.4% to 0.5% (p = 0.003) whereas ibuprofen rose from 2.0% to 63.9% (p = <0.001), acetaminophen from 42.8% to 77.2% (p = <0.001), ketorolac from 1.2% to 9.2% (p = <0.001), and oxycodone from 2.0% to 30.9% (p = <0.001). No change was detected in use of hydrocodone. CONCLUSION Analgesics used post-tonsillectomy in children have changed since the FDA Boxed Warning against codeine. There has been a small but statistically significant increase in post-tonsillectomy bleeding. LEVEL OF EVIDENCE IV Laryngoscope, 2024.
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Affiliation(s)
- Chloe Cottone
- Jacobs School of Medicine and Biomedical Sciences, The State University of New York at Buffalo, Buffalo, New York, U.S.A
| | - Arunima Vijay
- University of Florida College of Medicine, Gainesville, Florida, U.S.A
| | | | - Michele M Carr
- Department of Otolaryngology, Jacobs School of Medicine and Biomedical Sciences, The State University of New York at Buffalo, Buffalo, New York, U.S.A
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Ezeh UC, Kahn PJ, April MM. Management of Periodic Fever, Aphthous Stomatitis, Pharyngitis, Adenitis with Intracapsular Tonsillectomy. Laryngoscope 2024; 134:1967-1969. [PMID: 37597172 DOI: 10.1002/lary.30969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 07/24/2023] [Accepted: 07/31/2023] [Indexed: 08/21/2023]
Abstract
OBJECTIVE This study aimed to present 2 children clinically diagnosed with periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA) syndrome and treated with intracapsular tonsillectomy with adenoidectomy (ITA). METHODS We conducted a retrospective analysis of 2 children who were referred for an otolaryngology consultation between 2019 and 2022 for surgical treatment of PFAPA syndrome. Both patients had symptoms strongly suggestive of PFAPA and were at risk for total tonsillectomy (TT) complications. ITA was performed using a microdebrider. Both patients were followed up postoperatively to assess for symptomatic resolution and complications. RESULTS Two children exhibited recurrent febrile episodes prior to ITA. The procedure was efficacious in both patients, with neither experiencing postoperative complications or recurring PFAPA symptoms for over 1 year after surgery. CONCLUSION Our study reported on the use of ITA as a surgical treatment option for PFAPA. We showed that ITA eliminated febrile attacks and was safely performed without postoperative complications in 2 pediatric patients after 1-year follow-up. Future studies involving larger cohorts of PFAPA patients and lengthier follow-ups will need to be conducted to further evaluate ITA as a surgical option. Laryngoscope, 134:1967-1969, 2024.
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Affiliation(s)
- Uche C Ezeh
- Division of Pediatric Otolaryngology, Department of Otolaryngology-Head and Neck Surgery, New York University School of Medicine, New York, New York, U.S.A
| | - Philip J Kahn
- Department of Pediatrics, Hassenfeld Children's Hospital at NYU Langone Medical Center, New York, New York, U.S.A
| | - Max M April
- Division of Pediatric Otolaryngology, Department of Otolaryngology-Head and Neck Surgery, New York University School of Medicine, New York, New York, U.S.A
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Liu Z, Cheng S, Wang C, Liu X, Huang H, Zhu Y, Zhou B, Wu H, Cao M. Preoperative flurbiprofen diminishes the rate of reoperation after free flap reconstruction: A retrospective study. J Craniomaxillofac Surg 2023; 51:560-567. [PMID: 37620245 DOI: 10.1016/j.jcms.2023.08.014] [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: 03/31/2022] [Revised: 01/09/2023] [Accepted: 08/14/2023] [Indexed: 08/26/2023] Open
Abstract
This study aimed to evaluate the association between preoperative flurbiprofen, a non-selective COX inhibitor, and reoperation for flap crisis after free flap reconstruction. In this retrospective study, patients who underwent head and neck surgery with free flap reconstructions were collected. To identify risk factors for reoperation from demographic features and perioperative variables, univariate and multivariate logistic analyses were conducted. After propensity score matching (PSM), univariate and adjusted multivariate analyses were employed to explore the impact of preoperative flurbiprofen on reoperation after free flap reconstruction. This study comprised 437 patients, 33 of whom underwent reoperations for flap crisis. After multivariate analysis, radiotherapy history (P = 0.005; odds ratio [OR] = 0.225; 95% CI, 0.080-0.636) and preoperative flurbiprofen (P = 0.038; OR = 5.059; 95% CI, 1.094-23.386) were identified as independent factors for reoperation. PSM was achieved, and preoperative flurbiprofen was found to diminish the reoperation rate (P = 0.046; OR = 4.765; 95% CI, 1.029-22.202) without increasing bleeding complications. Within the limitations of the study, flurbiprofen should be administered preoperatively to reduce the rate of reoperations for flap crisis whenever appropriate.
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Affiliation(s)
- Zhongqi Liu
- Department of Anesthesiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Shi Cheng
- Department of Anesthesiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Chengli Wang
- Department of Anesthesiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xiaoqing Liu
- Department of Anesthesiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Haoquan Huang
- Department of Anesthesiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yingying Zhu
- Clinical Research Center, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Bin Zhou
- Department of Oral and Maxillofacial Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Haixuan Wu
- Department of Anesthesiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Minghui Cao
- Department of Anesthesiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China.
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Johnson RF, Beams DR, Zaniletti I, Chorney SR, Kou YF, Lenes-Voit F, Ulualp S, Liu C, Mitchell RB. Estimated Probability Distribution of Bleeding After Pediatric Tonsillectomy: A Retrospective National Cohort Study of US Children. JAMA Otolaryngol Head Neck Surg 2023; 149:431-438. [PMID: 36995688 PMCID: PMC10064285 DOI: 10.1001/jamaoto.2023.0268] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Accepted: 02/06/2023] [Indexed: 03/31/2023]
Abstract
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.
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Affiliation(s)
- Romaine F. Johnson
- Department of Otolaryngology–Head and Neck Surgery, University of Texas Southwestern Medical Center at Dallas
- Department of Pediatric Otolaryngology, Children’s Medical Center, Dallas, Texas
| | - Dylan R. Beams
- Department of Otolaryngology–Head and Neck Surgery, University of Texas Southwestern Medical Center at Dallas
| | | | - Stephen R. Chorney
- Department of Otolaryngology–Head and Neck Surgery, University of Texas Southwestern Medical Center at Dallas
- Department of Pediatric Otolaryngology, Children’s Medical Center, Dallas, Texas
| | - Yann-Fuu Kou
- Department of Otolaryngology–Head and Neck Surgery, University of Texas Southwestern Medical Center at Dallas
- Department of Pediatric Otolaryngology, Children’s Medical Center, Dallas, Texas
| | - Felicity Lenes-Voit
- Department of Otolaryngology–Head and Neck Surgery, University of Texas Southwestern Medical Center at Dallas
- Department of Pediatric Otolaryngology, Children’s Medical Center, Dallas, Texas
| | - Seckin Ulualp
- Department of Otolaryngology–Head and Neck Surgery, University of Texas Southwestern Medical Center at Dallas
- Department of Pediatric Otolaryngology, Children’s Medical Center, Dallas, Texas
| | - Christopher Liu
- Department of Otolaryngology–Head and Neck Surgery, University of Texas Southwestern Medical Center at Dallas
- Department of Pediatric Otolaryngology, Children’s Medical Center, Dallas, Texas
| | - Ron B. Mitchell
- Department of Otolaryngology–Head and Neck Surgery, University of Texas Southwestern Medical Center at Dallas
- Department of Pediatric Otolaryngology, Children’s Medical Center, Dallas, Texas
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Shih MC, Long BD, Pecha PP, White DR, Liu YC, Brennan E, Nguyen MI, Clemmens CS. A scoping review of randomized clinical trials for pain management in pediatric tonsillectomy and adenotonsillectomy. World J Otorhinolaryngol Head Neck Surg 2023; 9:9-26. [PMID: 37006744 PMCID: PMC10050970 DOI: 10.1002/wjo2.54] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Accepted: 12/23/2021] [Indexed: 12/15/2022] Open
Abstract
Objectives To examine the volume, topics, and reporting trends in the published literature of randomized clinical trials for pharmacologic pain management of pediatric tonsillectomy and adenotonsillectomy and to identify areas requiring further research. Data Sources PubMed (National Library of Medicine and National Institutes of Health), Scopus (Elsevier), CINAHL (EBSCO), and Cochrane Library (Wiley). Methods A systematic search of four databases was conducted. Only randomized controlled or comparison trials examining pain improvement with a pharmacologic intervention in pediatric tonsillectomy or adenotonsillectomy were included. Data collected included demographics, pain-related outcomes, sedation scores, nausea/vomiting, postoperative bleeding, types of drug comparisons, modes of administration, timing of administration, and identities of the investigated drugs. Results One hundred and eighty-nine studies were included for analysis. Most studies included validated pain scales, with the majority using visual-assisted scales (49.21%). Fewer studies examined pain beyond 24 h postoperation (24.87%), and few studies included a validated sedation scale (12.17%). Studies have compared several different dimensions of pharmacologic treatment, including different drugs, timing of administration, modes of administration, and dosages. Only 23 (12.17%) studies examined medications administered postoperatively, and only 29 (15.34%) studies examined oral medications. Acetaminophen only had four self-comparisons. Conclusion Our work provides the first scoping review of pain and pediatric tonsillectomy. With drug safety profiles considered, the literature does not have enough data to determine which treatment regimen provides superior pain control in pediatric tonsillectomy. Even common drugs like acetaminophen and ibuprofen require further research for optimizing the treatment of posttonsillectomy pain. The heterogeneity in study design and comparisons weakens the conclusions of potential systematic reviews and meta-analyses. Future directions include more noninferiority studies of unique comparisons and more studies examining oral medications given postoperatively.
