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Jaensch SL, Cheng AT, Waters KA. Adenotonsillectomy for Obstructive Sleep Apnea in Children. Otolaryngol Clin North Am 2024; 57:407-419. [PMID: 38575485 DOI: 10.1016/j.otc.2024.02.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2024]
Abstract
Obstructed breathing is the most common indication for tonsillectomy in children. Although tonsillectomy is performed frequently worldwide, the surgery is associated with a number of significant complications such as bleeding and respiratory failure. Complication risk depends on a number of complex factors, including indications for surgery, demographics, patient comorbidities, and variations in perioperative techniques. While polysomnography is currently accepted as the gold standard diagnostic tool for obstructive sleep apnea, studies evaluating outcomes following surgery suggest that more research is needed on the identification of more readily available and accurate tools for the diagnosis and follow-up of children with obstructed breathing.
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Affiliation(s)
- Samantha L Jaensch
- Northern Clinical School, The University of Sydney, Sydney, New South Wales, Australia; Sydney Medical School - Northern, L7 Kolling Building RNSH, Reserve Road, St Leonards, NSW 2065, Australia
| | - Alan T Cheng
- Discipline of Child and Adolescent Health, Faculty of Medicine, The University of Sydney, Sydney, New South Wales, Australia; Department of Ear Nose & Throat Surgery, The Children's Hospital at Westmead, Locked Bag 4001, Westmead, NSW 2145, Australia
| | - Karen A Waters
- Discipline of Child and Adolescent Health, Faculty of Medicine, The University of Sydney, Sydney, New South Wales, Australia; Respiratory Support Services, The Children's Hospital at Westmead, Locked Bag 4001, Westmead, NSW 2145, Australia.
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Goldbart AD, Abuhasira R, Shiloh A, Even-Tsur J, Tarasiuk A. Childhood Adenotonsillectomy Does Not Increase the Risk of Being Overweight in Adulthood. Am J Respir Crit Care Med 2024; 209:1261-1263. [PMID: 38417070 DOI: 10.1164/rccm.202311-2175le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 02/28/2024] [Indexed: 03/01/2024] Open
Affiliation(s)
| | | | | | | | - Ariel Tarasiuk
- Sleep-Wake Disorders Unit, Soroka University Medical Center, and
- Department of Physiology and Cell Biology, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
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Shaikh N, Kais A, Dewey J, Jaffal H. Effect of perioperative ketorolac on postoperative bleeding after pediatric tonsillectomy. Int J Pediatr Otorhinolaryngol 2024; 180:111953. [PMID: 38653108 DOI: 10.1016/j.ijporl.2024.111953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2024] [Revised: 03/28/2024] [Accepted: 04/11/2024] [Indexed: 04/25/2024]
Abstract
INTRODUCTION Ketorolac is a frequently used anesthetic pain agent which is traditionally avoided during tonsillectomy due to concern for postoperative hemorrhage. Our goal was to assess the degree of risk associated with the use of Ketorolac following pediatric tonsillectomy. METHODS The TriNetX electronic health records research database was queried in January 2024 for patients undergoing tonsillectomy with or without adenoidectomy under the age of 18 years and without a diagnosed bleeding disorder. Patients were separated into two cohorts either having received or not having received ketorolac the same day as surgery. Propensity score matching was performed for age at the time of surgery, sex, race, ethnicity, and preoperative diagnoses. The outcomes assessed were postoperative hemorrhage requiring operative control within the first day (primary hemorrhage) and within the first month after surgery (secondary hemorrhage). RESULTS 17,434 patients were identified who had undergone pediatric tonsillectomy with or without adenoidectomy and had received ketorolac the same day as surgery. 290,373 patients were identified who had undergone pediatric tonsillectomy with or without adenoidectomy and had not received ketorolac the same day as surgery. 1:1 propensity score matching resulted in 17,434 patients within each cohort. Receipt of ketorolac the same day as surgery resulted in an increased risk of primary hemorrhage OR 2.158 (95 % CI 1.354, 3.437) and secondary hemorrhage OR 1.374 (95 % CI 1.057, 1.787) requiring operative control. CONCLUSION Ketorolac use during pediatric tonsillectomy with or without adenoidectomy was associated with an increased risk of postoperative primary and secondary bleeding requiring surgery.
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Affiliation(s)
- Noah Shaikh
- Department of Otolaryngology-Head and Neck Surgery, West Virginia University, Morgantown, WV, USA
| | - Amani Kais
- Department of Otolaryngology-Head and Neck Surgery, West Virginia University, Morgantown, WV, USA
| | - John Dewey
- Department of Otolaryngology-Head and Neck Surgery, West Virginia University, Morgantown, WV, USA
| | - Hussein Jaffal
- Department of Otolaryngology-Head and Neck Surgery, West Virginia University, Morgantown, WV, USA.
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Feng B, Guo Y, Tang S, Zhang T, Gao Y, Ni X. Association of preoperative neutrophil-lymphocyte ratios with the emergence delirium in pediatric patients after tonsillectomy and adenoidectomy: an observational prospective study. J Anesth 2024; 38:206-214. [PMID: 38267728 DOI: 10.1007/s00540-023-03303-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 12/17/2023] [Indexed: 01/26/2024]
Abstract
PURPOSE The study aimed to investigate potential risk factors for emergence delirium (ED) in pediatric patients after tonsillectomy and adenoidectomy (T&A). METHODS This prospective, single-center observational study enrolled children aged 3-7 years who underwent T&A under general anesthesia. ED was assessed according to DSM-IV or V criteria. Receiver operating characteristic curve analysis was performed to evaluate the predicative and cut-off values of risk factors, including age, preoperative anxiety level, postoperative pain and neutrophil-lymphocyte ratio (NLR) for ED. Univariate and multivariate logistic regression analyses were performed to investigate risk factors for ED. RESULTS 94 pediatric patients who underwent T&A were enrolled and 19 developed ED (an incidence of 25.3%). Receiver operating characteristic analysis indicated that preoperative NLR was a significant predictor of ED with a cut-off value of 0.8719 and an area under the curve (AUC) of 0.671 (95% confidence interval (CI) 0.546-0.796, P = 0.022). Preoperative NLR (< 0.8719) and postoperative pain were independent risk factors associated with ED (odds ratio: 0.168, 95% CI 0.033-0.858, P = 0.032; odds ratio: 7.298, 95% CI 1.563-34.083, P = 0.011) according to multivariate logistic regression analysis. CONCLUSIONS Preoperative NLR level and postoperative pain were independent risk factors for ED in pediatric patients undergoing T&A.
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Affiliation(s)
- Bei Feng
- Department of Anesthesiology and Perioperative Medicine, General Hospital of Ningxia Medical University, 804, Shengli South Street, Xingqing District, Yinchuan, 750004, China
| | - Yuhao Guo
- Department of Anesthesiology and Perioperative Medicine, General Hospital of Ningxia Medical University, 804, Shengli South Street, Xingqing District, Yinchuan, 750004, China
| | - Shaling Tang
- Department of Anesthesiology and Perioperative Medicine, General Hospital of Ningxia Medical University, 804, Shengli South Street, Xingqing District, Yinchuan, 750004, China
| | - Tie Zhang
- Department of Anesthesiology and Perioperative Medicine, General Hospital of Ningxia Medical University, 804, Shengli South Street, Xingqing District, Yinchuan, 750004, China
| | - Yubo Gao
- Department of Anesthesiology and Perioperative Medicine, General Hospital of Ningxia Medical University, 804, Shengli South Street, Xingqing District, Yinchuan, 750004, China.
| | - Xinli Ni
- Department of Anesthesiology and Perioperative Medicine, General Hospital of Ningxia Medical University, 804, Shengli South Street, Xingqing District, Yinchuan, 750004, China.
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Heward E, Rocke J, McNally G, Thompson G, Oladokun D, Timms S, Abbas JR, Chu MMH, Akbar S, Dobbs S, Chudek D, Jaiswal I, Vora D, Harrison A, Oremule B, Sarwar S, Menon SS, Advani R, Daniels J, Ellis S, Abdelaziz M, Husain P, Anmolsingh R, Venugopal A, Beena M, Sheik-Ali S, Saeed H, Shenton C, Ghosh S, Khwaja S, Kumar N. The post-operative tonsillectomy (POPT) study: A multi-centre prospective paediatric cohort study. Clin Otolaryngol 2024; 49:176-184. [PMID: 37915294 DOI: 10.1111/coa.14110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Revised: 06/01/2023] [Accepted: 09/23/2023] [Indexed: 11/03/2023]
Abstract
OBJECTIVES Tonsillectomy is the most common operation performed by otolaryngologists in the UK, despite this we have a poor understanding of the post-operative recovery. We aimed to investigate post-operative bleeding and pain following paediatric tonsillectomy using a patient diary. DESIGN Prospective observational cohort study. SETTING Multi-centre study involving 12 secondary and tertiary otolaryngology units across the North of England. Patients were recruited from 1st March 2020 to 30th June 2022. Multilevel ordered logistic regression model statistics were performed. PARTICIPANTS Children (≥4 years, ≤16 years) undergoing tonsillectomy (with or without adenoidectomy) for benign pathology. MAIN OUTCOME MEASURES Frequency and severity of post-operative bleeding. Intensity and pattern of post-operative pain. RESULTS In total 297 children were recruited, with 91 (30.6%) diaries eligible for analysis. Post-operative bleeding occurred in 44% of children. Most frequently blood in the saliva was reported (82.9%). Increasing age significantly increased bleeding odds by 17% per year (p = .001). Bleeding frequency decreased with higher surgeon grade (p = .003) and when performing intracapsular coblation tonsillectomy (p = .02) compared with other techniques. Lower age and intracapsular coblation tonsillectomy, against other techniques, significantly reduced rates of pain post-operatively (p < .0001 and p = .0008). CONCLUSION A high level of low-level post-operative bleeding was observed. Pain scores remained high for 5 days post-operatively then gradually reduce to normal by day 13. Intracapsular coblation tonsillectomy appears to be superior to all other techniques in terms of reducing post-operative bleeding and pain. These findings should be used to guide patients in the consent process to inform them of the expected nature of post-surgical recovery.
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Affiliation(s)
- Elliot Heward
- Wrightington, Wigan and Leigh NHS Foundation Trust, Wigan, UK
| | - John Rocke
- Wrightington, Wigan and Leigh NHS Foundation Trust, Wigan, UK
| | - George McNally
- Wrightington, Wigan and Leigh NHS Foundation Trust, Wigan, UK
| | | | - Dare Oladokun
- York and Scarborough Teaching Hospitals NHS Foundation Trust, York, UK
| | | | | | - Michael M H Chu
- Wrightington, Wigan and Leigh NHS Foundation Trust, Wigan, UK
| | - Sarah Akbar
- Wrightington, Wigan and Leigh NHS Foundation Trust, Wigan, UK
| | - Sian Dobbs
- Northern Care Alliance NHS Foundation Trust, Salford, UK
| | - Dorota Chudek
- Wrightington, Wigan and Leigh NHS Foundation Trust, Wigan, UK
| | - Ishank Jaiswal
- Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
| | - Devan Vora
- East Lancashire Hospitals NHS Trust, Blackburn, UK
| | - Anna Harrison
- Manchester University NHS Foundation Trust, Manchester, UK
| | | | - Safdar Sarwar
- Manchester University NHS Foundation Trust, Manchester, UK
| | | | - Rajeev Advani
- Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
| | | | - Sarah Ellis
- Tameside and Glossop Integrated Care NHS Foundation Trust, Ashton-under-Lyne, UK
| | - Mohammed Abdelaziz
- Tameside and Glossop Integrated Care NHS Foundation Trust, Ashton-under-Lyne, UK
| | | | - Rajesh Anmolsingh
- Manchester University NHS Foundation Trust, Manchester, UK
- Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | | | - Meera Beena
- Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, UK
| | - Shirwa Sheik-Ali
- Tameside and Glossop Integrated Care NHS Foundation Trust, Ashton-under-Lyne, UK
| | - Haroon Saeed
- Manchester University NHS Foundation Trust, Manchester, UK
| | - Catriona Shenton
- Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, UK
| | - Samit Ghosh
- Northern Care Alliance NHS Foundation Trust, Salford, UK
| | - Sadie Khwaja
- Manchester University NHS Foundation Trust, Manchester, UK
| | - Nirmal Kumar
- Wrightington, Wigan and Leigh NHS Foundation Trust, Wigan, UK
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Trombetta A, Sanson I, Barbi E, Zamagni G, Fabbris C, Dall'Amico R, Orzan E, Giacomarra V, Grasso DL. Effectiveness of bismuth subgallate for preventing bleeding following adenotonsillectomy: A multicentre study. Am J Otolaryngol 2024; 45:104194. [PMID: 38141566 DOI: 10.1016/j.amjoto.2023.104194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 12/10/2023] [Indexed: 12/25/2023]
Abstract
BACKGROUND Tonsillectomy and adenotonsillectomy are surgical procedures routinely performed worldwide, with various complications, including postoperative bleeding (PTH). Among haemostatic agents, bismuth subgallate (BS) has been employed in the past decades, but its use is controversial in children. OBJECTIVE This retrospective, multicentre study aims to evaluate the effectiveness and safety of BS in preventing PTH following tonsillectomy and adenotonsillectomy. MATERIALS AND METHODS Two cohorts of children between 0 and 18 years of age were compared in two different hospitals. The first (active) group of patients included children who underwent tonsillectomy/adenotonsillectomy performed using BS added to gauze swabs, whereas this agent was not administered to the second (control) group. The following variables were analysed: age, gender, degree of tonsillar hyperplasia, length of hospital stay, acute complications (including bleeding and infection), further admissions to the Paediatric Emergency Department (PED), and further hospital admissions in the 30 days postoperatively. RESULTS Four-thousand- seven hundred forty-four children were included in the study, 2598 in the active group and 2146 in the control group. The cases included in the active treatment group displayed a significantly reduced PTH prevalence, 1.4 versus 2.6 % (p < 0.05). No cases of neurological complications or aspiration pneumonia were detected. CONCLUSIONS This study supports BS as a safe and reliable option for preventing severe PTH following tonsillectomy/adenotonsillectomy.
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Affiliation(s)
- Andrea Trombetta
- University of Trieste, Italy; Ospedale Santa Maria degli Angeli, Pordenone, Italy.
| | | | - Egidio Barbi
- University of Trieste, Italy; Italy Institute for Maternal and Child Health "IRCCS Burlo Garofolo", Trieste, Italy
| | - Giulia Zamagni
- Italy Institute for Maternal and Child Health "IRCCS Burlo Garofolo", Trieste, Italy
| | | | | | - Eva Orzan
- University of Trieste, Italy; Italy Institute for Maternal and Child Health "IRCCS Burlo Garofolo", Trieste, Italy
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Martin E, Frank M, Nguyen C, Bhatt J, Huoh K, Ahuja G, Pham N. Supplemental oxygen requirement after tonsillectomy in children >3 years of age. Int J Pediatr Otorhinolaryngol 2024; 178:111893. [PMID: 38382259 DOI: 10.1016/j.ijporl.2024.111893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 02/01/2024] [Accepted: 02/07/2024] [Indexed: 02/23/2024]
Abstract
INTRODUCTION The indications for postoperative admission after tonsillectomy in children >3 years of age are less well defined than for children <3 years old, and typically include severe obstructive sleep apnea (OSA), obesity, comorbidities, or behavioral factors. Inpatient care after tonsillectomy typically consists of respiratory monitoring and support, as respiratory compromise is the most common complication after pediatric tonsillectomy. We aim to evaluate risk factors associated with postoperative oxygen supplementation and to identify high risk populations within the admitted population who use additional resources or require additional interventions. METHODS Retrospective chart review of patients between the ages of 3 and 18 years old who underwent tonsillectomy by four surgeons at a tertiary care children's hospital was performed. Data including demographics, comorbidities, surgical intervention, pre- and postoperative AHI, admission, postoperative oxygen requirement, and postoperative complications was collected and analyzed. RESULTS There were 401 patients included in the analysis. Of the patients in this study, 65.59% were male, 43.39% were Latino, and 53.87% were ages 3 to 7. Of the 397 patients with a record for supplemental oxygen, 36 (9.07%) received supplemental oxygen. The LASSO regression odds ratios (OR) found to be important for modeling supplemental oxygen use (in decreasing order of magnitude) are BMI ≥35 (OR = 2.30), pre-op AHI >30 (OR = 2.28), gastrointestinal comorbidities (OR = 2.20), musculoskeletal comorbidities (OR = 1.91), cardiac comorbidities (OR = 1.20), pulmonary comorbidities (OR = 1.14), and BMI 30 to <35 (OR = 1.07). Female gender was found to be negatively associated with risk of supplemental oxygen use (OR = 0.84). Age, race, AHI ≥15-30, neurologic comorbidities, syndromic patients, admission reason, and undergoing other procedures concomitantly were not found to be associated with increased postoperative oxygen requirement. CONCLUSION BMI ≥30, pre-op AHI >30, male gender, and gastrointestinal, musculoskeletal, cardiac, and pulmonary comorbidities are all associated with postoperative supplemental oxygen use. Age, race, AHI ≥15-30, neurologic comorbidities, syndromic patients, admission reason, and undergoing other procedures concomitantly were not found to be associated with increased postoperative oxygen requirement.