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Affiliation(s)
- Michael C. Shih
- Department of Otolaryngology—Head and Neck SurgeryMedical University of South CarolinaCharlestonSouth CarolinaUSA
- Baylor College of MedicineHoustonTexasUSA
| | - Barry D. Long
- Department of Otolaryngology—Head and Neck SurgeryMedical University of South CarolinaCharlestonSouth CarolinaUSA
- Department of Otolaryngology—Head and Neck SurgeryVirginia Commonwealth University School of MedicineRichmondVirginiaUSA
| | - Phayvanh P. Pecha
- Department of Otolaryngology—Head and Neck SurgeryMedical University of South CarolinaCharlestonSouth CarolinaUSA
| | - David R. White
- Department of Otolaryngology—Head and Neck SurgeryMedical University of South CarolinaCharlestonSouth CarolinaUSA
| | - Yi‐Chun C. Liu
- Department of Otolaryngology—Head and Neck SurgeryBaylor College of MedicineHoustonTexasUSA
- Department of Surgery ‐ Division of Pediatric OtolaryngologyTexas Children's HospitalHoustonTexasUSA
| | - Emily Brennan
- Department of Research and Education ServicesMedical University of South Carolina LibraryCharlestonSouth CarolinaUSA
| | - Mariam I. Nguyen
- Charleston County School of the ArtsNorth CharlestonSouth CarolinaUSA
| | - Clarice S. Clemmens
- Department of Otolaryngology—Head and Neck SurgeryMedical University of South CarolinaCharlestonSouth CarolinaUSA
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Johnson RF, Zhang J, Chorney SR, Kou YF, Lenes-Voit F, Ulualp S, Liu C, Mitchell RB. Estimations of Inpatient and Ambulatory Pediatric Tonsillectomy in the United States: A Cross-sectional Analysis. Otolaryngol Head Neck Surg 2023. [PMID: 36939461 DOI: 10.1002/ohn.268] [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: 08/22/2022] [Revised: 12/26/2022] [Accepted: 12/29/2022] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To estimate the incidence of inpatient and ambulatory pediatric tonsillectomies in the United States in 2019. STUDY DESIGN Cross-sectional analysis. SETTING Healthcare Cost and Utilization Project databases. METHODS We determined national incidences of hospital-based ambulatory procedures, inpatient admissions, and readmissions among pediatric tonsillectomy patients, ages 0 to 20 years, using the Kids Inpatient Database, Nationwide Ambulatory Surgery Sample, and Nationwide Readmission Database. We described the demographics, commonly associated conditions, complications, and predictors of readmission. RESULTS An estimated 559,900 ambulatory and 7100 inpatient tonsillectomies were performed in 2019. Among inpatients, the majority were male (59%) and the largest ethnic group was white (37%). Adenotonsillar hypertrophy (ATH), 79%, and obstructive sleep apnea (OSA), 74%, were the most frequent diagnosis and Medicaid (61%) was the most frequent primary payer. The majority of ambulatory tonsillectomy patients were female (52%) and white (65%); ATH, OSA, and Medicaid accounted for 62%, 29%, and 45% of cases, respectively, (all p < .001 when compared to inpatient cases). Common inpatient complications were bleeding (2%), pain/nausea/vomiting (5.6%), and postprocedural respiratory failure (1.7%). On the other hand, ambulatory complications occurred in less than 1% of patients. The readmission rate was 5.2%, with pain/nausea/vomiting and bleeding accounting for 35% and 23% of overall readmissions. All Patient Refined Diagnosis Related Groups severity of illness subclass predicted readmission (odds ratio = 2.18, 95% confidence interval = 1.73-2.73, p < .001). CONCLUSION A total of 567,000 pediatric ambulatory and inpatient tonsillectomies were performed in 2019; the majority were performed in ambulatory settings. The index admission severity of illness was associated with readmission risk.
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Affiliation(s)
- Romaine F Johnson
- Department of Otolaryngology-Head and Neck Surgery, UT Southwestern Medical Center at Dallas, Dallas, Texas, USA.,Department of Pediatric Otolaryngology-Head and Neck Surgery, Children's Health, Dallas, Texas, USA
| | - Jinghan Zhang
- Department of Otolaryngology-Head and Neck Surgery, UT Southwestern Medical Center at Dallas, Dallas, Texas, USA
| | - Stephen R Chorney
- Department of Otolaryngology-Head and Neck Surgery, UT Southwestern Medical Center at Dallas, Dallas, Texas, USA.,Department of Pediatric Otolaryngology-Head and Neck Surgery, Children's Health, Dallas, Texas, USA
| | - Yann-Fuu Kou
- Department of Otolaryngology-Head and Neck Surgery, UT Southwestern Medical Center at Dallas, Dallas, Texas, USA.,Department of Pediatric Otolaryngology-Head and Neck Surgery, Children's Health, Dallas, Texas, USA
| | - Felicity Lenes-Voit
- Department of Otolaryngology-Head and Neck Surgery, UT Southwestern Medical Center at Dallas, Dallas, Texas, USA.,Department of Pediatric Otolaryngology-Head and Neck Surgery, Children's Health, Dallas, Texas, USA
| | - Seckin Ulualp
- Department of Otolaryngology-Head and Neck Surgery, UT Southwestern Medical Center at Dallas, Dallas, Texas, USA.,Department of Pediatric Otolaryngology-Head and Neck Surgery, Children's Health, Dallas, Texas, USA
| | - Christopher Liu
- Department of Otolaryngology-Head and Neck Surgery, UT Southwestern Medical Center at Dallas, Dallas, Texas, USA.,Department of Pediatric Otolaryngology-Head and Neck Surgery, Children's Health, Dallas, Texas, USA
| | - Ron B Mitchell
- Department of Otolaryngology-Head and Neck Surgery, UT Southwestern Medical Center at Dallas, Dallas, Texas, USA.,Department of Pediatric Otolaryngology-Head and Neck Surgery, Children's Health, Dallas, Texas, USA
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Giordano T, Durkin A, Simi A, Shannon M, Dailey J, Facey H, Ballester L, Wetmore RF, Germiller JA. High-Dose Celecoxib for Pain After Pediatric Tonsillectomy: A Randomized Controlled Trial. Otolaryngol Head Neck Surg 2023; 168:218-226. [PMID: 35412873 DOI: 10.1177/01945998221091695] [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: 12/01/2021] [Accepted: 03/12/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Pediatric tonsillectomy causes significant postoperative pain. Newer nonsteroidal anti-inflammatory drugs such as celecoxib control pain without increasing bleeding risk, but in prior studies provided only modest pain reduction at standard doses. We aimed to determine if high-dose celecoxib (double the usual pediatric dose) is effective for pain, without increasing bleeding or other risks. STUDY DESIGN Randomized double-blind trial. SETTING Pediatric tertiary center. METHODS Children aged 3 to 11 years undergoing total tonsillectomy were randomized to receive celecoxib (6 mg/kg/dose) or placebo, twice daily, for up to 10 days. All cases were supplemented with acetaminophen and oxycodone as needed. All participants and personnel were blinded to treatment group. Subjects recorded coanalgesic consumption, pain, diet, and activity. RESULTS The celecoxib group (n = 68) consumed 0.72 mg/kg of oxycodone, as compared with 1.12 mg/kg in the placebo group (n = 62), a 36% difference that was not significant. However, multivariate analysis by treatment group, separate from pain levels, confirmed that this reduction was due to celecoxib treatment (P = .03). In subjects with more prolonged pain (n = 88), celecoxib reduced consumption by 52% (P = .02). Celecoxib showed greater benefit for subjects in the prolonged pain group than for those in the lesser pain group (P = .006). Incidence of adverse events was similar between groups. Minor hemorrhage occurred in 4.6% (5 placebo, 3 celecoxib). CONCLUSION High-dose celecoxib is effective in controlling pain after tonsillectomy, with no adverse effects in this relatively small sample. It reduces narcotic consumption, and its impact appears greater in children with higher degrees of pain. Celecoxib can be considered an effective alternative to ibuprofen after tonsillectomy. This trial was registered at ClinicalTrials.gov: NCT02934191.
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Affiliation(s)
- Teresa Giordano
- Division of Pediatric Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Alexandra Durkin
- Division of Pediatric Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Andrea Simi
- Division of Pediatric Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Megan Shannon
- Division of Pediatric Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Julia Dailey
- Division of Pediatric Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Hannah Facey
- Division of Pediatric Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Lance Ballester
- Biostatistics and Data Management Core, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Ralph F Wetmore
- Division of Pediatric Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Otorhinolaryngology-Head and Neck Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - John A Germiller
- Division of Pediatric Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Otorhinolaryngology-Head and Neck Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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10
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Characterization of litigation after tonsillectomy in the United States. Am J Otolaryngol 2022; 43:103566. [DOI: 10.1016/j.amjoto.2022.103566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 07/18/2022] [Accepted: 07/31/2022] [Indexed: 11/20/2022]
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11
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The Effect of Pre-Emptive Analgesia on the Postoperative Pain in Pediatric Otolaryngology: A Randomized, Controlled Trial. J Clin Med 2022; 11:jcm11102713. [PMID: 35628840 PMCID: PMC9146866 DOI: 10.3390/jcm11102713] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 05/04/2022] [Accepted: 05/09/2022] [Indexed: 02/06/2023] Open
Abstract
The aim of this randomized, controlled trial was to determine whether children undergoing otolaryngological procedures (adenoidectomy, adenotonsillotomy, or tonsillectomy) benefit from pre-emptive analgesia in the postoperative period. Methods: Fifty-five children were assessed for eligibility for the research. Four children refused to participate during the first stage of the study, leaving fifty-one (n = 51) to be randomly assigned either to receive pre-emptive analgesic acetaminophen (15 mg/kg; n = 26) or a placebo (n = 25) in addition to midazolam (0.5 mg/kg) as premedication. All children were anesthetized with sevoflurane, propofol (2−4 mg/kg), and fentanyl (2 mcg/kg). Postoperative pain was assessed using the Visual Analogue Scale (VAS), the Wong−Baker Faces Pain Rating Scale, and the Face, Legs, Activity, Cry, and Consolability (FLACC) scale. The postoperative pain was measured 1, 2, 4, and 6 h after the surgery. Results: The clinical trial reported a statistically significant correlation between administering pre-emptive analgesia (acetaminophen) and reducing pain in children after otolaryngological procedures compared to placebo. The ratio of boys to girls and age were similar among the groups (p > 0.05), so the groups of children were not divided by gender or age. Conclusions: Standard pre-emptive analgesia reduced the severity of pain in the postoperative period after otolaryngological procedures in children. Acetaminophen given before surgery reduces postoperative pain in children undergoing otolaryngological procedures.
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12
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McLean JE, Hill CJ, Riddick JB, Folsom CR. Investigation of Adult Post-Tonsillectomy Hemorrhage Rates and the Impact of NSAID Use. Laryngoscope 2022; 132:949-953. [PMID: 34473351 DOI: 10.1002/lary.29844] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 08/14/2021] [Accepted: 08/20/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVES/HYPOTHESIS Tonsillectomy is one of the most common ambulatory surgeries performed in the United States, yet the incidence of post-tonsillectomy hemorrhage (PTH) in adults remains unclear. In addition, any association between non-steroidal anti-inflammatory drugs (NSAIDs) and PTH in adults is currently unknown. The aim of this study is to examine the incidence and management of adult PTH at a single academic center and to assess for any association between NSAID use and PTH in adults. STUDY DESIGN Retrospective chart review. METHODS We conducted a retrospective chart review of adult tonsillectomies performed at our institution between January 1, 2012, and December 30, 2019. Demographics, past medical history, medications, NSAID use, surgical indication, bleeding events, and interventions were documented. The rate of PTH was calculated, logistic regression was performed to assess for any predictive factors, and odds ratios were calculated for NSAID use and PTH. RESULTS A total of 1,057 adult tonsillectomies were performed within the aforementioned time period. A total of 126 patients experienced 163 bleeding events for a postoperative hemorrhage rate of 11.9%. Most were controlled with bedside interventions, while 29 (23%) bled more than once. The hemorrhage rate for those who were not prescribed NSAIDs postoperatively (n = 625) was 11.7%, compared to 12.6% for those who did receive NSAIDs postoperatively (n = 432), which was not significantly different (adjusted odds ratio 1.01, 95% confidence interval 0.69-1.49; P = .95). CONCLUSIONS This retrospective cohort study of 1,057 adult patients found the incidence of PTH to be 11.9%. This study found no association between the use of NSAIDs and the rate of PTH, although a higher-powered study is needed. LEVEL OF EVIDENCE 3 Laryngoscope, 132:949-953, 2022.
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Affiliation(s)
- James E McLean
- Department of Otolaryngology - Head and Neck Surgery, Naval Medical Center Portsmouth, Portsmouth, Virginia, U.S.A
| | - Christopher J Hill
- Department of Otolaryngology - Head and Neck Surgery, Naval Medical Center Portsmouth, Portsmouth, Virginia, U.S.A
| | - Jeanelle B Riddick
- Clinical Investigations Department, Naval Medical Center Portsmouth, Portsmouth, Virginia, U.S.A
| | - Craig R Folsom
- Department of Otolaryngology - Head and Neck Surgery, Naval Medical Center Portsmouth, Portsmouth, Virginia, U.S.A
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13
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Esce AR, Meiklejohn DA. Ibuprofen prescription following adult tonsillectomy reduces postoperative opioid use. Am J Otolaryngol 2022; 43:103436. [PMID: 35429845 DOI: 10.1016/j.amjoto.2022.103436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 04/02/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Based on a 2018 American Academy of Otolaryngology - Head and Neck Surgery survey, an average of 37 tablets of opioid medication, or about a week's worth of medication, were prescribed after adult tonsillectomy. Nearly 15% of patients will still be taking opioids one year after an initial weeklong prescription, according to data from the Centers for Disease Control and Prevention. Non-steroidal anti-inflammatory medications have traditionally been avoided in adult tonsillectomy patients due to concern for increased bleeding risk from platelet dysfunction, despite little evidence supporting this claim. This study sought to demonstrate that ibuprofen prescriptions after tonsillectomy could be a safe and effective way to reduce postoperative opioid use. METHODS This study was a retrospective chart review of patients undergoing tonsillectomy with one surgeon over three years. Half of the patients received a prescription for postoperative opioid medications and were counseled against taking ibuprofen. The other half of patients were prescribed ibuprofen following surgery and only provided with opioid analgesia as a rescue medication. The New Mexico Prescription Monitoring System was used to verify opioid prescriptions. Descriptive statistics and logistic regression were used to analyze the data. RESULTS Ninety-nine patients were included in analysis, with 53 in the first group that did not receive ibuprofen and 46 in the second group that did receive ibuprofen. There was no difference in the bleeding rate between the two groups. Significantly fewer patients in the ibuprofen group filled postoperative opioid prescriptions when compared to the group that did not receive ibuprofen (40% vs. 96.2%, p < 0.0001, OR = 0.02). CONCLUSION Ibuprofen is a safe and effective analgesic following adult tonsillectomy and significantly reduces the proportion of patients who must fill a postoperative opioid prescription.
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Affiliation(s)
- Antoinette R Esce
- Department of Surgery, Division of Otolaryngology Head and Neck Surgery, MSC10 5610, University of New Mexico, Albuquerque, NM 87131, United States of America.
| | - Duncan A Meiklejohn
- Department of Surgery, Division of Otolaryngology Head and Neck Surgery, MSC10 5610, University of New Mexico, Albuquerque, NM 87131, United States of America
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14
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Lee AC, Haché M. Pediatric Anesthesia Management for Post-Tonsillectomy Bleed: Current Status and Future Directions. Int J Gen Med 2022; 15:63-69. [PMID: 35027837 PMCID: PMC8749229 DOI: 10.2147/ijgm.s312866] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 12/20/2021] [Indexed: 11/23/2022] Open
Abstract
After medical stabilization, several techniques are considered for anesthesia in the surgical intervention of post-tonsillectomy bleeding in children. Hypoxia during induction of general anesthesia occurs more frequently than aspiration for this population. While classical (apneic) rapid sequence induction and intubation with cricoid pressure still has a role, controlled rapid sequence induction and intubation that incorporates mask ventilation at low pressure (<12 cm H2O) before direct laryngoscopy under a deep plane of anesthesia is a viable alternative for cases of slow venous bleeding. Supplemental oxygen delivery during laryngoscopy to permit apneic oxygenation is a future trend in management. While the routine administration of tranexamic acid during tonsillectomy has not been shown to be of benefit, it may have a role in post-tonsillectomy hemorrhage with further study.