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Affiliation(s)
- Elaine Martin
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, CA, USA.
| | - Madelyn Frank
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, CA, USA
| | - Cecilia Nguyen
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, CA, USA
| | - Jay Bhatt
- Department of Pediatric Otolaryngology - Head & Neck Surgery, Children's Hospital of Orange County, Orange, CA, USA
| | - Kevin Huoh
- Department of Pediatric Otolaryngology - Head & Neck Surgery, Children's Hospital of Orange County, Orange, CA, USA
| | - Gurpreet Ahuja
- Department of Pediatric Otolaryngology - Head & Neck Surgery, Children's Hospital of Orange County, Orange, CA, USA
| | - Nguyen Pham
- Department of Pediatric Otolaryngology - Head & Neck Surgery, Children's Hospital of Orange County, Orange, CA, USA
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Engelhardt T, Kaspy KR, Daniel SJ. Measuring immediate surgical success in children undergoing adenotonsillectomy. Br J Anaesth 2024; 132:234-236. [PMID: 38104005 DOI: 10.1016/j.bja.2023.11.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 11/15/2023] [Indexed: 12/19/2023] Open
Abstract
Adenotonsillectomy is the most common indication for sleep-disordered breathing in children. Measuring pharyngeal closing pressures in anaesthetised children allows identification of severe obstructive sleep apnoea. This technique could help quantify immediate surgical impact and risk stratify postoperative treatment in these patients.
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Affiliation(s)
- Thomas Engelhardt
- Department of Anesthesiology, Montreal Children's Hospital, McGill University, Montreal, QC, Canada.
| | - Kimberley R Kaspy
- Department of Pediatrics, Respiratory Medicine, Montreal Children's Hospital, McGill University, Montreal, QC, Canada
| | - Samuel J Daniel
- Department of Pediatric Surgery, Montreal Children's Hospital, McGill University, Montreal, QC, Canada; Department of Otolaryngology-Head and Neck Surgery, Montreal Children's Hospital, McGill University, Montreal, QC, Canada
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Fenton D, Dimitroyannis R, Petrauskas L, Nordgren R, Tesema N, Aggarwal S, Patel N, Shogan A. Socioeconomic status is associated with pediatric adenotonsillectomy outcomes: A single institution study. Int J Pediatr Otorhinolaryngol 2024; 177:111844. [PMID: 38185004 DOI: 10.1016/j.ijporl.2023.111844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 12/16/2023] [Accepted: 12/29/2023] [Indexed: 01/09/2024]
Abstract
OBJECTIVE Our institution serves a diverse patient population across a large metropolitan city. Literature has shown pediatric otolaryngology patients with lower socioeconomic status (SES) have higher rates of sleep-disordered breathing, delays in treatment time, and greater risks of complications post-tonsillectomy. This study aims to examine the effects of SES on adenotonsillectomy outcomes performed at our institution. STUDY DESIGN A retrospective chart review including 1560 pediatric patients (ages 0-18) who underwent adenotonsillectomy between January 2015 and December 2020. SETTING Large metropolitan hospital, level 1 trauma center. METHODS Outcome variables included postoperative hospital admission, phone calls, 30-day follow-up, and persistent obstructive sleep apnea (OSA). Descriptive statistics using Wilcoxon Signed Rank Tests and univariate and multivariate logistic regression modeling were used to determine statistically significant covariates at α = 0.05. RESULTS The cohort included Non-Hispanic White (n = 488, 31 %), Non-Hispanic Black (n = 801, 51 %), Hispanic (n = 210, 13 %), and other (n = 61, 4 %) groups. Using multivariate regression, privately insured patients were less likely to have moderate-to-severe OSA before surgery (0.65 95 % CI 0.45, 0.93 p = 0.017) and be admitted postoperatively (0.73, 0.55-0.96, p < 0.01), while more likely to have postoperative follow-up phone calls (1.57, 1.19-2.09, p < 0.01) and visits (1.53, 1.22-1.92, p < 0.01). Increased income was associated with decreased rehospitalizations within three months of surgery (0.98, 0.97-1.00, p < 0.01). CONCLUSION This study suggests SES significantly affects adenotonsillectomy outcomes. Further studies are warranted to provide better care for all pediatric patients.
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Affiliation(s)
- David Fenton
- Pritzker School of Medicine, University of Chicago, Chicago, IL, USA
| | | | - Laura Petrauskas
- Department of Surgery, University of Chicago Medicine, Chicago, IL, USA
| | - Rachel Nordgren
- Department of Public Health Sciences, University of Chicago, Chicago, IL, USA
| | - Naomi Tesema
- Pritzker School of Medicine, University of Chicago, Chicago, IL, USA
| | - Sarthak Aggarwal
- Pritzker School of Medicine, University of Chicago, Chicago, IL, USA
| | - Nirali Patel
- Department of Surgery, University of Chicago Medicine, Chicago, IL, USA
| | - Andrea Shogan
- Department of Surgery, University of Chicago Medicine, Chicago, IL, USA.
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Yuen HS, Sandeman J, Hone R. The role of overnight pulse oximetry in risk stratification of paediatric sleep disordered breathing in a district general hospital. Int J Pediatr Otorhinolaryngol 2024; 177:111869. [PMID: 38266379 DOI: 10.1016/j.ijporl.2024.111869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 12/26/2023] [Accepted: 01/10/2024] [Indexed: 01/26/2024]
Abstract
OBJECTIVES Adenoidectomy and tonsillectomy are common surgical interventions in paediatric patients with sleep disordered breathing. Post operative respiratory complications are a recognised risk, and pre-operative risk stratification of patients is important to enable safe delivery of peri-operative care. Due to easy accessibility, overnight pulse oximetry is commonly used for this purpose. However, its limitations have been widely reported and recent national guidance recommends limiting use to patients with significant risk factors. We reviewed the use of overnight pulse oximetry in our local unit to determine if local guidelines should be adapted in line with these national recommendations. METHODS Retrospective analysis of all paediatric patients referred for overnight pulse oximetry over an eighteen month period between August 2020 to February 2022. Data collection included patient age, weight, and relevant co-morbidities. The McGill score was used to risk stratify patients and determine the need for an overnight bed. This was then correlated with the occurrence of post operative respiratory complications. RESULTS 200 patients were referred for overnight pulse oximetry, with a mean age of 7.5 years. 7.5 % (15/200) had significant comorbidities. 64 % (128/200) of patients were subsequently listed for surgery. 20.3 % (26/128) were deemed at risk of post-operative complications due to McGill scores of 3 and 4 and planned for overnight ward observation. Of these, 15 % (4/26) were subsequently discharged the same day. None of our patients developed major respiratory complications in the post operative period. CONCLUSION Our findings support national recommendations that overnight pulse oximetry is not an accurate predictor of post-operative respiratory complications and resulted in unnecessary inpatient stays. Following discussion with the trust paediatric anaesthetist lead, our local guidance was tightened, limiting overnight pulse oximetry to children with relevant identifiable co-morbidities.
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Affiliation(s)
- Huay Shan Yuen
- William Harvey Hospital, Kennington Road, Ashford, TN24 0LZ, United Kingdom.
| | - Jack Sandeman
- Leeds General Infirmary, Great George Street, LS1 3EX, United Kingdom
| | - Robert Hone
- William Harvey Hospital, Kennington Road, Ashford, TN24 0LZ, United Kingdom
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Polytarchou A, Moudaki A, Van de Perck E, Boudewyns A, Kaditis AG, Verhulst S, Ersu R. An update on diagnosis and management of obstructive sleep apnoea in the first 2 years of life. Eur Respir Rev 2024; 33:230121. [PMID: 38296343 PMCID: PMC10828842 DOI: 10.1183/16000617.0121-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 12/05/2023] [Indexed: 02/03/2024] Open
Abstract
The aim of this review is to summarise evidence that became available after publication of the 2017 European Respiratory Society statement on the diagnosis and management of obstructive sleep apnoea syndrome (OSAS) in 1- to 23-month-old children. The definition of OSAS in the first 2 years of life should probably differ from that applied in children older than 2 years. An obstructive apnoea-hypopnoea index >5 events·h-1 may be normal in neonates, as obstructive and central sleep apnoeas decline in frequency during infancy in otherwise healthy children and those with symptoms of upper airway obstruction. A combination of dynamic and fixed upper airway obstruction is commonly observed in this age group, and drug-induced sleep endoscopy may be useful in selecting the most appropriate surgical intervention. Adenotonsillectomy can improve nocturnal breathing in infants and young toddlers with OSAS, and isolated adenoidectomy can be efficacious particularly in children under 12 months of age. Laryngomalacia is a common cause of OSAS in young children and supraglottoplasty can provide improvement in children with moderate-to-severe upper airway obstruction. Children who are not candidates for surgery or have persistent OSAS post-operatively can be treated with positive airway pressure (PAP). High-flow nasal cannula may be offered to young children with persistent OSAS following surgery, as a bridge until definitive therapy or if they are PAP intolerant. In conclusion, management of OSAS in the first 2 years of life is unique and requires consideration of comorbidities and clinical presentation along with PSG results for treatment decisions, and a multidisciplinary approach to treatment with medical and otolaryngology teams.
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Affiliation(s)
- Anastasia Polytarchou
- Division of Pediatric Pulmonology, First Department of Pediatrics, National and Kapodistrian University of Athens School of Medicine and Agia Sofia Children's Hospital, Athens, Greece
- These authors contributed equally to this review article and share first authorship
| | - Angeliki Moudaki
- Division of Pediatric Pulmonology, First Department of Pediatrics, National and Kapodistrian University of Athens School of Medicine and Agia Sofia Children's Hospital, Athens, Greece
- These authors contributed equally to this review article and share first authorship
| | - Eli Van de Perck
- Department of Otorhinolaryngology, Head and Neck Surgery, Antwerp University Hospital, Antwerp, Belgium
- Faculty of Medicine Translational Neurosciences, University of Antwerp, Antwerp, Belgium
- These authors contributed equally to this review article and share first authorship
| | - An Boudewyns
- Department of Otorhinolaryngology, Head and Neck Surgery, Antwerp University Hospital, Antwerp, Belgium
- Faculty of Medicine Translational Neurosciences, University of Antwerp, Antwerp, Belgium
| | - Athanasios G Kaditis
- Division of Pediatric Pulmonology, First Department of Pediatrics, National and Kapodistrian University of Athens School of Medicine and Agia Sofia Children's Hospital, Athens, Greece
| | - Stijn Verhulst
- Department of Pediatric Pulmonology and Sleep Medicine, Antwerp University Hospital, Antwerp, Belgium
- Laboratory of Experimental Medicine and Pediatrics, University of Antwerp, Antwerp, Belgium
| | - Refika Ersu
- Division of Respiratory Medicine, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
- University of Ottawa, Ottawa, ON, Canada
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12
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Wang Y, Zhao L, Wang J, Li X. The efficacy of perioperative antibiotic therapy in adenotonsillectomy children. Eur Arch Otorhinolaryngol 2024; 281:267-272. [PMID: 37737873 DOI: 10.1007/s00405-023-08244-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 09/12/2023] [Indexed: 09/23/2023]
Abstract
PURPOSE To evaluate the role of perioperative antibiotics use in children after adenotonsillectomy. METHODS SPSS 27.0 was used for statistical analysis. Two independent samples mean T test was used to evaluate the throat pain scores consecutive 3 days after the surgery, the time to resume to normal diet, and the wound healing time. Logistic regression analysis was used to evaluate the independent risk factors of the two groups. The generalized estimation model was used to evaluate the correlation between age and postoperative pain scores, and the relationship between different tonsillar bed gradings and postoperative pain scores. RESULTS The pain scores were 5.83 ± 1.879, 5.20 ± 1.933, and 4.02 ± 1.936 in the observation group; and 6.83 ± 1.892, 6.17 ± 2.001, and 5.29 ± 2.068 in the control group on days 1-3 after surgery, respectively. The time of pain disappearance was 6.24 ± 2.121 days in the observation group and 7.73 ± 2.210 days in the control group. The wound repair time was 18.66 ± 2.200 days in the observation group and 18.70 ± 2.468 days in the control group. Logistic regression analysis showed that fever was an independent risk factor for the two groups and was negatively correlated (B = - 1.237, P < 0.001, OR = 0.290). Generalized estimation model showed that there was a positive correlation between age and pain scores (P < 0.001), and with the increasing grading of tonsillar bed, the higher the pain scores was (P < 0.001). CONCLUSIONS Perioperative use of antibiotics in children with adenotonsillectomy can effectively reduce postoperative fever, throat pain symptoms, and shorten the pain time. With the increasing of tonsillar bed grading, perioperative antibiotic therapy was more necessary.
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Affiliation(s)
- Ying Wang
- Department of Otorhinolaryngology Head and Neck Surgery, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, No.355, Luding Road, Shanghai, 200062, People's Republic of China
| | - Limin Zhao
- Department of Otorhinolaryngology Head and Neck Surgery, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, No.355, Luding Road, Shanghai, 200062, People's Republic of China
| | - Jing Wang
- Department of Otorhinolaryngology Head and Neck Surgery, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, No.355, Luding Road, Shanghai, 200062, People's Republic of China
| | - Xiaoyan Li
- Department of Otorhinolaryngology Head and Neck Surgery, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, No.355, Luding Road, Shanghai, 200062, People's Republic of China.
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Cohen N, Schissler K, Jeter J, Stathas A, Lozano J, Dave S, Lowe D. Change in Pediatric Adenotonsillectomy Postoperative Visit Patterns After Opioid Food and Drug Administration Warning. Pediatr Emerg Care 2024; 40:38-44. [PMID: 36972489 DOI: 10.1097/pec.0000000000002926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
Abstract
STUDY OBJECTIVE This study aimed to determine the association between opioid prescriptions given after tonsillectomy with adenoidectomy (T + A) and pain-related return visit rates in pediatric patients. Determine association between Food and Drug Administration (FDA) black box warning against opioid use in this population and pain-related return visit rates. METHODS This was a single-institution retrospective cohort study of pediatric patients who underwent T + A between April 2012 and December 2015 and had return visits to the emergency department or urgent care center. Data were obtained from the hospital electronic warehouse using International Classification of Diseases-9/10 procedure codes. Odds ratios (ORs) with 95% confidence intervals (CIs) for return visits were calculated. Multivariate logistic regression analysis was used to measure association between opioid prescriptions and return visit rates as well as FDA warning and return visit rates adjusting for confounders. RESULTS There were 4778 patients who underwent T + A, median age, 5 years. Of these, 752 (15.7%) had return visits. Pain-related return visits were higher in patients who received opioid prescriptions (adjusted OR, 1.31; 95% CI, 1.09-1.57). After FDA warning, opioids were prescribed at a lower rate (47.9%) compared with previous (98.6%) (OR, 0.01; 95% CI, 0.008-0.02). Pain-related return visits were lower after FDA warning (OR, 0.73; 95% CI, 0.61-0.87). Steroid prescription rate increased after FDA warning (OR, 415; 95% CI, 197-874). CONCLUSIONS Opioid prescriptions were associated with higher pain-related return visits after T + A, whereas issuance of FDA black box warning against codeine use was associated with lower pain-related return visits. Our data suggest that the black box warning potentially had unintended benefits in pain management and health care usage.
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Affiliation(s)
- Naiomi Cohen
- From the Department of Pediatric Emergency Medicine, Nicklaus Children's Hospital, Miami, FL
| | - Kathryn Schissler
- Department of Pediatric Emergency Medicine, Connecticut Children's, University of Connecticut School of Medicine, Hartford, CT
| | | | - Adam Stathas
- Department of Medical Education, Nicklaus Children's Hospital, Miami, FL
| | - Juan Lozano
- Division of Medical and Population Health Sciences Education and Research, College of Medicine, Florida International University, Miami, FL
| | - Sandeep Dave
- Division of Pediatric Otolaryngology, Nicklaus Children's Hospital, Miami, FL
| | - David Lowe
- From the Department of Pediatric Emergency Medicine, Nicklaus Children's Hospital, Miami, FL
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14
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Nixon GM, Horne RSC. Untangling the relationship between childhood risk factors and obstructive sleep apnoea in adulthood. Respirology 2024; 29:14-15. [PMID: 37771297 DOI: 10.1111/resp.14608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 09/20/2023] [Indexed: 09/30/2023]
Abstract
See related article
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Affiliation(s)
- Gillian M Nixon
- Department of Paediatrics, Monash University, Melbourne, Victoria, Australia
- Melbourne Children's Sleep Centre, Monash Children's Hospital, Monash Health, Melbourne, Victoria, Australia
| | - Rosemary S C Horne
- Department of Paediatrics, Monash University, Melbourne, Victoria, Australia
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Redline S, Cook K, Chervin RD, Ishman S, Baldassari CM, Mitchell RB, Tapia IE, Amin R, Hassan F, Ibrahim S, Ross K, Elden LM, Kirkham EM, Zopf D, Shah J, Otteson T, Naqvi K, Owens J, Young L, Furth S, Connolly H, Clark CAC, Bakker JP, Garetz S, Radcliffe J, Taylor HG, Rosen CL, Wang R. Adenotonsillectomy for Snoring and Mild Sleep Apnea in Children: A Randomized Clinical Trial. JAMA 2023; 330:2084-2095. [PMID: 38051326 PMCID: PMC10698619 DOI: 10.1001/jama.2023.22114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Accepted: 10/04/2023] [Indexed: 12/07/2023]
Abstract
Importance The utility of adenotonsillectomy in children who have habitual snoring without frequent obstructive breathing events (mild sleep-disordered breathing [SDB]) is unknown. Objectives To evaluate early adenotonsillectomy compared with watchful waiting and supportive care (watchful waiting) on neurodevelopmental, behavioral, health, and polysomnographic outcomes in children with mild SDB. Design, Setting, and Participants Randomized clinical trial enrolling 459 children aged 3 to 12.9 years with snoring and an obstructive apnea-hypopnea index (AHI) less than 3 enrolled at 7 US academic sleep centers from June 29, 2016, to February 1, 2021, and followed up for 12 months. Intervention Participants were randomized 1:1 to either early adenotonsillectomy (n = 231) or watchful waiting (n = 228). Main Outcomes and Measures The 2 primary outcomes were changes from baseline to 12 months for caregiver-reported Behavior Rating Inventory of Executive Function (BRIEF) Global Executive Composite (GEC) T score, a measure of executive function; and a computerized test of attention, the Go/No-go (GNG) test d-prime signal detection score, reflecting the probability of response to target vs nontarget stimuli. Twenty-two secondary outcomes included 12-month changes in neurodevelopmental, behavioral, quality of life, sleep, and health outcomes. Results Of the 458 participants in the analyzed sample (231 adenotonsillectomy and 237 watchful waiting; mean age, 6.1 years; 230 female [50%]; 123 Black/African American [26.9%]; 75 Hispanic [16.3%]; median AHI, 0.5 [IQR, 0.2-1.1]), 394 children (86%) completed 12-month follow-up visits. There were no statistically significant differences in change from baseline between the 2 groups in executive function (BRIEF GEC T-scores: -3.1 for adenotonsillectomy vs -1.9 for watchful waiting; difference, -0.96 [95% CI, -2.66 to 0.74]) or attention (GNG d-prime scores: 0.2 for adenotonsillectomy vs 0.1 for watchful waiting; difference, 0.05 [95% CI, -0.18 to 0.27]) at 12 months. Behavioral problems, sleepiness, symptoms, and quality of life each improved more with adenotonsillectomy than with watchful waiting. Adenotonsillectomy was associated with a greater 12-month decline in systolic and diastolic blood pressure percentile levels (difference in changes, -9.02 [97% CI, -15.49 to -2.54] and -6.52 [97% CI, -11.59 to -1.45], respectively) and less progression of the AHI to greater than 3 events/h (1.3% of children in the adenotonsillectomy group compared with 13.2% in the watchful waiting group; difference, -11.2% [97% CI, -17.5% to -4.9%]). Six children (2.7%) experienced a serious adverse event associated with adenotonsillectomy. Conclusions In children with mild SDB, adenotonsillectomy, compared with watchful waiting, did not significantly improve executive function or attention at 12 months. However, children with adenotonsillectomy had improved secondary outcomes, including behavior, symptoms, and quality of life and decreased blood pressure, at 12-month follow-up. Trial Registration ClinicalTrials.gov Identifier: NCT02562040.
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Affiliation(s)
- Susan Redline
- Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Kaitlyn Cook
- Program in Statistical and Data Sciences, Smith College, Northampton, Massachusetts
- Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, Massachusetts
| | - Ronald D. Chervin
- Sleep Disorders Center and Department of Neurology, University of Michigan, Ann Arbor
| | - Stacey Ishman
- Department of Otolaryngology, Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Cristina M. Baldassari
- Department of Otolaryngology, Eastern Virginia Medical School, Children’s Hospital of The King’s Daughters, Norfolk
| | - Ron B. Mitchell
- Departments of Otolaryngology-Head and Neck Surgery and Neurology Sleep Disorders Center, UT Southwestern Medical Center, Children’s Medical Center, Dallas
| | - Ignacio E. Tapia
- Department of Pediatrics, Children’s Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Raouf Amin
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Fauziya Hassan
- Sleep Disorders Center and Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor
| | - Sally Ibrahim
- Department of Pediatrics, University Hospitals Rainbow Babies & Children’s Hospital, Cleveland, Ohio
| | - Kristie Ross
- Department of Pediatrics, University Hospitals Rainbow Babies & Children’s Hospital, Cleveland, Ohio
| | - Lisa M. Elden
- Division of Pediatric Otolaryngology, Children’s Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Erin M. Kirkham
- Department of Otolaryngology–Head and Neck Surgery, University of Michigan, Ann Arbor
| | - David Zopf
- Department of Otolaryngology–Head and Neck Surgery, University of Michigan, Ann Arbor
| | - Jay Shah
- Department of Otolaryngology, University Hospitals Rainbow Babies
- University Hospitals Rainbow Babies & Children’s Hospital, Case Western Reserve University, Cleveland, Ohio
| | - Todd Otteson
- Department of Otolaryngology, University Hospitals Rainbow Babies
- University Hospitals Rainbow Babies & Children’s Hospital, Case Western Reserve University, Cleveland, Ohio
| | - Kamal Naqvi
- Department of Pediatrics, UT Southwestern Medical Center, Dallas
| | - Judith Owens
- Department of Neurology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Lisa Young
- Department of Pediatrics, Children’s Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Susan Furth
- Department of Pediatrics, Children’s Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Heidi Connolly
- Department of Pediatrics, University of Rochester, Rochester, New York
| | - Caron A. C. Clark
- Department of Educational Psychology, University of Nebraska-Lincoln
| | - Jessie P. Bakker
- Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Susan Garetz
- Department of Otolaryngology–Head and Neck Surgery and Department of Neurology-Sleep Disorders Center, University of Michigan, Ann Arbor
| | - Jerilynn Radcliffe
- Department of Pediatrics, Children’s Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - H. Gerry Taylor
- Abigail Wexner Research Institute at Nationwide Children’s Hospital and The Ohio State University, Columbus
| | - Carol L. Rosen
- Case Western Reserve University School of Medicine, Department of Pediatrics, Cleveland, Ohio
| | - Rui Wang
- Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, Massachusetts
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
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Hazkani I, Serino MA, Thompson DM, Lavin J. Review of the Utility of Extended Recovery Room Observation after Adenotonsillectomy. Laryngoscope 2023; 133:3582-3587. [PMID: 36960875 DOI: 10.1002/lary.30673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 03/09/2023] [Accepted: 03/11/2023] [Indexed: 03/25/2023]
Abstract
BACKGROUND Our institution implemented a post-anesthesia care unit (PACU) extended-stay model (Grey Zone model), where the post-operative level of care for high-risk adenotonsillectomy patients (general care vs. intensive care unit) was decided based on the clinical course of 2-4 h of PACU admission. OBJECTIVE To assess the correlation between post-tonsillectomy respiratory compromise and the need for respiratory support during an extended stay at PACU. To identify comorbidities associated with a need for intensive care after extended observation. METHODS A retrospective cohort study of high-risk children who underwent adenotonsillectomy and were admitted to the Grey Zone following surgery. RESULTS 274 patients met inclusion criteria. 262 (95.6%) met criteria for general care unit transfer (mean oxygen saturation 94.4 ± 5.1%). Twelve (4.4%) patients were transferred from the PACU to the ICU due to respiratory distress (mean oxygen saturation 86.8 ± 11%). Of the patients admitted to general care, 4 (1.5%) secondarily developed respiratory compromise, requiring escalation of care. Three of these maintained oxygen saturation ≥95% throughout the PACU period. There was no difference between the groups with respect to demographic data, rates of morbid obesity, and severity of obstructive sleep apnea. Neuromuscular disease, chronic lung disease, seizure disorder, and gastrostomy-tube status were more prevalent in those requiring ICU level of care compared to the general care unit. CONCLUSIONS The Grey Zone model accurately identifies patients requiring ICU-level care following adenotonsillectomy, allowing for a safe reduction in the utilization of ICU resources. Due to rare delayed respiratory events, overnight observation in this cohort is recommended. LEVEL OF EVIDENCE 4 Laryngoscope, 133:3582-3587, 2023.
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Affiliation(s)
- Inbal Hazkani
- Division of Pediatric Otolaryngology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, U.S.A
- Department of Otolaryngology-Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, U.S.A
| | - Maeve A Serino
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, U.S.A
| | - Dana M Thompson
- Division of Pediatric Otolaryngology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, U.S.A
- Department of Otolaryngology-Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, U.S.A
| | - Jennifer Lavin
- Division of Pediatric Otolaryngology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, U.S.A
- Department of Otolaryngology-Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, U.S.A
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17
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MacKeith S, Mulvaney CA, Galbraith K, Webster KE, Paing A, Connolly R, Marom T, Daniel M, Venekamp RP, Schilder AG. Adenoidectomy for otitis media with effusion (OME) in children. Cochrane Database Syst Rev 2023; 10:CD015252. [PMID: 37870083 PMCID: PMC10591285 DOI: 10.1002/14651858.cd015252.pub2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2023]
Abstract
BACKGROUND Otitis media with effusion (OME) is an accumulation of fluid in the middle ear cavity, common amongst young children. The fluid may cause hearing loss. When persistent, it may lead to developmental delay, social difficulty and poor quality of life. Management of OME includes watchful waiting, autoinflation, medical and surgical treatment. Adenoidectomy has often been used as a potential treatment for this condition. OBJECTIVES To assess the benefits and harms of adenoidectomy, either alone or in combination with ventilation tubes (grommets), for OME in children. SEARCH METHODS The Cochrane ENT Information Specialist searched the Cochrane ENT Register; Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE; Ovid Embase; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 20 January 2023. SELECTION CRITERIA Randomised controlled trials and quasi-randomised trials in children aged 6 months to 12 years with unilateral or bilateral OME. We included studies that compared adenoidectomy (alone, or in combination with ventilation tubes) with either no treatment or non-surgical treatment. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Primary outcomes (determined following a multi-stakeholder prioritisation exercise): 1) hearing, 2) otitis media-specific quality of life, 3) haemorrhage. SECONDARY OUTCOMES 1) persistence of OME, 2) adverse effects, 3) receptive language skills, 4) speech development, 5) cognitive development, 6) psychosocial skills, 7) listening skills, 8) generic health-related quality of life, 9) parental stress, 10) vestibular function, 11) episodes of acute otitis media. We used GRADE to assess the certainty of evidence for each outcome. Although we included all measures of hearing assessment, the proportion of children who returned to normal hearing was our preferred method to assess hearing, due to challenges in interpreting the results of mean hearing thresholds. MAIN RESULTS We included 10 studies (1785 children). Many of the studies used concomitant interventions for all participants, including insertion of ventilation tubes or myringotomy. All included studies had at least some concerns regarding the risk of bias. We report results for our main outcome measures at the longest available follow-up. We did not identify any data on disease-specific quality of life for any of the comparisons. Further details of additional outcomes and time points are reported in the review. 1) Adenoidectomy (with or without myringotomy) versus no treatment/watchful waiting (three studies) After 12 months there was little difference in the proportion of children whose hearing had returned to normal, but the evidence was very uncertain (adenoidectomy 68%, no treatment 70%; risk ratio (RR) 0.97, 95% confidence interval (CI) 0.65 to 1.46; number needed to treat to benefit (NNTB) 50; 1 study, 42 participants). There is a risk of haemorrhage from adenoidectomy, but the absolute risk appears small (1/251 receiving adenoidectomy compared to 0/229, Peto odds ratio (OR) 6.77, 95% CI 0.13 to 342.54; 1 study, 480 participants; moderate certainty evidence). The risk of persistent OME may be slightly lower after two years in those receiving adenoidectomy (65% versus 73%), but again the difference was small (RR 0.90, 95% CI 0.81 to 1.00; NNTB 13; 3 studies, 354 participants; very low-certainty evidence). 2) Adenoidectomy (with or without myringotomy) versus non-surgical treatment No studies were identified for this comparison. 3) Adenoidectomy and bilateral ventilation tubes versus bilateral ventilation tubes (four studies) There was a slight increase in the proportion of ears with a return to normal hearing after six to nine months (57% adenoidectomy versus 42% without, RR 1.36, 95% CI 0.98 to 1.89; NNTB 7; 1 study, 127 participants (213 ears); very low-certainty evidence). Adenoidectomy may give an increased risk of haemorrhage, but the absolute risk appears small, and the evidence was uncertain (2/416 with adenoidectomy compared to 0/375 in the control group, Peto OR 6.68, 95% CI 0.42 to 107.18; 2 studies, 791 participants). The risk of persistent OME was similar for both groups (82% adenoidectomy and ventilation tubes compared to 85% ventilation tubes alone, RR 0.96, 95% CI 0.86 to 1.07; very low-certainty evidence). 4) Adenoidectomy and unilateral ventilation tube versus unilateral ventilation tube (two studies) Slightly more children returned to normal hearing after adenoidectomy, but the confidence intervals were wide (57% versus 46%, RR 1.24, 95% CI 0.79 to 1.96; NNTB 9; 1 study, 72 participants; very low-certainty evidence). Fewer children may have persistent OME after 12 months, but again the confidence intervals were wide (27.2% compared to 40.5%, RR 0.67, 95% CI 0.35 to 1.29; NNTB 8; 1 study, 74 participants). We did not identify any data on haemorrhage. 5) Adenoidectomy and ventilation tubes versus no treatment/watchful waiting (two studies) We did not identify data on the proportion of children who returned to normal hearing. However, after two years, the mean difference in hearing threshold for those allocated to adenoidectomy was -3.40 dB (95% CI -5.54 to -1.26; 1 study, 211 participants; very low-certainty evidence). There may be a small reduction in the proportion of children with persistent OME after two years, but the evidence was very uncertain (82% compared to 90%, RR 0.91, 95% CI 0.82 to 1.01; NNTB 13; 1 study, 232 participants). We noted that many children in the watchful waiting group had also received surgery by this time point. 6) Adenoidectomy and ventilation tubes versus non-surgical treatment No studies were identified for this comparison. AUTHORS' CONCLUSIONS When assessed with the GRADE approach, the evidence for adenoidectomy in children with OME is very uncertain. Adenoidectomy may reduce the persistence of OME, although evidence about the effect of this on hearing is unclear. For patients and carers, a return to normal hearing is likely to be important, but few studies measured this outcome. We did not identify any evidence on disease-specific quality of life. There were few data on adverse effects, in particular postoperative bleeding. The risk of haemorrhage appears to be small, but should be considered when choosing a treatment strategy for children with OME. Future studies should aim to determine which children are most likely to benefit from treatment, rather than offering interventions to all children.