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Affiliation(s)
- Angela C Lee
- Division of Anesthesiology, Pain and Perioperative Medicine, Children's National Hospital, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Manon Haché
- Division of Pediatric Anesthesia, Department of Anesthesiology, Columbia University Irving Medical Center, New York, NY, USA
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15
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Huang F, Wang M, Chen H, Cheng N, Wang Y, Wu D, Zhou S. Analgesia and patient comfort after enhanced recovery after surgery in uvulopalatopharyngoplasty: a randomised controlled pilot study. BMC Anesthesiol 2021; 21:237. [PMID: 34600487 PMCID: PMC8487110 DOI: 10.1186/s12871-021-01458-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 09/28/2021] [Indexed: 12/20/2022] Open
Abstract
Background Uvulopalatopharyngoplasty(UPPP) is the most prevalent surgical treatment of obstructive sleep apnea, but postoperative pharyngeal pain may affect patient comfort. The enhanced recovery after surgery pathway has been proved beneficial to many types of surgery but not to UPPP yet. The aim of this pilot study was to preliminarily standrize an enhanced recovery after surgery protocol for UPPP, to assess whether it has positive effects on reducing postoperative pharyngeal pain and improving patient comfort, and to test its feasibility for an international multicentre study. Methods This randomised controlled study analysed 116 patients with obstructive sleep apnoea (OSA) who were undergoing UPPP in a single tertiary care hospital. They were randomly divided according to treatment: the ERAS group (those who received ERAS treatment) and the control group (those who received traditional treatment). Ninety-five patients completed the assessment (ERAS group, 59 patients; control group, 36 patients). Pharyngeal pain and patient comfort were evaluated using a visual analogue scale (VAS) at 30 min and at 6, 12, 24 and 48 h after UPPP. Complications, hospitalisation duration, and hospital cost were recorded. Results The VAS scores for resting pain and swallowing pain were significantly lower in the ERAS group than those in the control group at 30 min and at 6, 12, 24 and 48 h after surgery. Patient comfort was improved in the ERAS group. The hospitalisation duration and cost were comparable between the groups. The incidence of complications showed an increasing trend in the ERAS group. Conclusion The ERAS protocol significantly relieved pharyngeal pain after UPPP and improved comfort in patients with OSA, which showed the prospect for an larger study. Meanwhile a potential increase of post-operative complications in the ERAS group should be noticed. Trial registration Chinese Clinical Trial Registry (23/09/2018, ChiCTR1800018537)
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Affiliation(s)
- Fei Huang
- Department of Anesthesiology, The Third Affiliated Hospital of Sun Yat-sen University, No. 600 Tianhe Road, Guangzhou, 510630, Guangdong Province, China
| | - Minxue Wang
- Department of Anesthesiology, The Third Affiliated Hospital of Sun Yat-sen University, No. 600 Tianhe Road, Guangzhou, 510630, Guangdong Province, China
| | - Huixin Chen
- Department of Anesthesiology, The Third Affiliated Hospital of Sun Yat-sen University, No. 600 Tianhe Road, Guangzhou, 510630, Guangdong Province, China
| | - Nan Cheng
- Department of Anesthesiology, The Third Affiliated Hospital of Sun Yat-sen University, No. 600 Tianhe Road, Guangzhou, 510630, Guangdong Province, China
| | - Yanling Wang
- Department of Anesthesiology, The Third Affiliated Hospital of Sun Yat-sen University, No. 600 Tianhe Road, Guangzhou, 510630, Guangdong Province, China
| | - Di Wu
- Department of Anesthesiology, The Third Affiliated Hospital of Sun Yat-sen University, No. 600 Tianhe Road, Guangzhou, 510630, Guangdong Province, China
| | - Shaoli Zhou
- Department of Anesthesiology, The Third Affiliated Hospital of Sun Yat-sen University, No. 600 Tianhe Road, Guangzhou, 510630, Guangdong Province, China.
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16
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Losorelli SD, Scheffler P, Qian ZJ, Lin HFC, Truong MT. Post-Tonsillectomy Ibuprofen: Is There a Dose-Dependent Bleeding Risk? Laryngoscope 2021; 132:1473-1481. [PMID: 34559405 DOI: 10.1002/lary.29876] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 08/25/2021] [Accepted: 09/13/2021] [Indexed: 12/31/2022]
Abstract
OBJECTIVES/HYPOTHESIS Post-tonsillectomy hemorrhage (PTH) is a potentially life-threatening complication. A recent meta-analysis suggests that ibuprofen may increase the risk of PTH. The aims of this study were to 1) re-evaluate the effect of ibuprofen on PTH given additional recent evidence and 2) to evaluate a potential dose effect of ibuprofen. STUDY DESIGN Meta-analysis and meta-regression; single-institution retrospective review. METHODS We conducted a systematic review of the literature and a meta-analysis of 12 studies comparing postoperative ibuprofen analgesia to non-nonsteroidal anti-inflammatory drug (NSAID) controls. Next, we performed a meta-regression analysis to assess for an effect of dose, if any, on rates of PTH. Five studies specifying a dose of 5 mg/kg (828 patients, 1,411 controls) and 7 studies using 10 mg/kg (5,633 patients, 7,656 controls) were included. We then conducted a novel single-institution, retrospective review of data for 1,046 patients prescribed intermediate-dose 7.5 mg/kg ibuprofen. RESULTS Ibuprofen was not associated with an increased rate of PTH (log odds ratio [OR], 0.21; 95% confidence interval [CI] -0.15, 0.57). Meta-regression showed that ibuprofen dose (5 and 10 mg/kg) did not have a statistically significant effect on PTH (OR, 1.32; 95% CI 0.30, 5.84). Uncontrolled, aggregate rates of PTH across all studies were 2.29% (N = 828) for 5 mg/kg and 4.65% (N = 5,633) for 10 mg/kg dosing. The rate of secondary hemorrhage in patients prescribed 7.5 mg/kg ibuprofen was 3.10% (N = 1,046). CONCLUSION We found no statistically significant increased risk of PTH when ibuprofen is prescribed at the low or high range of commonly used clinical dosages, compared to a non-ibuprofen regimen. Further studies with less heterogeneity are needed to determine if there is a clinically relevant dose-dependent difference in PTH with ibuprofen. LEVEL OF EVIDENCE 3 Laryngoscope, 2021.
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Affiliation(s)
- Steven D Losorelli
- Department of Otolaryngology-Head & Neck Surgery, Stanford University School of Medicine, Stanford, California, U.S.A
| | - Patrick Scheffler
- Department of Pediatric Otolaryngology, Phoenix Children's Hospital, Phoenix, Arizona, U.S.A
| | - Z J Qian
- Department of Otolaryngology-Head & Neck Surgery, Stanford University School of Medicine, Stanford, California, U.S.A
| | - Hung-Fu C Lin
- Department of Otolaryngology-Head & Neck Surgery, Stanford University School of Medicine, Stanford, California, U.S.A
| | - Mai Thy Truong
- Department of Otolaryngology-Head & Neck Surgery, Stanford University School of Medicine, Stanford, California, U.S.A
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17
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Kuo CC, DeGiovanni JC, Carr MM. The efficacy of Tranexamic Acid Administration in Patients Undergoing Tonsillectomy: An Updated Meta-Analysis. Ann Otol Rhinol Laryngol 2021; 131:834-843. [PMID: 34515540 DOI: 10.1177/00034894211045264] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE There is controversy regarding the efficacy and safety of tranexamic acid (TXA) in reducing tonsillectomy-related hemorrhage. We conducted a systematic review and meta-analysis to evaluate the prophylactic role of TXA in tonsillectomy. METHODS We searched 6 databases to identify studies that directly compare the effect of TXA versus controls in tonsillectomy patients. Standardized mean difference was applied to summate the findings across the studies. Dichotomous data were expressed as relative risk. RESULTS Ten studies representing a total of 111 898 patients were included. The pooled results showed a significant reduction of intraoperative blood loss by 39.02 ml (SMD = -1.05, 95% CI: -1.91 to -0.20, P = .016) and the rate of post-tonsillectomy hemorrhage (RR = 0.42, 95% CI: 0.28 to 0.65, P < .0001), with no significant difference in reduction of further intervention risk (RR = 0.78, 95% CI: 0.45 to 1.35, P = .373). CONCLUSIONS Overall, this study indicates that TXA may reduce blood loss and frequency of post-operative hemorrhage associated with tonsillectomy. Further large, high-quality clinical trials are still needed to explore TXA's effect on post-tonsillectomy hemorrhage and the safety of its use.