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Affiliation(s)
- Samuel MacKeith
- ENT Department, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Caroline A Mulvaney
- Cochrane ENT, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Kevin Galbraith
- Cochrane ENT, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Katie E Webster
- Cochrane ENT, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Aye Paing
- Guideline Development Team A, NICE, London, UK
| | | | - Tal Marom
- Department of Otolaryngology-Head and Neck Surgery, Samson Assuta Ashdod University Hospital, Ben Gurion University Faculty of Health Sciences, Ashdod, Israel
| | - Mat Daniel
- Nottingham Children's Hospital, Nottingham, UK
| | - Roderick P Venekamp
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Anne Gm Schilder
- evidENT, Ear Institute, University College London, London, UK
- NIHR UCLH Biomedical Research Centre, University College London, London, UK
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18
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Leroyer H, De Cock A, Fries S, Guinchard AC. [Postoperative monitoring after adenotonsillectomy of children with obstructive sleep apnea syndrome]. Rev Med Suisse 2023; 19:1780-1783. [PMID: 37791691 DOI: 10.53738/revmed.2023.19.844.1780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/05/2023]
Abstract
Tonsillotomy or tonsillectomy, with or without adenoidectomy, is one of the most frequently performed procedure in the pediatric population. Obstructive sleep apnea is one of the main indications for these procedures. Respiratory problems following surgery are the most feared surgical complications. The criteria for identifying patients at risk of complications and the level of care required during monitoring remain controversial. This article reviews the literature on risk factors for respiratory complications. Recommendations for postoperative monitoring are proposed.
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Affiliation(s)
- Hajdi Leroyer
- Service d'ORL et de chirurgie cervico-faciale, Département de chirurgie, Centre hospitalier universitaire vaudois, 1011 Lausanne
| | - Adrien De Cock
- Service d'anesthésiologie, Département des centres interdisciplinaires, Centre hospitalier universitaire vaudois, 1011 Lausanne
| | - Sophie Fries
- Service d'ORL et de chirurgie cervico-faciale, Département de chirurgie, Centre hospitalier universitaire vaudois, 1011 Lausanne
| | - Anne-Claude Guinchard
- Service d'ORL et de chirurgie cervico-faciale, Département de chirurgie, Centre hospitalier universitaire vaudois, 1011 Lausanne
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19
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Gutierrez JA, Shannon CM, Nguyen SA, Labadie RF, White DR. The Impact of Surgical Indication on Posttonsillectomy Hemorrhage: A Systematic Review and Meta-Analysis. Otolaryngol Head Neck Surg 2023; 169:780-791. [PMID: 37003296 DOI: 10.1002/ohn.339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 02/16/2023] [Accepted: 03/13/2023] [Indexed: 04/03/2023]
Abstract
OBJECTIVE To investigate the impact of the surgical indication on posttonsillectomy bleed rates. DATA SOURCES PubMed, Scopus, CINAHL. REVIEW METHODS A systematic review was performed searching for articles published from the date of inception to July 6, 2022. English language articles describing posttonsillectomy hemorrhage rates in pediatric patients (age ≤ 18) stratified by indication were selected for inclusion. A meta-analysis of proportions with comparison (Δ) of weighted proportions was conducted. All studies were assessed for risk of bias. RESULTS A total of 72 articles with 173,970 patients were selected for inclusion. The most common indications were chronic/recurrent tonsillitis (CT/RT), obstructive sleep apnea/sleep-disordered breathing (OSA/SDB), and adenotonsillar hypertrophy (ATH). Posttonsillectomy hemorrhage rates for CT/RT, OSA/SDB, and ATH were 3.57%, 3.69%, and 2.72%, respectively. Patients operated on for a combination of CT/RT and OSA/SDB had a bleed rate of 5.99% which was significantly higher than those operated on for CT/RT alone (Δ2.42%, p = .0006), OSA/SDB alone (Δ2.30%, p = .0016), and ATH alone (Δ3.27%, p < .0001). Additionally, those operated on for a combination of ATH and CT/RT had a hemorrhage rate of 6.93%, significantly higher than those operated on for CT/RT alone (Δ3.36%, p = .0003), OSA/SDB alone (Δ3.01%, p = .0014), and ATH alone (Δ3.98%, p < .0001). CONCLUSION Patients operated on for multiple indications had significantly higher rates of posttonsillectomy hemorrhage than those operated on for a single surgical indication. Better documentation of patients with multiple indications would help further characterize the magnitude of the compounding effect described here.
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Affiliation(s)
- Jorge A Gutierrez
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Christian M Shannon
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Shaun A Nguyen
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Robert F Labadie
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - David R White
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
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20
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Tuggle E, Gettis M, Brown AM, Jeter L, Fujimoto A. Effects of Gabapentin on Emergence Delirium in Pediatric Tonsillectomy/Adenoidectomy Patients: A Post-Hoc Analysis. AANA J 2023; 91:380-384. [PMID: 37788180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 10/05/2023]
Abstract
Emergence delirium (ED) is a significant source of both short- and long-term negative effects in the postoperative pediatric population, most notably following otolaryngology surgeries with an occurrence rate of 17.9%. Gabapentin, a gamma aminobutyric acid agonist, has been used for enhanced recovery in adult patients and for the purpose of decreasing ED in some pediatric patients undergoing strabismus surgery. This secondary analysis examined the effects of preoperative administration of gabapentin on the reduction of postoperative ED in pediatric patients between the ages of 3-18 undergoing elective tonsillectomy and adenoidectomy. The parent study randomized subjects to receive preoperative gabapentin vs placebo. Our chart review encompassed both objective and subjective measures to identify the incidence of ED. While we found no statistical significance between the treatment and control groups, there was a clinically significant reduction of ED behaviors in the gabapentin group. The limitations included nonstandardized intraoperative medication administration, small sample size, and the lack of a validated tool for documenting behaviors associated with ED in the immediate postoperative period. Based on the results of this analysis, further investigation is warranted into the potential benefit of gabapentin to reduce the incidence of postoperative ED in the pediatric patient.
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Affiliation(s)
| | - Margaret Gettis
- Nurse Scientist/Pediatric Nurse Practitioner, Children's Healthcare of Atlanta, Georgia; Children's Healthcare of Atlanta clinical affiliate with Nell Hodgson Woodruff School of Nursing, Emory University.
| | - Ann-Marie Brown
- is Professor and Director of Acute Care Pediatric NP Specialty, Nell Hodgson Woodruff School of Nursing, Emory University, Nurse Scientist Children's Healthcare of Atlanta, Pediatric ICU Nurse Practitioner, Atlanta, Georgia.
| | - Leslie Jeter
- is Senior Clinical Instructor, Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia.
| | - Akane Fujimoto
- Nursing Research GRA, Children's Healthcare of Atlanta, Atlanta, Georgia.
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21
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Jang W, Schwartz C, Zeitouni J, Raghuram A, Idicula WK, Nguyen TQ, Cordero J, Dundar Y. Effect of gold laser energy delivery on postoperative adenotonsillectomy complications. Int J Pediatr Otorhinolaryngol 2023; 172:111662. [PMID: 37494775 DOI: 10.1016/j.ijporl.2023.111662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 06/17/2023] [Accepted: 07/15/2023] [Indexed: 07/28/2023]
Abstract
BACKGROUND This study aimed to determine if the energy delivered by the Gold laser impacted postoperative complication rates after adenoidectomy, tonsillectomy, or adenotonsillectomy. METHODS A retrospective chart review identified 420 patients who met the criteria within the last five years. Indications for the surgeries included recurrent tonsillitis, obstructive sleep apnea, sleep-disordered breathing, adenoiditis, peritonsillar abscess, and other indications. The relationship between the energy delivered (kJ) and various complications such as bleeding, pain, dehydration, readmission, emergency center visits, and clinic calls was evaluated. RESULTS There was a significant correlation between higher kJ delivered and the incidence of major bleeding requiring cauterization in the operating room (p = 0.0311). In addition, emergency center visits (p = 0.0131) and readmission (p = 0.0210) showed a significant correlation with the amount of energy (kJ) delivered. Furthermore, higher energy correlated to higher maximum post-operative pain scores (p = 0.0302). Attendings displayed a different pattern of energy delivery compared to residents (p < 0.0001), which also differed by PGY (p < 0.0001). CONCLUSION There are significant correlations between higher energy delivered in kJ using the Gold laser and less desirable post-operative results. In addition, residents tend to utilize higher energy levels than attendings, but this trend tapers off in the 4th and 5th years. Clinicians utilizing the Gold laser during these procedures should be mindful of the amount of kJ they use.
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Affiliation(s)
- Wooyoung Jang
- Texas Tech University Health Sciences Center - School of Medicine, 3601 4th Street, Lubbock, TX, 79430, USA
| | - Cynthia Schwartz
- Texas Tech University Health Sciences Center - Department of Otolaryngology, 3601 4th Street, STOP 8315, Lubbock, TX, 79430-8315, USA
| | - Jad Zeitouni
- Texas Tech University Health Sciences Center - School of Medicine, 3601 4th Street, Lubbock, TX, 79430, USA
| | - Akshay Raghuram
- Texas Tech University Health Sciences Center - School of Medicine, 3601 4th Street, Lubbock, TX, 79430, USA
| | - Winslo K Idicula
- Texas Tech University Health Sciences Center - Department of Otolaryngology, 3601 4th Street, STOP 8315, Lubbock, TX, 79430-8315, USA
| | - Tam Q Nguyen
- Texas Tech University Health Sciences Center - Department of Otolaryngology, 3601 4th Street, STOP 8315, Lubbock, TX, 79430-8315, USA
| | - Joehassin Cordero
- Texas Tech University Health Sciences Center - Department of Otolaryngology, 3601 4th Street, STOP 8315, Lubbock, TX, 79430-8315, USA
| | - Yusuf Dundar
- Texas Tech University Health Sciences Center - Department of Otolaryngology, 3601 4th Street, STOP 8315, Lubbock, TX, 79430-8315, USA.
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22
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Sant'Ana JP, Mastrandonakis ICF, Silva RSB, Duprat ADC, Floriano CG, Miyake MM. Reliability of nasofibroscopy for the evaluation of adenoid hypertrophy and its correlation with clinical symptoms. Braz J Otorhinolaryngol 2023; 89:101307. [PMID: 37690427 PMCID: PMC10493505 DOI: 10.1016/j.bjorl.2023.101307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 07/14/2023] [Accepted: 08/09/2023] [Indexed: 09/12/2023] Open
Abstract
OBJECTIVE To analyze the reliability of estimating the percentage of rhinopharyngeal obstruction by the adenoid using nasofibroscopy and its correlation with clinical symptoms. METHODS Cross-sectional observational study was conducted, involving 80 patients between 4 and 14 years old, recruited from Santa Casa of São Paulo general otorhinolaryngology outpatient service during the years of 2020 and 2021. All patients underwent nasal endoscopy examination, and the recorded videos were randomly assigned to four evaluators in two different sessions, with a minimum interval of 1 month. The evaluators estimated the percentage of rhinopharyngeal obstruction caused by the adenoid. Intra- and inter-evaluator correlations were established by comparing the reports from each evaluator. The data were compared to the Pro Image J Software report, that also estimates a percentage of obstruction by computer graphics. To correlate the grading of obstruction with clinical symptoms, all patients completed the OSA (Obstructive Sleep Apnea) 18 questionnaire, a validated tool for assessing sleep apnea in children. The questionnaire data were then compared to the average scores assigned by the evaluators. RESULTS Satisfactory intra- and inter-rater correlations were observed, and the results were consistent with the Pro Image J Software. However, no correlation was found between the percentage of obstruction and the severity of clinical symptoms. CONCLUSION Nasofibroscopy demonstrates good reliability in assessing a percentage of rhinopharyngeal obstruction caused by adenoids. However, there is no correlation between the degree of obstruction of the rhinopharynx and the clinical symptoms. LEVEL OF EVIDENCE: 4
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Affiliation(s)
| | | | | | | | - Caio Gomes Floriano
- Santa Casa de São Paulo, Departamento de Otorrinolaringologia, São Paulo, SP, Brazil
| | - Marcel Menon Miyake
- Santa Casa de São Paulo, Departamento de Otorrinolaringologia, São Paulo, SP, Brazil
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23
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Epure V, Hainarosie R, Gheorghe DC. Efficacy of Continuous Suctioning in Adenoidectomy Haemostasis-Clinical Study. Medicina (Kaunas) 2023; 59:1534. [PMID: 37763653 PMCID: PMC10535848 DOI: 10.3390/medicina59091534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 08/03/2023] [Accepted: 08/23/2023] [Indexed: 09/29/2023]
Abstract
Introduction: Adenoidectomy is often the first major surgical challenge for the child's haemostatic system, and controlling intraoperative bleeding can be a challenge for the surgeon. Different methods have been used intraoperatively by surgeons in order to enhance haemostasis. The cold air effect (continuous suctioning) has been used by some surgeons during adenoidectomy; however, no documentation of its haemostatic effect has been made. Objectives: Our prospective randomised controlled study enrolled a sample of 140 children undergoing adenoidectomy, and we studied the effect of continuous suctioning on the duration of haemostasis in paediatric adenoidectomy. Materials and Methods: We evaluated the effect of using continuous suctioning during haemostasis at the end of adenoidectomy procedures, comparing variables such as total surgery time, total haemostasis time, and intraoperative blood loss, between two groups: 70 adenoidectomy procedures where no continuous suctioning was used to enhance haemostasis versus the other 70 patients where continuous suctioning was the haemostatic method employed. RESULTS: After statistical analysis of the recorded data, we found that the total duration of adenoidectomy, the duration of haemostasis in adenoidectomy, and the intraoperative blood loss were significantly lower in patients in whom cold air was used for haemostasis. Intraoperative haemostasis failure (and consequent use of electrocautery for haemostasis) was more frequent in patients in whom no suctioning was used; as for the rates of postoperative primary bleeding after adenoidectomy, they were similar in both groups of patients, regardless of the technique used for haemostasis. Conclusions: The use of continuous suctioning during adenoidectomy haemostasis significantly shortens total surgical and haemostasis time, reduces intraoperative blood loss, and reduces the incidence of haemostasis failure (with the consequent need for bipolar electrocautery haemostasis).