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Affiliation(s)
- Cathleen C Kuo
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Jason C DeGiovanni
- Department of Otolaryngology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Michele M Carr
- Department of Otolaryngology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
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18
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Kolb CM, Jain N, Schillinger K, Born K, Banker K, Aaronson NL, Nardone HC. Does perioperative ketorolac increase bleeding risk after intracapsular tonsillectomy? Int J Pediatr Otorhinolaryngol 2021; 147:110781. [PMID: 34052574 DOI: 10.1016/j.ijporl.2021.110781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 04/29/2021] [Accepted: 05/17/2021] [Indexed: 10/21/2022]
Abstract
IMPORTANCE Conflicting evidence exists regarding the post-tonsillectomy bleed risk associated with perioperative ketorolac use in the pediatric population. Surgical technique for tonsillectomy can further confound this risk. OBJECTIVE The primary objective was to retrospectively quantify the post-tonsillectomy bleed rate after single-dose administration of ketorolac in pediatric patients following intracapsular tonsillectomy. The secondary objective was to determine if age, sex, body mass index, medical comorbidities, and indication for surgery increased post-tonsillectomy bleed risk. DESIGN Retrospective cohort study of 1920 children who underwent intracapsular tonsillectomies between January 2017 and December 2018. SETTING This study was completed at a tertiary-care pediatric referral center. PARTICIPANTS 1920 children who underwent intracapsular tonsillectomies between January 2017 and December 2018 at a single tertiary-care children's hospital. EXPOSURES Patients were divided into two cohorts: 1458 patients (75.9%) received ketorolac (K+), and 462 (24.1%) did not (NK). Age, sex, body mass index, comorbidities, and indication for surgery also were evaluated for association with post-tonsillectomy bleed risk. MAIN OUTCOME(S) AND MEASURE(S) Primary study outcome for both cohorts was post-tonsillectomy hemorrhage requiring operative intervention. RESULTS 1920 study participants were included with an average age of 6.5 years; 51.5% of participants were males; and, 63.9% were white. Overall, the postoperative bleeding rate was 1.5%. However, there was no significant difference when comparing bleeding rates for the ketorolac group and the non-keterolac group (1.4%-1.7%; P = .82) Age, chronic tonsillitis, higher body mass index Z-scores, attention-deficit/hyperactivity disorder, and behavioral diagnoses were statistically significant risk factors for post-tonsillectomy hemorrhage. CONCLUSIONS AND RELEVANCE Single-dose postoperative ketorolac does not appear to be associated with increased risk of post-tonsillectomy bleed in pediatric patients undergoing intracapsular tonsillectomy. Providers should not avoid using ketorolac in patients undergoing intracapsular tonsillectomy due to concerns over bleeding risk.
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Affiliation(s)
- Caroline M Kolb
- Division of Pediatric Otolaryngology, Nemours/Alfred I. DuPont Hospital for Children, 1600 Rockland Road, Wilmington, DE, 19803, USA; Department of Otolaryngology - Head and Neck Surgery, Tripler Army Medical Center, 1 Jarrett White Road, Honolulu, HI, 96859, USA
| | - Nikhita Jain
- Department of Otolaryngology-Head and Neck Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, 19107, USA
| | - Kristen Schillinger
- Division of Pediatric Otolaryngology, Nemours/Alfred I. DuPont Hospital for Children, 1600 Rockland Road, Wilmington, DE, 19803, USA
| | - Kristen Born
- Division of Pediatric Otolaryngology, Nemours/Alfred I. DuPont Hospital for Children, 1600 Rockland Road, Wilmington, DE, 19803, USA
| | - Karen Banker
- Division of Pediatric Otolaryngology, Nemours/Alfred I. DuPont Hospital for Children, 1600 Rockland Road, Wilmington, DE, 19803, USA
| | - Nicole L Aaronson
- Division of Pediatric Otolaryngology, Nemours/Alfred I. DuPont Hospital for Children, 1600 Rockland Road, Wilmington, DE, 19803, USA; Department of Otolaryngology-Head and Neck Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, 19107, USA.
| | - Heather C Nardone
- Division of Pediatric Otolaryngology, Nemours/Alfred I. DuPont Hospital for Children, 1600 Rockland Road, Wilmington, DE, 19803, USA; Department of Otolaryngology-Head and Neck Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, 19107, USA
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19
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Muzzi E, Ronfani L, Bossini B, Lezcano C, Orzan E, Barbi E. Effects of Intraoperative Auditory Stimulation on Pain and Agitation on Awakening After Pediatric Adenotonsillectomy: A Randomized Clinical Trial. JAMA Otolaryngol Head Neck Surg 2021; 147:638-645. [PMID: 34014258 PMCID: PMC8138746 DOI: 10.1001/jamaoto.2021.0870] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Importance Severe pain on awakening (POA) and emergence delirium (ED) are common following pediatric adenotonsillectomy. Effective preventive interventions are lacking. Objective To determine the effects of intraoperative auditory stimulation on reduction of POA and ED after pediatric adenotonsillectomy. Design, Setting, and Participants Single-center, double-blinded, 4-armed, randomized clinical trial of children undergoing adenotonsillectomy from March 2018 to May 2019 at a tertiary care pediatric referral center. Interventions Children were randomized to 1 of the following groups: auditory stimulation with music, auditory stimulation with noise, ambient noise insulation with masking earplugs, and a control group receiving no intervention. Ear inserts were placed in the operating room once general anesthesia was administered. Stimulation parameters were based on the preoperative audiological evaluation and the appropriate fitting of the transduction system, including ambient noise level monitoring. Main Outcomes and Measures The primary outcome was POA levels measured on 10-point scales according to age-appropriate validated tools. The secondary outcome was ED levels assessed according to the Pediatric Anesthesia Emergence Delirium 20-point scale. Results A total of 104 consecutive healthy children (median [interquartile range] age at surgery, 5.0 [3.8-6.4] years) were included in the analysis. Music had a large effect size on POA (0.63; 98% CI, 0.43-0.84) and a medium effect size on ED (0.47; 98% CI, 0.21-0.75), while noise had a medium effect size on POA (0.47; 98% CI, 0.22-0.73) and a large effect size on ED (0.63; 98% CI, 0.44-0.85) compared with controls. The earplugs group showed a small effect size on POA and ED. Considering a clinically meaningful threshold of greater than 4 for POA and 10 or greater for ED at dichotomized analysis, a large effect size was achieved by music (1.39; odds ratio [OR], 0.08; 98% CI, 0.02-0.29; and 0.84; OR, 0.22; 98% CI, 0.06-0.75, respectively) and noise (0.97; OR, 0.17; 98% CI, 0.05-0.6; and 1.48; OR, 0.07; 98% CI, 0.02-0.26, respectively), while earplugs resulted in a small effect size. Conclusions and Relevance In this randomized clinical trial, children undergoing adenotonsillectomy who received intraoperative auditory stimulation demonstrated a clinically meaningful decrease in POA and ED in the immediate postoperative period. Further research is needed to assess whether intraoperative auditory stimulation may decrease POA and ED in children undergoing other types of surgical procedures. Trial Registration ClinicalTrials.gov Identifier: NCT04112979.
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Affiliation(s)
- Enrico Muzzi
- Otorhinolaryngology and Audiology, Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy
| | - Luca Ronfani
- Clinical Epidemiology and Public Health Research Unit, Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy
| | | | | | - Eva Orzan
- Otorhinolaryngology and Audiology, Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy
| | - Egidio Barbi
- University of Trieste School of Medicine, Trieste, Italy
- Department of Pediatrics, Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy
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20
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O’Brien DC, Zalzal H, Adkins D, Gates C, Gonzaga J, Sanders L, Carr MM, Kellermeyer B. Standardization and Reduction of Narcotics After Pediatric Tonsillectomy. Otolaryngol Head Neck Surg 2021; 164:932-937. [PMID: 32746739 PMCID: PMC7858697 DOI: 10.1177/0194599820946274] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Accepted: 07/01/2020] [Indexed: 11/16/2022]
Abstract
OBJECTIVES (1) To measure caregiver satisfaction with a nonstandardized postoperative pain regimen after pediatric tonsillectomy. (2) To implement a quality improvement project (QIP) to reduce the number and volume of narcotics prescribed and to describe the effect on caregiver satisfaction. METHODS A prospective cohort study at a tertiary children's hospital examined postoperative narcotics prescribed to children following adenotonsillectomy. A QIP was implemented 3 months into the observation, with the goal to standardize nonnarcotic analgesics and reduce the volume of narcotics prescribed. Caregivers were called 2 to 3 weeks postoperatively to assess pain control and caregiver satisfaction. RESULTS Over an 8-month period, 118 patients were recruited (66 before the QIP, 52 after induction). Prior to the QIP, 47% of patients were prescribed postoperative narcotics, as opposed to 27% after the QIP (P < .05). There was a significant reduction in the volume of narcotics prescribed before (mean ± SD, 300 ± 150 mL) versus after (180 ± 111 mL) the initiative (P < .05). The per-kilogram dose did not change over the study time frame. On a 5-point Likert scale, there was no difference in the caregivers' satisfaction regarding pain control before (4.37 ± 0.85) versus after (4.35 ± 1.0) the project started. DISCUSSION A system shift was identified with the establishment of a posttonsillectomy pain control protocol associated with a reduction in prescribed narcotics without a significant change in caregiver satisfaction. IMPLICATIONS FOR PRACTICE Implementing a standardized plan for the use of nonnarcotic medications was associated with reduced frequency and volume of narcotics prescribed. Future work will further standardize our postoperative pain regimen.