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Affiliation(s)
- Veronica Epure
- ENT Department, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania
- ENT Department, “Marie Curie” Children Hospital, Bd. C. Brâncoveanu 20, 041451 Bucharest, Romania
| | - Razvan Hainarosie
- ENT Department, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania
- I.F.A.C.F.-ORL Prof Dr. D. Hociota, M. Cioranu 21, 061344 Bucharest, Romania
| | - Dan Cristian Gheorghe
- ENT Department, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania
- ENT Department, “Marie Curie” Children Hospital, Bd. C. Brâncoveanu 20, 041451 Bucharest, Romania
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24
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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25
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Luttrell JB, Nieri CA, Mamidala M, Sheyn A. Outcomes and considerations in children with developmental delay undergoing tonsillectomy. Int J Pediatr Otorhinolaryngol 2023; 164:111393. [PMID: 36473255 DOI: 10.1016/j.ijporl.2022.111393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 11/06/2022] [Accepted: 11/16/2022] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Developmental delay (DD) affects one in six children and has been shown to require more health care than the average child [1-2]. Certain recent studies have suggested an increased rate of complications/costs in children with DD [3-5]. Our objective was to perform a retrospective study comparing DD children to non-DD controls in patients presenting for tonsillectomy over a 1-year period to further define the relationship between DD and post-operative complications. METHODS We conducted a retrospective chart review of children undergoing tonsillectomy over a one-year period. We collected demographic information, polysomnogram, comorbidities, complications, and length of stay. A diagnosis of developmental delay was considered if recorded prior to the tonsillectomy or workup was ongoing at the time of tonsillectomy. All data was analyzed using IBM SPSS Statistics 25. RESULTS The final cohort included 400 patients. Our cohort had 56 patients with diagnosis of DD. We recorded 18 complications in the DD population (32.14%) compared to 30 complications in the control group (8.72%) (p < 0.00001). Children with DD had higher incidence of comorbidities (p < 0.00001), complication with comorbidities (p < 0.00001), and incidence of prematurity (p < 0.00001); whereas, they did not have increased length of stay (LOS) (p = 0.33) or complications if premature (p = 0.22). Pre-operative polysomnogram was associated with higher incidence of complication (p = 0.035) in the total population but children with DD did not have higher pre-operative obstructive apnea-hypopnea index (oAHI)compared to the control patients (p = 0.25). CONCLUSION Children with DD were found to have a significantly higher complication rate compared to children without DD in our patient population. They did have higher incidence of additional comorbidities and prematurity. This elevated risk should at least be included in pre-operative counseling, but additionally has potential implications for pre-operative decision making and treatment plans in this high-risk population.
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Affiliation(s)
- Jordan B Luttrell
- Department of Otolaryngology - Head and Neck Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Chad A Nieri
- Department of Otolaryngology - Head and Neck Surgery, University of Tennessee Health Science Center, Memphis, TN, USA.
| | - Madhu Mamidala
- Department of Otolaryngology - Head and Neck Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Anthony Sheyn
- Department of Otolaryngology - Head and Neck Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
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Vaughn WL, Cordray H, Baranwal N, Rahman R, Mahendran GN, Clark A, Wright EA, Pak-Harvey E, Patel C, Evans SS. Evaluating obesity as a risk factor for complications after pediatric adenotonsillectomy. Int J Pediatr Otorhinolaryngol 2022; 163:111333. [PMID: 36257170 DOI: 10.1016/j.ijporl.2022.111333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 09/26/2022] [Accepted: 09/29/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVES To evaluate associations between childhood obesity and post-adenotonsillectomy complications, informing guidelines for postoperative management. METHODS The retrospective review assessed outpatient pediatric tonsillectomy/adenoidectomy cases performed at 2 ambulatory surgery centers in 2020. Complications in the recovery unit and within 2 weeks of surgical discharge were reviewed along with clinical and demographic variables. Obesity was defined as sex-specific body mass index-for-age, or weight-for-age if height data were unavailable, at/above the 95th percentile. The 99th percentile served as the threshold for severe obesity. Analyses used Chi-square/Fisher's exact tests and independent-samples t-tests with relative risk or effect sizes. RESULTS The review included 707 cases (180 patients with obesity). Overall incidence of complications in the recovery unit was 9.1%. Patients with obesity were significantly more likely to require supplemental blow-by oxygen (P = .02); relative risk was 1.65 (95% CI: 1.16-2.35) times greater in the cohort with obesity. Obesity had a small effect on postoperative oxygen saturation nadirs, which were significantly lower among patients with obesity (d = -0.34; P < .001). No differences emerged between cohorts with and without obesity in the incidence of any other complications before or after surgical discharge. Overall incidence of post-discharge returns was 7.9%. Incidence of complications did not vary by obesity severity. CONCLUSION From this cohort, childhood obesity without other significant comorbidities may not warrant routine inpatient care following adenotonsillectomy. Patients with obesity should receive additional monitoring for oxygen desaturation events during the first hours of recovery. Further prospective studies should continue to address this important topic.
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Affiliation(s)
| | - Holly Cordray
- Children's Healthcare of Atlanta, Atlanta, GA, USA; Department of Otolaryngology-Head and Neck Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Navya Baranwal
- Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Rahiq Rahman
- Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Geethanjeli N Mahendran
- Emory University School of Medicine, Atlanta, GA, USA; Rollins School of Public Health, Atlanta, GA, USA
| | - Addison Clark
- Department of Biological and Environmental Sciences, Georgia College and State University, USA
| | | | | | - Chhaya Patel
- Children's Healthcare of Atlanta, Atlanta, GA, USA; Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Sean S Evans
- Children's Healthcare of Atlanta, Atlanta, GA, USA; Department of Otolaryngology-Head and Neck Surgery, Emory University School of Medicine, Atlanta, GA, USA.
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27
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Gerhardsson H, Stalfors J, Sunnergren O. Postoperative morbidity and mortality after adenoidectomy: A national population-based study of 51 746 surgeries. Int J Pediatr Otorhinolaryngol 2022; 163:111335. [PMID: 36265351 DOI: 10.1016/j.ijporl.2022.111335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 06/22/2022] [Accepted: 10/01/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVES To investigate postoperative morbidity and mortality after paediatric adenoidectomy. METHODS This was a retrospective national population-based cohort study of data from the Swedish National Patient Register (NPR) and The Swedish Cause of Death Register (CDR). All patients aged 0-18 years who underwent adenoidectomy from 2007 to 2017 (without concomitant tonsil surgery) were included in this study. To evaluate postoperative morbidity and mortality, all diagnostic and surgical codes registered in the NPR for health care contacts within 30 days of surgery were analysed. The patients retrieved from the NPR were matched with the CDR to identify any deaths occurring within 30 days of the surgery. RESULTS A total of 51 746 adenoidectomies were included in this study. No deaths related to adenoidectomy were identified. All types of haemorrhagic complications were rare. Only 0.1% of the surgeries resulted in an outpatient contact due to postoperative haemorrhage and only 0.1% of the adenoidectomies resulted in a readmission due to haemorrhage. The rarest haemorrhagic complication was RTT (return to theatre), with only 4 events (0.01%). Postoperative haemorrhage was most frequent on the first day after surgery. Other complications were rare as well, requiring a total of 922 (2.6%) outpatient visits and 75 (0.2%) readmissions in the adenoidectomy group, with postoperative infection being the most commonly reported. CONCLUSIONS Overall, adenoidectomy should be considered a safe surgical procedure associated with few postoperative complications. No deaths related to adenoidectomy were found. Severe complications, such as late postoperative haemorrhage after adenoidectomy, were rare, and haemorrhage resulting in RTT was even rarer. The highest rate of postoperative haemorrhage was observed the first day after surgery, and most haemorrhagic complications occurred within a week. Comparisons with studies on tonsil surgery show that adenoidectomy is associated with substantially lower postoperative morbidity.
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Affiliation(s)
- Hanna Gerhardsson
- Department of Otorhinolaryngology, Region Jönköping County, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden.
| | - Joacim Stalfors
- Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Göteborg, Sweden
| | - Ola Sunnergren
- Department of Otorhinolaryngology, Region Jönköping County, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
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Kukkala S, Vazifedan T, Baldassari CM. Association of Apnea vs Hypopnea Predominance With Pediatric Sleep Apnea Outcomes: A Secondary Analysis of the Childhood Adenotonsillectomy Trial. JAMA Otolaryngol Head Neck Surg 2022; 148:1038-1043. [PMID: 36201186 PMCID: PMC9539728 DOI: 10.1001/jamaoto.2022.3031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Accepted: 08/20/2022] [Indexed: 12/13/2022]
Abstract
Importance Children with apnea-predominant obstructive sleep apnea (OSA) are hypothesized to have a more severe form of the disease. However, research is lacking as to whether there is a significant difference in outcomes between children with apnea-predominant vs hypopnea-predominant OSA. Objective To assess the association between baseline apnea-predominant or hypopnea-predominant OSA on polysomnography and quality of life (QOL) outcomes in children with obstructive sleep apnea managed by watchful waiting with supportive care (WWSC) or adenotonsillectomy (AT). Design, Setting, and Participants This case-control study is a secondary analysis of a randomized clinical trial, the Childhood Adenotonsillectomy Trial, which was conducted at multiple tertiary children's hospitals from October 2007 to June 2012. Children aged 5.0 to 9.9 years with OSA were randomized to WWSC or AT and underwent polysomnography and completed validated QOL and symptom assessments at baseline and 7 months. The current data analysis was performed from October 2020 to February 2022. Main Outcomes and Measures Apnea-predominant OSA was defined as an apnea hypopnea index (AHI) greater than 2 with more than 50% of the obstructive events being apneas. Patients were considered to have hypopnea-predominant OSA if they had an AHI greater than 2 and more than 50% of the obstructive events were hypopneas. Results A total of 386 children (185 boys [48%]; mean [SD] age, 6.56 [1.4] years) were analyzed. The mean (SD) obstructive AHI for patients was 6.98 (5.62), with 198 patients (51%) having mild disease. Thirty-seven children (10%) had apnea-predominant OSA at baseline. Black children were at increased risk for apnea-predominant OSA vs White children (odds ratio [OR], 13.40; 95% CI, 5.70-33.90). Children with apnea predominance were more likely to have severe OSA (AHI >10) compared with children with hypopnea predominance (OR, 2.30; 95% CI, 1.03-5.03); baseline Pediatric Sleep Questionnaire and OSA-18 QOL scores were similar between the 2 groups. Among children undergoing AT, those with baseline apnea predominance were more likely to have a Pediatric Sleep Questionnaire score greater than 0.33 at follow-up (OR, 3.30; 95% CI, 1.01-10.80). Rates of OSA resolution and improvements in QOL scores following AT or WWSC were similar between the apnea-predominant and hypopnea-predominant groups. Conclusions and Relevance In children with OSA, apnea-predominant disease is uncommon. Apnea predominance was not associated with symptom resolution and cure rates in children undergoing AT or WWSC for OSA. Further research is needed to assess how apnea predominance affects AT outcomes in children with more severe disease.
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Affiliation(s)
| | - Turaj Vazifedan
- Department of Pediatrics, Children’s Hospital of the King’s Daughters, Norfolk, Virginia
| | - Cristina M. Baldassari
- Department of Otolaryngology Head and Neck Surgery, Eastern Virginia Medical School, Norfolk
- Division of Sleep Medicine, Children’s Hospital of the King’s Daughters, Norfolk, Virginia
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Kaditis AG, Gozal D. Adenotonsillectomy: the good, the bad and the unknown. Curr Opin Pulm Med 2022; 28:537-542. [PMID: 36039903 DOI: 10.1097/mcp.0000000000000911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Adenotonsillar hypertrophy is the most common pathogenetic contributor to obstructive sleep apnea syndrome (OSAS) in childhood, and adenotonsillectomy is the standard initial treatment. Here, we summarize the most recent evidence on the efficacy and complications of adenotonsillectomy and explore knowledge gaps in clinical management. RECENT FINDINGS Favorable adenotonsillectomy effects have been reported in children with very severe OSAS [apnea-hypopnea index (AHI) >20 episodes/h] and extremely severe OSAS (AHI >100 episodes/h), without postoperative mortality, need for endotracheal intubation, prolonged hospital stay or re-admission after hospital discharge. However, the risk of residual OSAS after adenotonsillectomy, which may reach 30-60%, has not been thoroughly established. Behavior, OSAS-related symptoms and quality of life improve postoperatively even in children with AHI 1-5 episodes/h. Natural history of enuresis resolution is accelerated postadenotonsillectomy and office-based systemic blood pressure is decreased in OSAS and hypertension. However, which children younger than 2 years should undergo adenotonsillectomy instead of adenoidectomy only to prevent recurrence of OSAS symptoms and revision surgery remains unclear. Adenotonsillectomy in children with Prader-Willi syndrome is frequently accompanied by postoperative residual OSAS while complications are not uncommon. SUMMARY In the last 2 years, several studies have provided evidence supporting the efficacy and safety of adenotonsillectomy as treatment intervention for otherwise healthy children with OSAS.
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Affiliation(s)
- Athanasios G Kaditis
- Division of Pediatric Pulmonology, First Department of Pediatrics, National and Kapodistrian University of Athens School of Medicine and Agia Sofia Children's Hospital, Athens, Greece
- Division of Pediatric Pulmonology and Pediatric Sleep Center, Department of Child Health, University of Missouri School of Medicine and MU Children's Hospital, Columbia, Missouri, USA
| | - David Gozal
- Division of Pediatric Pulmonology and Pediatric Sleep Center, Department of Child Health, University of Missouri School of Medicine and MU Children's Hospital, Columbia, Missouri, USA
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钟 建, 罗 向, 仇 书, 程 超, 周 宜, 陈 兰, 杨 李, 王 顺, 刘 大. [Preliminary study on efficacy and safety of submucosal plasma ablation of inferior turbinate in children with allergic rhinitis complicated with obstructive sleep apnea syndrome]. Lin Chuang Er Bi Yan Hou Tou Jing Wai Ke Za Zhi 2022; 36:758-762. [PMID: 36217654 PMCID: PMC10128553 DOI: 10.13201/j.issn.2096-7993.2022.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Indexed: 06/16/2023]
Abstract
Objective:This study aimed to investigate the long-term clinical efficacy and safety of inferior turbinate submucosal plasma ablation combined with or without tonsillar and adenoid surgery in children with allergic rhinitis(AR) combined with obstructive sleep apnea syndrome(OSAS) who were ineffective after conservative systemic treatment. Methods:A total of 43 children with AR complicated with OSAS who met the inclusion criteria among 68 children hospitalized from January 2019 to February 2022 were retrospectively analyzed. The data were collected, including the clinical characteristics, surgical methods perioperative management and prevention and treatment of complications. Moreover, one year follow-up was performed to compare the VAS scores of children before and after surgery, and to evaluate their mid-term and long-term outcomes. Results:The average operation time was 36 minutes, meanwhile, the intraoperative blood was limited. The symptoms of nasal congestion, runny nose, sleep snoring, and mouth breathing were significantly improved after operation, and the results were satisfactory after one-year follow-up without complications such as bleeding, hematoma, intraoperative adhesion, and nasal dryness. Conclusion:Submucosal plasma ablation of inferior turbinate with or without tonsillectomy adenoidectomy in children with AR can effectively improve the clinical symptoms of AR combined with OSAS children who are ineffective after conservative treatment. It can improve the symptoms of sleep-disordered breathing such as sleep snoring and mouth breathing, with good mid-and long-term curative effects and fewer complications, which is an effective and safe treatment for children with AR combined with OSAS.