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Affiliation(s)
- Daniel C. O’Brien
- Department of Otolaryngology–Head and Neck Surgery, West Virginia University, Morgantown, West Virginia, USA
| | - Habib Zalzal
- Department of Otolaryngology–Head and Neck Surgery, West Virginia University, Morgantown, West Virginia, USA
| | - David Adkins
- School of Medicine, West Virginia University, Morgantown, West Virginia, USA
| | - Christopher Gates
- School of Medicine, West Virginia University, Morgantown, West Virginia, USA
| | - Joedell Gonzaga
- Ambulatory Pharmacy Services, West Virginia University, Morgantown, West Virginia, USA
| | - Logan Sanders
- Ambulatory Pharmacy Services, West Virginia University, Morgantown, West Virginia, USA
| | - Michele M. Carr
- Department of Otolaryngology–Head and Neck Surgery, West Virginia University, Morgantown, West Virginia, USA
| | - Brian Kellermeyer
- Department of Otolaryngology–Head and Neck Surgery, West Virginia University, Morgantown, West Virginia, USA
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21
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Shotts SD, Welsh DV, Nakamura A, Stromberg AJ. Very-Low Energy Monopolar Reduces Post-Tonsillectomy Hemorrhage Versus Standard Energy Techniques. Laryngoscope 2021; 131:2505-2511. [PMID: 33904597 DOI: 10.1002/lary.29587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 04/04/2021] [Accepted: 04/07/2021] [Indexed: 11/09/2022]
Abstract
OBJECTIVES/HYPOTHESIS To compare rates of post-tonsillectomy hemorrhage (PTH) between a very-low energy transfer monopolar technique (VLET) and standard energy techniques. STUDY DESIGN Retrospective controlled cohort study. METHODS All tonsillectomies performed by practice physicians during the period January 1, 2010 to August 31, 2019 were identified. Three groups were created based on surgeon technique utilization: the study group (VLET) and two control groups (exclusive standard energy monopolar [Standard]; exclusive "hot" technique without exclusive monopolar use [Mixed "Hot"]). Each group's PTH occurrences requiring surgical intervention (PTHRSI) were identified and rates compared. RESULTS During the study period 11,348 tonsillectomies were performed (4,427 Standard, 1,374 VLET, 5,547 Mixed "Hot"), and 167 (1.47%) PTHRSI events identified (14 primary (<24 hours), 153 secondary (>24 hours), 12 repeat (>1PTHRSI/patient). Compared to the Standard group secondary and total PTHRSI rates (1.47%, 1.60%), the Mixed "Hot" group experienced similar rates (1.57%, P = .54; 1.68%, P = .64), but the VLET group experienced significantly lower rates (0.15%, P = .0026, adjusted odds ratio [OR] 0.114 [0.028-0.469]; 0.22%, P = .0016, adjusted OR 0.155 [0.048-0.494]). Age was a significant risk factor for both secondary and total PTHRSI (P = .0025, P = .0024, adjusted OR 1.02/year [1.01-1.03]). No significant difference in rate of primary PTHRSI was seen collectively or in any age group. The <12VLET Group experienced 0 episodes of secondary PTHRSI and a total PTHRSI rate of 0.09% in 1060 tonsillectomies. CONCLUSIONS Standard energy techniques had an adjusted odds ratio over 8-fold higher for secondary PTHRSI and over 6-fold higher for total PTHRSI compared to the minimized energy transfer VLET technique. LEVEL OF EVIDENCE 3 Laryngoscope, 2021.
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Affiliation(s)
| | | | - Aisaku Nakamura
- Dr Bing Zhang Department of Statistics, University of Kentucky, Lexington, Kentucky, U.S.A
| | - Arnold J Stromberg
- Dr Bing Zhang Department of Statistics, University of Kentucky, Lexington, Kentucky, U.S.A
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22
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Wang TV, Okose O, Abt NB, Kamani D, Emerick KS, Randolph GW. One institution's experience with self-audit of opioid prescribing practices for common cervical procedures. Head Neck 2021; 43:2385-2394. [PMID: 33797813 DOI: 10.1002/hed.26697] [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: 01/03/2021] [Revised: 02/04/2021] [Accepted: 03/16/2021] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND We aim to audit our institution's opioid prescribing practices after common cervical procedures. METHODS Retrospective cohort study from one medical center. Reviewed records from 2016-2019 for 472 patients who underwent one of several common cervical procedures. Data collected on demographics, perioperative details, in-hospital pain medication use, and opioids prescribed at discharge. Multivariable logistic regression was run. RESULTS In hospital, median daily milligram morphine equivalents (MME) was 4 (IQR 0-15). Median MME prescribed at discharge was 112.5 MME (IQR 75-150). 3/472 patients received NSAIDs. Predictors of decreased discharge MME were age 70 and older (OR 0.33, p = 0.037) and more recent year (compared to 2016, OR 0.23 [p = 0.031] for 2017, OR 0.13 [p = 0.001] for 2018, and OR 0.070 [p < 0.001] for 2019). CONCLUSIONS MME prescribed at discharge was 28 times the daily in-hospital MME. Only 3/472 patients received postoperative NSAIDs. Self-auditing of opioid prescribing practices identifies actionable items for change.
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Affiliation(s)
- Tiffany V Wang
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
| | - Okenwa Okose
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
| | - Nicholas B Abt
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
| | - Dipti Kamani
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
| | - Kevin S Emerick
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
| | - Gregory W Randolph
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
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23
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Mann GE, Flamer SZ, Nair S, Maher JN, Cowan B, Streiff A, Adams D, Shaparin N. Opioid-free anesthesia for adenotonsillectomy in children. Int J Pediatr Otorhinolaryngol 2021; 140:110501. [PMID: 33290925 DOI: 10.1016/j.ijporl.2020.110501] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 10/21/2020] [Accepted: 11/12/2020] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Opioids are administered during the intraoperative and postoperative periods in pediatric adenotonsillectomy and tonsillectomy. Non-opioid analgesics are often used as an analgesic during pediatric adenotonsillectomy and tonsillectomy. In this hypothesis generating study, we are evaluating safety and efficacy of stand-alone opioid analgesia for adenotonsillectomy and tonsillectomy. METHODS This is a single-center retrospective chart review of patients ages 2 to 13 who underwent elective adenotonsillectomy and tonsillectomy. We used a convenience sampling method to select patients who received intraoperative intravenous fentanyl, acetaminophen, ibuprofen, or any combination thereof. The following outcomes were analyzed in this study: (i) the length of Post Anesthesia Care Unit stay, (ii) administration of postoperative opioids; (iii) postoperative opioid equivalents required; (iv) administration of postoperative non-opioid analgesics; and (v) inpatient admission from ED within 30 days. We used univariate analysis to compare the data points. RESULTS We analyzed data from 323 patients who underwent adenotonsillectomy and tonsillectomy. The Post Anesthesia Care Unit length stay was similar for the intraoperative opioid-free and intraoperative opioid groups, 146.68 (±67.35) and 143.18 (±37.85) minutes, respectively (p = 0.586). Additionally, 102 patients (73.4%) in the intraoperative opioid-free group and 184 patients (83.2%) in the intraoperative opioid group did not receive any postoperative opioids (p = 0.033). The incidence of adverse events was similar between the intraoperative opioid-free and intraoperative opioid groups 3 (2.2%) and 5 (2.7%) respectively, p-value 0.749. A subgroup analysis comparing extracapsular 235 (72.8%) versus intracapsular 88 (27.2%) tonsillectomy yielded similar results. CONCLUSION In this study, our data indicates that American Society of Anesthesiologists I- II pediatric patients undergoing adenotonsillectomy and tonsillectomy can be efficiently and safely managed with an opioid-free intraoperative and postoperative analgesic regimen. Due to the explained limitations, our study results should be interpreted cautiously.
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Affiliation(s)
- Glenn E Mann
- Albert Einstein College of Medicine, Bronx, USA; Montefiore Medical Center, Department of Anesthesiology, USA.
| | | | - Singh Nair
- Montefiore Medical Center, Department of Anesthesiology, USA
| | - James N Maher
- Icahn School of Medicine at Mount Sinai, Department of Anesthesiology, Perioperative and Pain Medicine, USA
| | - Brandon Cowan
- Oakland University William Beaumont School of Medicine, USA
| | - Agathe Streiff
- Montefiore Medical Center, Department of Anesthesiology, USA
| | - David Adams
- Montefiore Medical Center, Department of Anesthesiology, USA
| | - Naum Shaparin
- Albert Einstein College of Medicine, Bronx, USA; Montefiore Medical Center, Department of Anesthesiology, USA
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24
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Simonini A, Murgia F, Cascella M, Marinangeli F, Vittori A, Calevo MG. Ibuprofen and postoperative bleeding in children undergoing tonsillectomy or adenotonsillectomy: a systematic review and meta-analysis of randomized clinical trials. Expert Rev Clin Pharmacol 2020; 14:33-45. [PMID: 33306914 DOI: 10.1080/17512433.2021.1863787] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Ibuprofen is a drug widely used in children who underwent elective tonsillectomy or adenotonsillectomy because compared to the other Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) it is considered a safe drug with a low risk of postoperative bleeding. AREAS COVERED We conducted a systematic review with meta-analysis of randomized clinical trials (RCTs) comparing ibuprofen vs. placebo or not-NSAIDs drugs in children aged up to 17 years of age, who underwent elective tonsillectomy or adenotonsillectomy. We searched in MEDLINE, EMBASE and Cochrane from 1990 through 30 April 2019. We searched www.clinicaltrials.gov for relevant ongoing studies. Our primary outcome was postoperative bleeding requiring surgical intervention. Secondary outcomes were postoperative bleeding not requiring further surgical intervention, the need for blood transfusion, nausea, vomiting, prolonged hospital stay, postoperative pain, and adverse events related to ibuprofen administration. The database search yielded 1227 patients from 7 studies. EXPERT OPINION Given the imprecision of our estimates, the quality of evidence very low/moderate and the few RCTs identified, the results of this analysis were consistent with either a benefit or a detrimental effect of the administration of ibuprofen and do not provide a definitive answer to the review question. Further studies are needed on this important topic.
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Affiliation(s)
- Alessandro Simonini
- Department Pediatric Anaesthesia and Intensive Care, Salesi Children's Hospital , Ancona, Italy
| | - Francesco Murgia
- Department of Anesthesiology and Intensive Care, University of Cagliari
| | - Marco Cascella
- Division of Anesthesia and Pain Medicine, Istituto Nazionale Tumori - IRCCS - Fondazione Pascale , Napoli, Italy
| | - Franco Marinangeli
- Department of Anesthesiology, Intensive Care and Pain Treatment, University of L'Aquila , Italy
| | - Alessandro Vittori
- Department of Anesthesia and Critical Care, ARCO. IRCCS Ospedale Pediatrico Bambino Gesù , Rome, Italy
| | - Maria Grazia Calevo
- Department of Epidemiology and Biostatistic, IRCCS Istituto Giannina Gaslini , Genova, Italy
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25
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Leung P, DeVore EK, Kawai K, Yuen S, Kenna M, Irace AL, Roberson D, Adil E. Does Ibuprofen Increase Bleed Risk for Pediatric Tonsillectomy? Otolaryngol Head Neck Surg 2020; 165:187-196. [PMID: 33170769 DOI: 10.1177/0194599820970943] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To evaluate risk factors for pediatric posttonsillectomy hemorrhage (PTH) and the need for transfusion using a national database. STUDY DESIGN Retrospective cohort study. SETTING The study was conducted using the Pediatric Health Information System (PHIS) database. METHODS Children ≤18 years who underwent tonsillectomy with or without adenoidectomy (T±A) between 2004 and 2015 were included. We evaluated the risk of PTH requiring cauterization according to patient demographics, comorbidities, indication for surgery, medications, year of surgery, and geographic region. RESULTS Of the 551,137 PHIS patients who underwent T±A, 8735 patients (1.58%) experienced a PTH. The risk of PTH increased from 1.33% (95% confidence interval [CI]: 1.15%, 1.53%) in 2010 to 1.91% (95% CI: 1.64%, 2.24%) in 2015 (P < .001). Older age (≥12 vs <5 years old: adjusted odds ratio [aOR] 3.17; 95% CI: 2.86, 3.52), male sex (aOR 1.11; 95% CI: 1.05, 1.17), medical comorbidities (aOR 1.18; 95% CI: 1.08, 1.29), recurrent tonsillitis (aOR 1.15; 95% CI: 1.07, 1.24), and intensive care unit admission (aOR 1.74; 95% CI: 1.55, 1.95) were significantly associated with an increased risk of PTH. Use of ibuprofen (aOR 1.36; 95% CI: 1.22, 1.52), ketorolac (aOR 1.39; 95% CI: 1.14, 1.69), anticonvulsant (aOR 1.23; 95% CI: 1.03, 1.76), and antidepressants (aOR 1.35; 95% CI: 1.03, 1.76) were also associated with an increased risk of PTH. The need for blood transfusion was 2.1% (181/8735). CONCLUSION The incidence of PTH increased significantly between 2011 and 2015, and ibuprofen appears to be one contributing factor. Given the benefits of ibuprofen, it is unclear whether this increased risk warrants a change in practice.
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Affiliation(s)
- Peggy Leung
- Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, Massachusetts, USA
| | | | - Kosuke Kawai
- Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, Massachusetts, USA.,Harvard Medical School Department of Otolaryngology, Boston, Massachusetts, USA
| | - Sonia Yuen
- Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Margaret Kenna
- Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, Massachusetts, USA.,Harvard Medical School Department of Otolaryngology, Boston, Massachusetts, USA
| | - Alexandria L Irace
- Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, Massachusetts, USA
| | - David Roberson
- Bayhealth Medical Center, Milford, Delaware, USA.,The Global Tracheostomy Collaborative, Raleigh, North Carolina, USA
| | - Eelam Adil
- Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, Massachusetts, USA.,Harvard Medical School Department of Otolaryngology, Boston, Massachusetts, USA
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26
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Agamawi YM, Cass LM, Mouzourakis M, Pannu JS, Brinkmeier JV. Pediatric Post-Tonsillectomy Opioid Prescribing Practices. Laryngoscope 2020; 131:1386-1391. [PMID: 33022125 DOI: 10.1002/lary.29157] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 09/03/2020] [Accepted: 09/13/2020] [Indexed: 01/22/2023]
Abstract
OBJECTIVE To evaluate the effect of discharge order sets on prescribing patterns of opioids after pediatric tonsillectomy. Secondary outcomes included encounters for postoperative pain, dehydration, and bleeding. METHODS Retrospective chart review of pre- and post-intervention in pediatric post-tonsillectomy patients, 0-18 years old (n = 1486). Order sets were installed with age-specific analgesic medication defaults and recommendation of concurrent alternating scheduled ibuprofen and acetaminophen. Time-balanced pre- and post-intervention cohorts were established. Opioid outcomes calculated in morphine milligram equivalents per kilogram (MME/kg) per dosage and total prescribed. RESULTS Discharge order set intervention resulted in 17% reduction of opioid dose prescribed (0.095 MME/kg [95% CI, 0.092-0.099] vs. 0.079 [95% CI, 0.076-0.083], P < .001). Total number of opioid doses prescribed was reduced after order set implementation (46.4 [95% CI, 43.6-49.1] to 20.3 [95% CI, 19.1-21.5], P < .001). Patients <7 years old prescribed opioids remained rare in pre- and post-intervention groups (1.6% and 1.8%, respectively, P = .86). Admissions and emergency department visits for postoperative dehydration and pain were significantly reduced. Post-intervention group showed an increase in readmissions for post-tonsillectomy hemorrhage (9.2% vs. 5.2%, P = .003) which was isolated to an increase in the older post-intervention group after stratification by age. CONCLUSION Utilization of order sets with standardized analgesic medication regimen of acetaminophen, ibuprofen, and opioid helped effectively reduce opioid amount per dose, total opioid amount dispensed, and variability in the total opioid amount dispensed while maintaining pain control. An increase in post-tonsillectomy hemorrhage was recognized following this implementation which did not persist after the study period despite continuation of intervention. LEVEL OF EVIDENCE 4 Laryngoscope, 131:1386-1391, 2021.