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Affiliation(s)
- 建文 钟
- 南方医科大学深圳医院儿童耳鼻咽喉科(广东深圳,518000)Department of Pediatric Otolaryngology, Shenzhen Hospital of Southern Medical University, Shenzhen, 518000, China
| | - 向前 罗
- 南方医科大学深圳医院儿童耳鼻咽喉科(广东深圳,518000)Department of Pediatric Otolaryngology, Shenzhen Hospital of Southern Medical University, Shenzhen, 518000, China
| | - 书要 仇
- 南方医科大学深圳医院儿童耳鼻咽喉科(广东深圳,518000)Department of Pediatric Otolaryngology, Shenzhen Hospital of Southern Medical University, Shenzhen, 518000, China
| | - 超 程
- 南方医科大学深圳医院儿童耳鼻咽喉科(广东深圳,518000)Department of Pediatric Otolaryngology, Shenzhen Hospital of Southern Medical University, Shenzhen, 518000, China
| | - 宜龙 周
- 南方医科大学深圳医院儿童耳鼻咽喉科(广东深圳,518000)Department of Pediatric Otolaryngology, Shenzhen Hospital of Southern Medical University, Shenzhen, 518000, China
| | - 兰 陈
- 南方医科大学深圳医院儿童耳鼻咽喉科(广东深圳,518000)Department of Pediatric Otolaryngology, Shenzhen Hospital of Southern Medical University, Shenzhen, 518000, China
| | - 李强 杨
- 南方医科大学深圳医院儿童耳鼻咽喉科(广东深圳,518000)Department of Pediatric Otolaryngology, Shenzhen Hospital of Southern Medical University, Shenzhen, 518000, China
| | - 顺成 王
- 南方医科大学深圳医院儿童耳鼻咽喉科(广东深圳,518000)Department of Pediatric Otolaryngology, Shenzhen Hospital of Southern Medical University, Shenzhen, 518000, China
| | - 大波 刘
- 南方医科大学深圳医院儿童耳鼻咽喉科(广东深圳,518000)Department of Pediatric Otolaryngology, Shenzhen Hospital of Southern Medical University, Shenzhen, 518000, China
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Tsampalieros A, Murto K, Barrowman N, Vaillancourt R, Bromwich M, Monsour A, Chan T, Katz SL. Opioid dose and postoperative respiratory adverse events after adenotonsillectomy in medically complex children. J Clin Sleep Med 2022; 18:2405-2413. [PMID: 35801349 PMCID: PMC9516588 DOI: 10.5664/jcsm.10120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 05/13/2022] [Accepted: 05/13/2022] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES Obstructive sleep-disordered breathing is commonly treated with adenotonsillectomy. Our study objective was to describe perioperative opioid dosing in children with a range of medical complexity evaluated for obstructive sleep-disordered breathing undergoing adenotonsillectomy and to investigate its association with postoperative respiratory adverse events (PRAEs). METHODS A retrospective chart review of children who underwent adenotonsillectomy and had preoperative polysomnography performed was conducted. PRAEs included requiring oxygen, jaw thrust, positive airway pressure, or mechanical ventilation. Multivariable logistic regression was performed to examine for associations between covariates and PRAEs. RESULTS The cohort included 374 children with obstructive sleep-disordered breathing, median (interquartile range) age 6.1 (3.9, 9.3) years; 344 (92%) had obstructive sleep apnea (apnea-hypopnea index > 1 events/h) while 30 (8%) had a normal polysomnogram (apnea-hypopnea index < 1 events/h). The median (interquartile range) postoperative morphine-equivalent dose administered was 0.17 (0.09, 0.25) mg/kg. Sixty-six (17.6%) experienced at least 1 PRAE. Multivariable modeling identified the following predictors of PRAE: younger age at surgery (odds ratio 0.90, 95% confidence interval 0.83, 0.98), presence of cardiac comorbidity (odds ratio 2.07, 95% confidence interval 1.09, 3.89), and presence of airway anomaly (odds ratio 3.48, 95% confidence interval 1.30, 8.94). Higher total apnea-hypopnea index and morphine-equivalent dose were associated with PRAE risk, and an interaction between these variables was detected (P = .01). CONCLUSIONS This study identified opioid dose in morphine equivalents to be a strong predictor of PRAE. Additionally, severity of obstructive sleep apnea and postoperative morphine-equivalent dose contributed together and independently to the occurrence of PRAEs. Attention to opioid dosing, particularly among medically complex children with obstructive sleep-disordered breathing, is required to mitigate risk of PRAEs. CITATION Tsampalieros A, Murto K, Barrowman N, et al. Opioid dose and postoperative respiratory adverse events after adenotonsillectomy in medically complex children. J Clin Sleep Med. 2022;18(10):2405-2413.
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Affiliation(s)
- Anne Tsampalieros
- Children’s Hospital of Eastern Ontario Research Institute, Ottawa, Canada
| | - Kimmo Murto
- Children’s Hospital of Eastern Ontario Research Institute, Ottawa, Canada
- Children’s Hospital of Eastern Ontario, Department of Anesthesiology and Pain Medicine, Ottawa, Canada
| | - Nicholas Barrowman
- Children’s Hospital of Eastern Ontario Research Institute, Ottawa, Canada
- Children’s Hospital of Eastern Ontario, Department of Pediatrics, Ottawa, Canada
| | - Regis Vaillancourt
- Children’s Hospital of Eastern Ontario, Department of Pharmacy, Ottawa, Canada
| | - Matthew Bromwich
- Children’s Hospital of Eastern Ontario, Department of Surgery, Ottawa, Canada
| | - Andrea Monsour
- Children’s Hospital of Eastern Ontario Research Institute, Ottawa, Canada
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Canada
| | - Theadora Chan
- Children’s Hospital of Eastern Ontario Research Institute, Ottawa, Canada
| | - Sherri L. Katz
- Children’s Hospital of Eastern Ontario Research Institute, Ottawa, Canada
- Children’s Hospital of Eastern Ontario, Department of Pediatrics, Ottawa, Canada
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Yang X, Lin C, Chen S, Huang Y, Cheng Q, Yao Y. Remimazolam for the Prevention of Emergence Delirium in Children Following Tonsillectomy and Adenoidectomy Under Sevoflurane Anesthesia: A Randomized Controlled Study. Drug Des Devel Ther 2022; 16:3413-3420. [PMID: 36203819 PMCID: PMC9531607 DOI: 10.2147/dddt.s381611] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 09/20/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose To identify the effectiveness of remimazolam at the end of tonsillectomy and adenoidectomy for preventing emergence delirium in children under sevoflurane anesthesia. Patients and Methods One hundred and four patients aged 3–7 years scheduled for tonsillectomy and adenoidectomy under sevoflurane anesthesia were recruited. Patients were randomly assigned to receive either remimazolam 0.2 mg kg–1 (intervention, n=52) or 0.9% normal saline (control, n=52) at the end of the procedure. The primary outcome was the incidence of emergence delirium, defined as a Pediatric Anesthesia Emergence Delirium (PAED) score ≥10. Secondary outcomes were peak PAED score, emergence time, postoperative pain intensity, length of postanesthesia care unit (PACU) stay, parental satisfaction, and postoperative behavior changes three days postoperatively. Results Emergence delirium occurred in 6 of 51 (12%) patients receiving remimazolam versus 22 of 50 (44%) patients receiving saline (risk difference 32% [95% confidence interval, 16% to 49%], relative risk 0.27 [95% confidence interval, 0.12 to 0.60]; P<0.001). The peak PAED scores (median [interquartile range]) were lower in the remimazolam group than in the saline group (7 [6–8] versus 9 [8–11], P<0.001). Likewise, parental satisfaction was improved in the remimazolam group compared with the saline group (9 [8–10] versus 8 [7–8], P<0.001). There was no difference between groups concerning postoperative pain scores, length of PACU stay, or postoperative behavior changes. Conclusion In children undergoing tonsillectomy and adenoidectomy, administration of remimazolam 0.2 mg kg–1 at the end of the surgery, compared with 0.9% saline, resulted in a significantly lower likelihood of emergence delirium after sevoflurane anesthesia.
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Affiliation(s)
- Xue Yang
- Department of Neurology, Shengli Clinical Medical College of Fujian Medical University, Fuzhou, People’s Republic of China
| | - Chuantao Lin
- Department of Anesthesiology, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, People’s Republic of China
| | - Sisi Chen
- Department of Anesthesiology, Shengli Clinical Medical College of Fujian Medical University, Fuzhou, People’s Republic of China
| | - Yuezhou Huang
- Department of Anesthesiology, Shengli Clinical Medical College of Fujian Medical University, Fuzhou, People’s Republic of China
| | - Qiong Cheng
- Department of Neurology, Shengli Clinical Medical College of Fujian Medical University, Fuzhou, People’s Republic of China
- Correspondence: Qiong Cheng, Email
| | - Yusheng Yao
- Department of Anesthesiology, Shengli Clinical Medical College of Fujian Medical University, Fuzhou, People’s Republic of China
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Dalesio NM, Kudchadkar SR. Perioperative Respiratory Adverse Events After Pediatric Adenotonsillectomy-Evaluating the Role of Preoperative Pharmacologic Anxiolysis. JAMA Netw Open 2022; 5:e2225482. [PMID: 35943746 DOI: 10.1001/jamanetworkopen.2022.25482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Nicholas M Dalesio
- Department of Anesthesiology and Critical Care Medicine, Division of Pediatric Anesthesiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sapna R Kudchadkar
- Department of Anesthesiology and Critical Care Medicine, Division of Pediatric Anesthesiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Shen F, Zhang Q, Xu Y, Wang X, Xia J, Chen C, Liu H, Zhang Y. Effect of Intranasal Dexmedetomidine or Midazolam for Premedication on the Occurrence of Respiratory Adverse Events in Children Undergoing Tonsillectomy and Adenoidectomy: A Randomized Clinical Trial. JAMA Netw Open 2022; 5:e2225473. [PMID: 35943745 PMCID: PMC9364121 DOI: 10.1001/jamanetworkopen.2022.25473] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
IMPORTANCE Perioperative respiratory adverse events (PRAEs) are the most common complication during pediatric anesthesia, and they may be affected by the administration of preoperative sedatives. OBJECTIVE To investigate the effect of intranasal dexmedetomidine or midazolam used for premedication on the occurrence of PRAEs. DESIGN, SETTING, AND PARTICIPANTS This single-center, double-blind, randomized clinical trial was conducted among children aged 0 to 12 years undergoing elective tonsillectomy and adenoidectomy from October 2020 to June 2021 at Children's Hospital of Xuzhou Medical University, Xuzhou, China. Data analysis was performed from June to October 2021. INTERVENTIONS Children were randomly assigned to 3 groups: the midazolam group received intranasal midazolam (0.1 mg/kg), and the dexmedetomidine group received intranasal dexmedetomidine (2.0 μg/kg) for premedication. The normal saline group received intranasal 0.9% saline for control. MAIN OUTCOMES AND MEASURES The primary outcome was the difference in the incidence of PRAEs among the 3 groups. The secondary outcomes were the frequency of the individual PRAEs, including the incidence of such events during the induction and recovery periods, postoperative emergence delirium, postoperative pain score, sedation success rate, and heart rate values. RESULTS A total of 384 children (median [IQR] age, 7 [5-10] years; 227 boys [59.1%]) were enrolled and randomized; 373 data sets were available for intention-to-treat analysis (124 children in the midazolam group, 124 children in the dexmedetomidine group, and 125 children in the normal saline group). After the data were adjusted for age, sex, American Society of Anesthesiologists physical status, body mass index, obstructive sleep apnea, upper respiratory tract infection, and passive smoking, children in the midazolam group were more likely to experience PRAEs than those in the normal saline group (70 of 124 children [56.5%] vs 51 of 125 children [40.8%]; adjusted odds ratio [aOR], 1.99; 95% CI, 1.18-3.35), whereas the dexmedetomidine group had a significantly lower PRAEs incidence than the normal saline group (30 of 124 children [24.2%] vs 51 of 125 children [40.8%]; aOR, 0.45; 95% CI, 0.26-0.78). Compared with the dexmedetomidine group, the midazolam group had a higher risk of PRAEs (aOR, 4.44; 95% CI, 2.54-7.76), but no other serious clinical adverse events were observed. CONCLUSIONS AND RELEVANCE In this randomized clinical trial, intranasal midazolam used for premedication was associated with increased incidence of PRAEs, whereas premedication with intranasal dexmedetomidine was associated with reduced incidence of PRAEs. Where clinically appropriate, anesthesiologists should consider using intranasal dexmedetomidine for sedation in children undergoing tonsillectomy and adenoidectomy. TRIAL REGISTRATION Chinese Clinical Trial Register Identifier: ChiCTR2000038359.
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Affiliation(s)
- Fangming Shen
- Jiangsu Province Key Laboratory of Anesthesiology, Xuzhou Medical University, Xuzhou, Jiangsu, China
- Department of Anesthesiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, China
| | - Qin Zhang
- Jiangsu Province Key Laboratory of Anesthesiology, Xuzhou Medical University, Xuzhou, Jiangsu, China
- Department of Anesthesiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, China
| | - Yahui Xu
- Jiangsu Province Key Laboratory of Anesthesiology, Xuzhou Medical University, Xuzhou, Jiangsu, China
- Department of Anesthesiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, China
| | - Xinghe Wang
- Jiangsu Province Key Laboratory of Anesthesiology, Xuzhou Medical University, Xuzhou, Jiangsu, China
- Department of Anesthesiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, China
| | - Jiayi Xia
- Jiangsu Province Key Laboratory of Anesthesiology, Xuzhou Medical University, Xuzhou, Jiangsu, China
- Department of Anesthesiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, China
| | - Chao Chen
- The Children’s Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, China
| | - He Liu
- Department of Anesthesiology, Huzhou Central Hospital, The Affiliated Huzhou Hospital, Zhejiang University School of Medicine, Huzhou, Zhejiang, China
| | - Yueying Zhang
- Jiangsu Province Key Laboratory of Anesthesiology, Xuzhou Medical University, Xuzhou, Jiangsu, China
- Department of Anesthesiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, China
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Friedman NR, Meier M, Tholen K, Crowder R, Hoefner-Notz R, Nguyen T, Derieg S, Campbell K, McLeod L. Tonsillectomy for Obstructive Sleep-Disordered Breathing: Should They Stay, or Could They Go? Laryngoscope 2022; 132:1675-1681. [PMID: 34672364 DOI: 10.1002/lary.29909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 10/05/2021] [Accepted: 10/12/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVES/HYPOTHESIS Children who do not require oxygen beyond 3 hours after surgery and pass a sleep room air challenge (SRAC) are safe for discharge regardless of polysomnogram (PSG) results or comorbidities. STUDY DESIGN Cross-sectional prospective study. METHODS All children observed overnight undergoing an adenotonsillectomy for obstructive sleep-disordered breathing were prospectively recruited. Demographic, clinical, and PSG characteristics were stratified by whether the patient had required oxygen beyond 3 hours postoperatively (prolonged oxygen requirement [POR]) and compared using t test, chi-squared test, or Fisher's exact test depending on distribution. Optimal cut points for predicting POR postsurgery were calculated using receiver operating characteristic curves. The primary analysis was performed on the full cohort via logistic regression using POR as the outcome. Significant characteristics were analyzed in a logistic regression model, with significance set at P < .05. RESULTS A total of 484 participants met the inclusion criteria. The mean age was 5.65 (standard deviation = 4.02) years. Overall, 365 (75%) did not have a POR or any other adverse respiratory event. In multivariable logistic regression, risk factors for POR were an asthma diagnosis (P < .001) and an awake SpO2 <96% (P = .005). The probability of a POR for those without asthma and a SpO2 ≥ 96% was 18% (95% confidence interval: 14-22). Age, obesity, and obstructive apnea/hypopnea index were not associated with POR. CONCLUSIONS In conclusion, all children in our study who are off oxygen within 3 hours of surgery and passed a SRAC were safe for discharge from a respiratory standpoint regardless of age, obesity status, asthma diagnosis, and obstructive apnea/hypopnea index. Additional investigations are necessary to confirm our findings. LEVEL OF EVIDENCE 3 Laryngoscope, 132:1675-1681, 2022.
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Affiliation(s)
- Norman R Friedman
- Department of Otolaryngology, University of Colorado School of Medicine, Aurora, Colorado, U.S.A
- Division of Pediatric Otolaryngology, Children's Hospital Colorado, Aurora, Colorado, U.S.A
| | - Maxene Meier
- The Center for Research in Outcomes for Children's Surgery, University of Colorado School of Medicine, Aurora, Colorado, U.S.A
| | - Kaitlyn Tholen
- Department of Otolaryngology, University of Colorado School of Medicine, Aurora, Colorado, U.S.A
- Division of Pediatric Otolaryngology, Children's Hospital Colorado, Aurora, Colorado, U.S.A
| | - Renee Crowder
- University of Colorado School of Medicine, Aurora, Colorado, U.S.A
| | - Regina Hoefner-Notz
- Perioperative Services, Children's Hospital Colorado, Aurora, Colorado, U.S.A
| | - Thanh Nguyen
- Division of Pediatric Anesthesia, Children's Hospital Colorado, Aurora, Colorado, U.S.A
- Department of Anesthesiology, School of Medicine, University of Colorado, Aurora, Colorado, U.S.A
| | - Sarah Derieg
- Ambulatory Services, Children's Hospital Colorado, Aurora, Colorado, U.S.A
| | - Kristen Campbell
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, U.S.A
| | - Lisa McLeod
- Pediatric Center of Excellence, Global Product Development, Pfizer, Inc., New York, New York, U.S.A
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Edmonson MB, Zhao Q, Francis DO, Kelly MM, Sklansky DJ, Shadman KA, Coller RJ. Association of Patient Characteristics With Postoperative Mortality in Children Undergoing Tonsillectomy in 5 US States. JAMA 2022; 327:2317-2325. [PMID: 35727278 PMCID: PMC9214584 DOI: 10.1001/jama.2022.8679] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
IMPORTANCE The rate of postoperative death in children undergoing tonsillectomy is uncertain. Mortality rates are not separately available for children at increased risk of complications, including young children (aged <3 y) and those with sleep-disordered breathing or complex chronic conditions. OBJECTIVE To estimate postoperative mortality following tonsillectomy in US children, both overall and in relation to recognized risk factors for complications. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study based on longitudinal analysis of linked records in state ambulatory surgery, inpatient, and emergency department discharge data sets distributed by the Healthcare Cost and Utilization Project for 5 states covering 2005 to 2017. Participants included 504 262 persons younger than 21 years for whom discharge records were available to link outpatient or inpatient tonsillectomy with at least 90 days of follow-up. EXPOSURES Tonsillectomy with or without adenoidectomy. MAIN OUTCOME AND MEASURES Postoperative death within 30 days or during a surgical stay lasting more than 30 days. Modified Poisson regression with sample weighting was used to estimate postoperative mortality per 100 000 operations, both overall and in relation to age group, sleep-disordered breathing, and complex chronic conditions. RESULTS The 504 262 children in the cohort underwent a total of 505 182 tonsillectomies (median [IQR] patient age, 7 [4-12] years; 50.6% females), of which 10.1% were performed in young children, 28.9% in those with sleep-disordered breathing, and 2.8% in those with complex chronic conditions. There were 36 linked postoperative deaths, which occurred a median (IQR) of 4.5 (2-20.5) days after surgical admission, and most of which (19/36 [53%]) occurred after surgical discharge. The unadjusted mortality rate was 7.04 (95% CI, 4.97-9.98) deaths per 100 000 operations. In multivariable models, neither age younger than 3 years nor sleep-disordered breathing was significantly associated with mortality, but children with complex chronic conditions had significantly higher mortality (16 deaths/14 299 operations) than children without these conditions (20 deaths/490 883 operations) (117.22 vs 3.87 deaths per 100 000 operations; adjusted rate difference, 113.55 [95% CI, 51.45-175.64] deaths per 100 000 operations; adjusted rate ratio, 29.39 [95% CI, 13.37-64.62]). Children with complex chronic conditions accounted for 2.8% of tonsillectomies but 44% of postoperative deaths. Most deaths associated with complex chronic conditions occurred in children with neurologic/neuromuscular or congenital/genetic disorders. CONCLUSIONS AND RELEVANCE Among children undergoing tonsillectomy, the rate of postoperative death was 7 per 100 000 operations overall and 117 per 100 000 operations among children with complex chronic conditions. These findings may inform decision-making for pediatric tonsillectomy.
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Affiliation(s)
- M. Bruce Edmonson
- Division of General Pediatrics and Adolescent Medicine, Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison
| | - Qianqian Zhao
- Department of Biostatistics and Medical Informatics, University of Wisconsin School of Medicine and Public Health, Madison
| | - David O. Francis
- Division of Otolaryngology, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison
| | - Michelle M. Kelly
- Division of Hospital Medicine, Department of Pediatrics, University of Wisconsin, Madison
| | - Daniel J. Sklansky
- Division of Hospital Medicine, Department of Pediatrics, University of Wisconsin, Madison
| | - Kristin A. Shadman
- Division of Hospital Medicine, Department of Pediatrics, University of Wisconsin, Madison
| | - Ryan J. Coller
- Division of Hospital Medicine, Department of Pediatrics, University of Wisconsin, Madison
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Han M, Lee MK, Yoo J, Hwang SJ, Seo MY, Lee SH. Effect of intravascular dexamethasone injection after powered intracapsular tonsillectomy and adenoidectomy in children. Am J Otolaryngol 2022; 43:103385. [PMID: 35151175 DOI: 10.1016/j.amjoto.2022.103385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 01/29/2022] [Indexed: 11/16/2022]
Abstract
PURPOSE To compare postoperative pain, nausea and vomiting, and bleeding between intravascular dexamethasone injection group and control group among children undergoing powered intracapsular tonsillectomy and adenoidectomy (PITA). MATERIALS AND METHODS Retrospective review of medical records was performed for pediatric patients who underwent PITA from March 1, 2017, to February 28, 2021, at a tertiary referral medical center in South Korea. Postoperative pain and nausea were measured using the visual analogue scale (VAS) from the postoperative day (POD) 0 to POD 6. The number of analgesics administered and the number of vomiting episodes were recorded in the same period. The repeatedly measured parameters were statistically analyzed between the dexamethasone group and control group. RESULTS A total of 71 children with complete questionnaires including 44 boys and 27 girls were included, and the mean age was 7.49 ± 2.44 years. There were 33 patients in the dexamethasone group and 38 in the control group. Postoperative pain (p = 0.169) or nausea (p = 0.460) on the VAS showed no statistically significant difference between the two groups. Postoperative analgesics showed no difference between the groups (p = 0.398), and neither did postoperative vomiting (p = 0.270). In both groups, no child showed signs of postoperative bleeding. CONCLUSIONS This study indicates that the beneficial effects of intravascular dexamethasone administration in PITA may not be evident. This might be due to the superior outcome of the PITA technique compared to total extracapsular tonsillectomy. Therefore, otolaryngologists performing PITA may not necessarily need to administer dexamethasone in children before surgery.
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Affiliation(s)
- Munsoo Han
- Department of Otorhinolaryngology-Head and Neck Surgery, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Republic of Korea
| | - Min Kyu Lee
- Department of Otorhinolaryngology-Head and Neck Surgery, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Republic of Korea
| | - Jun Yoo
- Department of Otorhinolaryngology-Head and Neck Surgery, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Republic of Korea
| | - Sun Jin Hwang
- Department of Otorhinolaryngology-Head and Neck Surgery, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Republic of Korea
| | - Min Young Seo
- Department of Otorhinolaryngology-Head and Neck Surgery, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Republic of Korea
| | - Seung Hoon Lee
- Department of Otorhinolaryngology-Head and Neck Surgery, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Republic of Korea.
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Patel PN, Rohlfing ML, Levi JR. Delayed onset of tooth decay in a routine pediatric adenotonsillectomy. Am J Otolaryngol 2021; 42:103019. [PMID: 33836484 DOI: 10.1016/j.amjoto.2021.103019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 03/28/2021] [Indexed: 11/15/2022]
Abstract
Adenotonsillectomy is a common pediatric surgical procedure with a well-defined safety profile. Major complications from this procedure include bleeding/hemorrhage, infection, pain leading to dehydration, and airway obstruction or edema. Though rare, oral endotracheal intubation and oral retractor placement may result in injuries to the teeth and the surrounding soft tissue. We describe a rare case of delayed tooth decay in a 3-year-old female following an otherwise routine adenotonsillectomy.
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Affiliation(s)
- Prachi N Patel
- Boston Medical Center- Department of Otolaryngology- Head and Neck Surgery, United States of America.
| | - Matthew L Rohlfing
- Boston Medical Center- Department of Otolaryngology- Head and Neck Surgery, United States of America.
| | - Jessica R Levi
- Boston Medical Center- Department of Otolaryngology- Head and Neck Surgery, United States of America.
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Sun YL, Yuan B, Kong F, Li XM. Effects of adenoidectomy or adenotonsillectomy on the cardiovascular system in children: a meta-analysis. Eur Arch Otorhinolaryngol 2021; 279:1147-1156. [PMID: 34269887 DOI: 10.1007/s00405-021-06986-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Accepted: 07/06/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Adenoid or adenotonsillar hypertrophy (AATH) causes upper airway obstruction, leading to cardiovascular complications. This meta-analysis was conducted to evaluate the efficacy of adenoidectomy or adenotonsillectomy (AATE) on the cardiovascular system. METHODS Using the Cochrane Central Register of Controlled Trials, PubMed, and EMBASE databases, we identified studies involving a comparison of preoperative and postoperative cardiovascular function in children with AATH. The Cochrane Collaboration's Review Manager 5.3 software was used for meta-analysis. RESULTS A total of 13 studies with 706 participants were included. The meta-analysis demonstrated a significant reduction in mean pulmonary artery pressure (mPAP) of patients after AATE compared with preoperative values. The left ventricular myocardial function index (LVMPI) and the right ventricular myocardial function index (RVMPI) showed a significant decrease after the operation. Moreover, AATE prominently increased left ventricular ejection time (LVET) and right ventricular ejection time (RVET) and reduced the left ventricular interventricular septum diameter (LVIVSD) and the right ventricular end-diastolic diameter (RVedD). There was no significant difference in mPAP, LVMPI, RVMPI, LVET, RVET, LVIVSD, and RVedD between postoperative patients and healthy children (P > 0.05). CONCLUSION AATE can improve cardiovascular function in pediatric patients with AATH. Specifically, it reduces mPAP and LVMPI/RVMPI in pediatric patients. Furthermore, AATE increases LVET and RVET and reduces LVIVSD and RVedD.
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Affiliation(s)
- Ya-Lei Sun
- Department of Pediatrics, Affiliated Hospital of Nanjing University of Chinese Medicine, No. 155 Hanzhong Road, Qinhuai District, Nanjing, 210000, Jiangsu, China
| | - Bin Yuan
- Department of Pediatrics, Affiliated Hospital of Nanjing University of Chinese Medicine, No. 155 Hanzhong Road, Qinhuai District, Nanjing, 210000, Jiangsu, China.
| | - Fei Kong
- Department of Pediatrics, Affiliated Hospital of Nanjing University of Chinese Medicine, No. 155 Hanzhong Road, Qinhuai District, Nanjing, 210000, Jiangsu, China
| | - Xin-Min Li
- Basic Medicine College, Henan University of Chinese Medicine, Zhengzhou, 450000, China
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Billings KR, Stake C, Arzu J, Lavin J. Outcomes of a Postoperative Data-Extraction Questionnaire After Adenotonsillectomy in Children. Laryngoscope 2021; 131:E2821-E2826. [PMID: 34014559 DOI: 10.1002/lary.29626] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 05/03/2021] [Accepted: 05/07/2021] [Indexed: 12/25/2022]
Abstract
OBJECTIVES/HYPOTHESIS To evaluate outcomes of a postoperative telephone questionnaire for children who underwent adenotonsillectomy (T&A). To determine whether episodes of postoperative hemorrhage were not captured until the call, and whether this impacted knowledge of physician rates of hemorrhage. STUDY DESIGN Retrospective database analysis. METHODS Retrospective analysis of outcomes of an 11-question data extraction tool utilized at a tertiary care children's hospital for follow-up in T&A patients <18 years of age over a 2-year period. Sub-analysis of positive responses to the question asking about incidence of postoperative hemorrhage. RESULTS During the study period, 1,068/3,142 (34.0%) parents responded to the phone call. Median age was 6.0 years (interquartile range [IQR] 4.0-8.2), and 566 (53.0%) were male. Ninety (8.4%) noted that the child was still snoring, but only 9 (0.84%) reported signs of obstructed breathing. A total of 402 (37.6%) reported a voice change after surgery. Most children (n = 885, 82.9%) did not receive opioid analgesics, and 252 (23.6%) received acetaminophen/ibuprofen 7 days postoperatively. Return visits to the emergency department were reported in 149 patients; primarily for hemorrhage in 46 (30.8%). In 7 (15.2%) patients, the hemorrhage event was not recorded until the call. The majority-of respondents (n = 1,031, 96.5%) were satisfied with the outcome of the procedure. CONCLUSIONS The postoperative T&A tool provided a means of gathering information on success and satisfaction with surgical outcomes. Children were able to be managed primarily with acetaminophen and ibuprofen. Most complications were captured in the electronic record, although some episodes of hemorrhage were not noted until the call, emphasizing the importance of follow-up. LEVEL OF EVIDENCE 3 Laryngoscope, 2021.
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Affiliation(s)
- Kathleen R Billings
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, U.S.A
- Department of Otolaryngology-Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, U.S.A
| | - Christine Stake
- Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, U.S.A
| | - Jennifer Arzu
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, U.S.A
| | - Jennifer Lavin
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, U.S.A
- Department of Otolaryngology-Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, U.S.A
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Wang L, Guo Y, Tian J. The comparison of ketamine with tramadol for postoperative pain relief on children following adenotonsillectomy or tonsillectomy: A meta-analysis of randomized controlled trials. Medicine (Baltimore) 2021; 100:e22541. [PMID: 33832058 PMCID: PMC8036051 DOI: 10.1097/md.0000000000022541] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 09/03/2020] [Indexed: 01/05/2023] Open
Abstract
INTRODUCTION The comparison of ketamine with tramadol for pain control remains controversial in pediatric adenotonsillectomy or tonsillectomy. We conduct a systematic review and meta-analysis to explore the efficacy of ketamine vs tramadol for pain relief in children following adenotonsillectomy or tonsillectomy. METHODS We have searched PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases through October 2019 for randomized controlled trials (RCTs) assessing the effect of ketamine vs tramadol for pediatric adenotonsillectomy or tonsillectomy. This meta-analysis is performed using the random-effects model. RESULTS Six RCTs are included in the meta-analysis. Overall, compared to ketamine group for pediatric adenotonsillectomy or tonsillectomy, tramadol is associated with substantially lower CHEOPS at 1 h (SMD = 1.56; 95% CI = 0.20-2.92; P = .02; low quality) and longer first time of additional pain medication (SMD = -0.47; 95% CI = -0.74 to -0.19; P = .0008; low quality), but demonstrates no obvious effect on CHEOPS at 6 h (SMD = 0.51; 95% CI = -1.17 to 2.19; P = .55; low quality), sedation scale at 1 h (SMD = -0.80; 95% CI = -3.07 to 1.48; P = .49; low quality) or additional pain medication (RR = 1.31; 95% CI = 0.85-2.02; P = .23; moderate quality). CONCLUSIONS Tramadol may be better to alleviate the postoperative pain after pediatric adenotonsillectomy or tonsillectomy.
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Affiliation(s)
| | | | - Jun Tian
- Department of Pediatrics, The First People's Hospital of Xiaoshan, Hangzhou, Zhejiang Province, P.R. China
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Abstract
OBJECTIVE The objective of this quality improvement project was to decrease the rate of nonemergent use of emergency department (ED) resources in children undergoing adenotonsillectomy by 50% and/or reach a future state of 5% or less overall ED visits among all postoperative patients within 1 year. A secondary objective was to standardize the preoperative, intraoperative, and postoperative management of these patients. METHODS The study was a quality improvement project using Lean. The target population was children younger than 18 years undergoing tonsillectomy with or without adenoidectomy. A retrospective review of adenotonsillectomy was performed for a 12-month period. Lean tools including A3 Thinking, Ishikawa "fishbone" diagram, and value stream mapping were used to analyze the problem and identify interventions. Postintervention data were collected for a 10-month period. RESULTS Compared with the baseline period, the ED visit rate after adenotonsillectomy decreased from 36.2% to 15.5% (P = 0.0095). The rate of ED visits for nonbleeding complaints decreased from 30.4% to 12.1% (P = 0.01748). There was no significant change in rate of ED visits for bleeding (decreased from 5.8% to 3.5% [P = 0.6873]). There was no significant change in the use of intraoperative dexamethasone and acetaminophen. CONCLUSIONS Postadenotonsillectomy patients often use emergency resources better reserved for other patients. Addressing this problem with Lean principles significantly decreased postoperative ED visit rates by more than 50%. IMPLICATIONS FOR PRACTICE To our knowledge, this is the first reported use of Lean principles to decrease utilization of emergency resources in the postoperative period. Lean can be applied to other processes in our field to eliminate waste and add value to improve patient outcomes. LEVEL OF EVIDENCE NA.