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Affiliation(s)
- Yusuf M Agamawi
- Department of Otolaryngology-Head and Neck Surgery, Saint Louis University School of Medicine, St. Louis, Missouri, U.S.A
| | - Lauren M Cass
- Department of Otolaryngology-Head and Neck Surgery, Saint Louis University School of Medicine, St. Louis, Missouri, U.S.A
| | | | - Jaibir S Pannu
- Saint Louis University School of Medicine, St. Louis, Missouri, U.S.A
| | - Jennifer V Brinkmeier
- Department of Otolaryngology-Head and Neck Surgery, Saint Louis University School of Medicine, St. Louis, Missouri, U.S.A
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27
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Cramer JD, Barnett ML, Anne S, Bateman BT, Rosenfeld RM, Tunkel DE, Brenner MJ. Nonopioid, Multimodal Analgesia as First-line Therapy After Otolaryngology Operations: Primer on Nonsteroidal Anti-inflammatory Drugs (NSAIDs). Otolaryngol Head Neck Surg 2020; 164:712-719. [PMID: 32806991 DOI: 10.1177/0194599820947013] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To offer pragmatic, evidence-informed advice on nonsteroidal anti-inflammatory drugs (NSAIDs) as first-line therapy after surgery. This companion to the American Academy of Otolaryngology-Head & Neck Surgery (AAO-HNS) clinical practice guideline (CPG), "Opioid Prescribing for Analgesia After Common Otolaryngology Operations," presents data on potency, bleeding risk, and adverse effects for ibuprofen, naproxen, ketorolac, meloxicam, and celecoxib. DATA SOURCES National Guidelines Clearinghouse, CMA Infobase, National Library of Guidelines, NICE, SIGN, New Zealand Guidelines Group, Australian National Health and Medical, Research Council, TRIP database, PubMed, Guidelines International Network, Cochrane Library, EMBASE, CINAHL, BIOSIS Previews, ISI Web of Science, AHRQ, and HSTAT. REVIEW METHODS AAO-HNS opioid CPG literature search strategy, supplemented by PubMed/MEDLINE searches on NSAIDs, emphasizing systematic reviews and randomized controlled trials. CONCLUSION NSAIDs provide highly effective analgesia for postoperative pain, particularly when combined with acetaminophen. Inconsistent use of nonopioid regimens arises from common misconceptions that NSAIDs are less potent analgesics than opioids and have an unacceptable risk of bleeding. To the contrary, multimodal analgesia (combining 500 mg acetaminophen and 200 mg ibuprofen) is significantly more effective analgesia than opioid regimens (15 mg oxycodone with acetaminophen). Furthermore, selective cyclooxygenase-2 inhibition reliably circumvents antiplatelet effects. IMPLICATIONS FOR PRACTICE The combination of NSAIDs and acetaminophen provides more effective postoperative pain control with greater safety than opioid-based regimens. The AAO-HNS opioid prescribing CPG therefore prioritizes multimodal, nonopioid analgesia as first-line therapy, recommending that opioids be reserved for severe or refractory pain. This state-of-the-art review provides strategies for safely incorporating NSAIDs into acute postoperative pain regimens.
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Affiliation(s)
- John D Cramer
- Department of Otolaryngology-Head and Neck Surgery, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Michael L Barnett
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Samantha Anne
- Section of Pediatric Otolaryngology, Head & Neck Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Brian T Bateman
- Department of Anesthesia, Perioperative, and Pain Medicine, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Richard M Rosenfeld
- Department of Otolaryngology, SUNY Downstate Health Sciences University, Brooklyn, New York, USA
| | - David E Tunkel
- Department of Otolaryngology-Head & Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Michael J Brenner
- Department of Otolaryngology-Head & Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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28
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Mast G, Henderson K, Carr MM. The Effect of Ibuprofen Dosing Interval on Post-Tonsillectomy Outcomes in Children: A Quality Improvement Study. Ann Otol Rhinol Laryngol 2020; 129:1210-1214. [PMID: 32546045 DOI: 10.1177/0003489420934843] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective: In this Quality Improvement (QI project) it was hypothesized that an increase in dosing intervals for postoperative analgesia when alternating Ibuprofen and Acetaminophen would reduce post-tonsillectomy hemorrhage (PTH) rates for those undergoing tonsillectomies with or without adenoidectomy, while maintaining the standard of postoperative analgesia and reducing visits to the Emergency Room (ER) for reasons other than PTH. Data was collected from 353 children. Utilizing run chart analysis, it was determined that patients experiencing the 4-hour dosing interval had lower rates of PTH, fewer ER visits, and no increase in postoperative phone calls from caregivers. Patients and Methods: Patients were treated with standing Acetaminophen 15 mg/kg q6h and Ibuprofen 10 mg/kg q6h for postoperative analgesia from July of 2017 until January of 2018. Starting January of 2018 through November of 2018, the dosage interval was lengthened 1 hour. Data relating to PTH, ER visits for reasons other than bleeding, and phone calls from caregivers was collected. Results: Run charts were used to assess outcomes regarding PTH, postoperative visits to the ER for reasons other than PTH, and phone calls from caregivers. Our results suggest that a standing protocol of alternating Acetaminophen and Ibuprofen given every 4 hours improves the post-tonsillectomy hemorrhage rate without increasing ER visits or calls about pain. Conclusions: This data shows promise in reducing PTH and ER visits with a longer dose interval when alternating Acetaminophen and Ibuprofen for postoperative analgesia in tonsillectomy patients. A randomized clinical trial should be carried out to further validate these claims.
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Affiliation(s)
- Grayson Mast
- School of Medicine, West Virginia University, Morgantown, WV, USA
| | | | - Michele M. Carr
- Department of Otolaryngology, University at Buffalo, Buffalo, NY, USA
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29
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Krouse JH. Highlights from the Current Issue: November 2019. Otolaryngol Head Neck Surg 2020; 161:723-724. [PMID: 31674889 DOI: 10.1177/0194599819878424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- John H Krouse
- School of Medicine, University of Texas Rio Grande Valley, Edinburg, Texas, USA
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30
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Huang GJ. Does Ibuprofen Really Increase Tendency to Posttonsillectomy Hemorrhage? Otolaryngol Head Neck Surg 2020; 162:263-264. [PMID: 32009555 DOI: 10.1177/0194599819892204] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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31
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O'Brien DC, Desai Y, Schubart J, Swanson RT, Chung S, Parekh U, Carr MM. Effect of intra-op morphine on children with OSA undergoing tonsillectomy. Int J Pediatr Otorhinolaryngol 2019; 125:141-146. [PMID: 31306896 DOI: 10.1016/j.ijporl.2019.07.003] [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: 11/02/2018] [Revised: 07/07/2019] [Accepted: 07/07/2019] [Indexed: 11/28/2022]
Abstract
OBJECTIVES 1. To compare outcomes after tonsillectomy for pediatric patients with obstructive sleep apnea (OSA) given morphine intra-operatively and post operatively compared to those who were not - specifically Recovery Room (RR) time, length of stay (LOS), Emergency Department (ER) visits. STUDY DESIGN Retrospective case series with chart review. SETTING Tertiary care children's hospital. SUBJECTS AND METHODS All children between 1 and 17 years old who had undergone tonsillectomy in a single institution from 2013 to 2016. Comparison between children who had received morphine intra-operatively was made for outcomes. RESULTS 556 patients were included, 73 patients had morphine intraoperatively and 483 did not; these latter children were older (8.8 vs 6.5 years, P < 0.001), and had fewer episodes of obstructive apnea and hypopnea (AHI 4.47 vs 10.15, p = 0.003) than children who did not receive intra-op morphine. There were no differences in co-morbidities including asthma, whether they had a sleep study, time in the operating room, emergence time, RR time, airway complications, IMC/PICU admission for respiratory distress, ER visits, readmissions, bleeding or post-discharge nurse phone calls. There was a longer LOS (25.9 vs 21.4 h, P = 0.011) for the group receiving intra-op morphine. CONCLUSION Children with OSA who receive intra-op morphine have a longer LOS suggesting that its use should be examined more closely in this population.
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Affiliation(s)
- Daniel C O'Brien
- Department of Otolaryngology - Head and Neck Surgery, West Virginia University School of Medicine, Morgantown, WV, USA
| | - Yuti Desai
- Drexel University, Philadelphia, PA, USA
| | - Jane Schubart
- Department of Surgery, The Pennsylvania State University, College of Medicine, Hershey, PA, USA; Department of Public Health Sciences, The Pennsylvania State University, College of Medicine, Hershey, PA, USA
| | - Robert T Swanson
- The Pennsylvania State University, College of Medicine, Hershey, PA, USA
| | - Scott Chung
- The Pennsylvania State University, College of Medicine, Hershey, PA, USA
| | - Uma Parekh
- Department of Anesthesiology, The Pennsylvania State University, College of Medicine, Hershey, PA, USA
| | - Michele M Carr
- Department of Otolaryngology - Head and Neck Surgery, West Virginia University School of Medicine, Morgantown, WV, USA.
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