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Affiliation(s)
- Mingyang L Gray
- From the Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
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Kang Y, Ku EJ, Jung IG, Kang MH, Choi YS, Jung HJ. Dexamethasone and post-adenotonsillectomy pain in children: Double-blind, randomized controlled trial. Medicine (Baltimore) 2021; 100:e24122. [PMID: 33466183 PMCID: PMC7808470 DOI: 10.1097/md.0000000000024122] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 12/09/2020] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVE To assess the impact of intraoperative intravenous dexamethasone on the reduction of postoperative morbidity in children undergoing adenotonsillectomy. METHODS A double blind randomized controlled trial conducted among children undergoing adenotonsillectomy at a tertiary hospital in Korea from November 2018 to June 2019. Children were randomly assigned to receive dexamethasone (0.5 mg/kg, maximum dose 24 mg) or placebo intravenously after induction of anesthesia. The primary endpoint was the reduction of postoperative pain and postoperative nausea and vomiting (PONV); secondary endpoints were adverse effects like postoperative hemorrhage. RESULTS The study included 105 children, and 67 were male. Their mean age was 6.2 ± 2.1 years. There was no significant difference between the groups in terms of demographic data or the operation time. The pain scores of the dexamethasone group were lower than those of the control group, but no significant difference was found (all P > .05). The average pain visual analog scale (VAS) during the study period (day 0-7) was 3.67 ± 1.59 and 4.40 ± 2.01 in the dexamethasone group and control group, respectively (P-value = .107). When we compared early pain VAS (day 0-2) and late pain VAS (day 5-7), the dexamethasone group showed significantly lower early mean VAS compared to the control group (4.55 ± 1.78 vs 5.40 ± 2.05, P-value = .046). The mean VAS for PONV was significantly lower in the dexamethasone group than in the control group (1.89 ± 2.22 vs 3.00 ± 2.37, P value = .044). CONCLUSION In children undergoing adenotonsillectomy, dexamethasone decreased the early postoperative pain and PONV without increasing postoperative hemorrhage.
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Affiliation(s)
- Young Kang
- Department of Otorhinolaryngology-Head and Neck Surgery
| | - Eu Jeong Ku
- Department of Internal Medicine, Chungbuk National University College of Medicine, Chungbuk National University Hospital, Cheongju, Korea
| | - Il Gu Jung
- Department of Otorhinolaryngology-Head and Neck Surgery
| | | | | | - Hahn Jin Jung
- Department of Otorhinolaryngology-Head and Neck Surgery
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Ji KSY, Greene NH, Eapen RJ, Commesso E, Raynor EM. Pre- Versus Post-Tonsillectomy Intraoperative Bupivacaine Injection in the Pediatric Population: An Age- and Surgical Indication-Stratified Analysis. Ear Nose Throat J 2020; 101:518-525. [PMID: 33095665 DOI: 10.1177/0145561320968926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES Postoperative respiratory depression is of concern in children undergoing adenotonsillectomy receiving postoperative opioids and may be mitigated with intraoperative bupivacaine. This study aims to compare the impact of bupivacaine on postoperative pain and sedation in various pediatric age and surgical indication subgroups. METHODS This is a case series with chart review of 181 patients <18 years old undergoing adenotonsillectomy at a tertiary care center (2013-2016). Postoperative outcomes were compared between those who received intraoperative bupivacaine before (pre-tonsillectomy) or after (post-tonsillectomy) tonsil removal and those who did not (none) using χ2 test and analysis of variance. Subanalysis was performed after stratifying into age and surgical indication subgroups. RESULTS Ninety-eight patients were included in the pre-tonsillectomy group, 47 in the post-tonsillectomy group, and 36 in the none group. The number of postanesthesia care unit opioid doses (P = .159) and pain scores at arrival (P = .362) or discharge (P = .255) were not significantly different between treatment groups overall. Among 0- to 5-year-olds, pre-tonsillectomy injection was associated with lowest mean (SD) discharge pain score of 0.55 (1.29) pre-tonsillectomy versus 0.71 (1.37) post-tonsillectomy versus 2 (1.63) none group (P = .004). Among 12- to 17-year-olds, no injection was associated with lowest mean (SD) discharge pain score of 2.33 (0.52) pre-tonsillectomy versus 5 (2.65) post-tonsillectomy versus 1.63 (1.60) none group (P = .020). Injection in patients with obstructive sleep apnea and/or sleep-disordered breathing did not improve postoperative outcomes. CONCLUSION Intraoperative bupivacaine may improve pain scores in younger pediatric populations, though it may not impact the amount of postoperative opioid use. Prospective analysis with a larger sample size is warranted to better outline opioid usage and pain control in this group.
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Affiliation(s)
- Keven S Y Ji
- Department of Otolaryngology-Head & Neck Surgery, Oregon Health & Science University, Portland, OR, USA
| | - Nathan H Greene
- Division of Pediatrics, Department of Anesthesiology, Duke University Hospital, Durham, NC, USA
| | - Rose J Eapen
- South Bay Pediatric Otolaryngology, Manhattan Beach, CA, USA
| | - Emily Commesso
- Department of Head and Neck Surgery & Communication Sciences, Duke University Hospital, Durham, NC, USA
| | - Eileen M Raynor
- Department of Head and Neck Surgery & Communication Sciences, Duke University Hospital, Durham, NC, USA
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Grant O, Harper P. Paediatric Day Case Tonsillectomy - Audit of a New Programme. Ir Med J 2020; 113:56. [PMID: 32268049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Aims The primary objective of this audit was to assess 30-day unplanned admission or readmission rates following day case tonsillectomy. Secondary objectives included assessing demographic characteristics of patients and surgical and anaesthetic techniques employed. Methods Retrospective chart review was performed. Results 34 tonsillectomies or adenotonsillectomies were performed for children aged between 5 and 17 years. A total of six patients (17.6%) were either admitted from the day ward or readmitted within 30 days. This was not statistically significantly greater than the maximum acceptable rate of 15% as recommended by ENT UK and the Royal College of Surgeons (95% confidence intervals 4.8% - 30.5%, p = 0.33). Of these admissions, one (2.9%) was due to nausea and inadequate oral intake, one (2.9%) was due to clinical concerns regarding sleep apnoea and four readmissions (11.8%) were due to bleeding. Anaesthesia techniques used varied considerably. Conclusion Further multidisciplinary co-operation and standardisation of care may help to improve this programme and reduce unplanned admission and readmission rates.
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Affiliation(s)
- O Grant
- Department of Anaesthesia, Children's Health Ireland at Temple Street, Dublin
| | - P Harper
- Department of Anaesthesia, Children's Health Ireland at Temple Street, Dublin
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Moroco AE, Saadi RA, Wilson MN. Post-tonsillectomy respiratory complications in children with sleep disordered breathing. Int J Pediatr Otorhinolaryngol 2020; 131:109852. [PMID: 31901486 DOI: 10.1016/j.ijporl.2019.109852] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Revised: 12/20/2019] [Accepted: 12/22/2019] [Indexed: 11/19/2022]
Abstract
OBJECTIVE A common indication for tonsillectomy in children is clinically diagnosed sleep disordered breathing (SDB) without confirmation of obstructive sleep apnea (OSA) by polysomnography (PSG). Our goal was to review rates of post-tonsillectomy respiratory complications in children with SDB without prior PSG in order to develop recommendations for postoperative monitoring and safe hospital discharge in this population. METHODS Following Institutional Review Board (IRB) approval at Penn State Milton S. Hershey Medical Center, a database query using Current Procedural Terminology (CPT) codes for tonsillectomy with or without adenoidectomy (42820, 42821, 42825, 42826) between January 1, 2012 and December 31, 2017 was performed. International Classification of Diseases (ICD) codes for sleep disordered breathing (G47.30), snoring (R06.83), and obstructive sleep apnea (G47.33) were applied for further selection. Charts were individually reviewed to confirm the inclusion criteria of pediatric patients (≤18 years) who underwent tonsillectomy without prior PSG and were monitored overnight. Demographic, operative, and relevant postoperative hospital course data (including desaturations, supplemental oxygen requirements, and upgraded level of care) were collected. RESULTS A total of 1874 unique patient encounters were identified by our database search and 364 children met inclusion criteria. The average age of the patient population was 6.5 ± 3.1 years and 52.2% of children were female. Mean z-score for the population was 0.6. The rate of overnight oxygen desaturation events (<95%) was 2.2%, with no severe complications found in this population. Children with desaturation events were supplemented with oxygen and resolved prior to hospital discharge. Only race was found to be significantly related to risk of mild overnight desaturations (P = 0.023). CONCLUSION A lack of significant postoperative respiratory complications or alterations in the clinical management of children with SDB without prior PSG supports the idea that such patients may safely be discharged from the hospital following tonsillectomy without overnight oxygen monitoring.
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Affiliation(s)
- Annie E Moroco
- The Pennsylvania State University, College of Medicine, Hershey, PA, USA
| | - Robert A Saadi
- Department of Otolaryngology - Head and Neck Surgery, The Pennsylvania State University, College of Medicine, Hershey, PA, USA.
| | - Meghan N Wilson
- Department of Otolaryngology - Head and Neck Surgery, The Pennsylvania State University, College of Medicine, Hershey, PA, USA
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Archer NM, Forbes PW, Dargie J, Manganella J, Licameli GR, Kenna MA, Brugnara C. Association of Blood Type With Postsurgical Mucosal Bleeding in Pediatric Patients Undergoing Tonsillectomy With or Without Adenoidectomy. JAMA Netw Open 2020; 3:e201804. [PMID: 32232448 PMCID: PMC7109594 DOI: 10.1001/jamanetworkopen.2020.1804] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
IMPORTANCE Blood type (BT) O has been identified as a risk factor for bleeding complications, while non-O BTs may increase risk for thromboembolic events. Limited data are available in children undergoing tonsillectomy with or without adenoidectomy. OBJECTIVE To determine whether BT O is associated with hemorrhage after tonsillectomy with or without adenoidectomy. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study of patients younger than 22 years who underwent tonsillectomy with or without adenoidectomy at a single institution between January 1, 2008, and August 7, 2017. Statistical analysis was performed from November 2017 to January 2019. MAIN OUTCOMES AND MEASURES Prevalence of hemorrhage following surgery was defined as any bleeding requiring cauterization up to 1 month after the procedure. Data on sex, age, von Willebrand disease (VWD) status, BT, white blood cell counts, and platelet counts closest to date of surgery were collected from an electronic medical record system, and the association of these factors with hemorrhage following surgery was investigated. RESULTS A total of 14 951 pediatric patients (median [range] age, 5.6 [0.8-21.9] years; 6956 [46.5%] female) underwent tonsillectomy with or without adenoidectomy. Prevalence of hemorrhage following the procedure was 3.9% (578 patients) for the full cohort and 2.8% (362 of 13 065) for patients with no BT identified or preprocedure VWD panel results at baseline. Children who had a BT identified and/or a VWD panel before surgery had higher bleeding rates (BT only, 14.9% [172 of 1156]; preprocedure VWD panel only, 4.6% [28 of 607]; and BT and preprocedure VWD panel, 13.0% [16 of 123]), all of which were significantly different from the baseline bleeding rate (P < .001). While the bleeding rates in children with BT O were not statistically different from those with non-O BT (14.8% and 14.6%, respectively; P > .99), mean von Willebrand factor values were statistically different (mean [SD] von Willebrand factor antigen level in O group, 86.9 [42.4] IU/dL in the O group vs 118.0 [53.8] IU/dL in the non-O group; P = .002; and mean [SD] von Willebrand factor ristocetin-cofactor in the O group, 72.2 [44.3] IU/dL vs 112.6 [68.0] IU/dL in the non-O group; P = .001). In addition, children older than 12 years had increased bleeding rates in the full cohort (8.3% vs 3.2%), in the testing-naive cohort (6.5% vs 2.3%), and in those with a preprocedure VWD panel only (13.5% vs 3.1%) compared with children aged 12 years or younger. CONCLUSIONS AND RELEVANCE Type O blood was not a risk factor associated with hemorrhage after tonsillectomy with or without adenoidectomy despite lower baseline von Willebrand factor antigen and von Willebrand factor ristocetin-cofactor values in children with BT O vs those with non-O BT in our study cohort. No association was found between VWD status and bleeding, and there was no difference in VWD panel values in those who experienced hemorrhage vs those who did not within BT groups. Further studies elucidating the utility of von Willebrand factor values for children undergoing tonsillectomy with or without adenoidectomy are needed.
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Affiliation(s)
- Natasha M. Archer
- Pediatric Hematology, Oncology Dana-Farber, Children’s Hospital Blood Disorders and Cancer Center, Boston, Massachusetts
| | - Peter W. Forbes
- Clinical Research Center, Boston Children's Hospital, Boston, Massachusetts
| | - Jenna Dargie
- Department of Otolaryngology and Communication Enhancement, Boston Children’s Hospital, Boston, Massachusetts
| | - Juliana Manganella
- Department of Otolaryngology and Communication Enhancement, Boston Children’s Hospital, Boston, Massachusetts
| | - Greg R. Licameli
- Department of Otolaryngology and Communication Enhancement, Boston Children’s Hospital, Boston, Massachusetts
| | - Margaret A. Kenna
- Department of Otolaryngology and Communication Enhancement, Boston Children’s Hospital, Boston, Massachusetts
| | - Carlo Brugnara
- Laboratory Medicine, Boston Children's Hospital, Boston, Massachusetts
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Wu J, Gui Q, Wang J, Ye J, Xia Z, Wang S, Liu F, Kong F, Zhong L. Oxycodone preemptive analgesia after endoscopic plasma total adenotonsillectomy in children: A randomized controlled trial. Medicine (Baltimore) 2020; 99:e19004. [PMID: 32028411 PMCID: PMC7015576 DOI: 10.1097/md.0000000000019004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Endoscopic tonsillectomy is associated with postoperative pain. Postoperative pain management remains to be improved in children. We aimed to investigate oxycodone preemptive analgesia in children undergoing endoscopic plasma total adenotonsillectomy. METHODS 166 children with adenotonsillar hypertrophy were recruited at Wuhan Children's Hospital between 08/2016 and 03/2017. They were randomly assigned to receive SPOA (postoperative sufentanil), SPEA+SPOA (preemptive sufentanil and postoperative sufentanil), and OPEA+SPOA (preemptive oxycodone and postoperative sufentanil). The primary endpoint was serum c-fos levels. The secondary endpoints were the response entropy (RE) value, Pediatric Anesthesia Emergence Delirium (PAED) score, FLACC score, and adverse events. RESULTS c-fos mRNA levels were increased significantly after surgery in the SPOA and SPEA+SPOA groups (P < .05). Postoperatively, c-fos mRNA levels were higher in the SPOA group compared with the OPEA+SPOA group (P = .044). The RE values increased in all groups after surgery (P < .05). At extubation, RE values were higher in the SPOA group compared with the SPEA+SPOA and OPEA+SPOA groups (P < .05). The PAED scores were higher in the SPOA group compared with the OPEA+SPOA group (P = .045). In the SPOA group, the FLACC scores were decreased at 24 h after surgery vs 4 hours (P = .044). Prediction probability (Pk) values indicated that RE and c-fos mRNA levels were quantitative predictors for early postoperative stress reaction after surgery. CONCLUSIONS The subanalgesic dose of oxycodone (0.1 mg/kg) as preemptive analgesia could improve pain after endoscopic plasma total adenotonsillectomy in children.
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Affiliation(s)
| | - Qi Gui
- Department of Otolaryngology, Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital), Tongji Medical College, Huazhong University of Science & Technology, Wuhan, Hubei, China
| | | | | | - Zhongfang Xia
- Department of Otolaryngology, Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital), Tongji Medical College, Huazhong University of Science & Technology, Wuhan, Hubei, China
| | - Shufen Wang
- Department of Otolaryngology, Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital), Tongji Medical College, Huazhong University of Science & Technology, Wuhan, Hubei, China
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49
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Chung SA, Han MR. Pupil-Involving Oculomotor Nerve Palsy Following Tonsillectomy and Adenoidectomy. J Pediatr Ophthalmol Strabismus 2019; 56:e76-e78. [PMID: 31821512 DOI: 10.3928/01913913-20190917-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 07/25/2019] [Indexed: 11/20/2022]
Abstract
Ocular complications of adenotonsillectomy are rare. The authors describe a 6-year-old boy who developed mydrasis and limitations of supraduction and infraduction after adenotonsillectomy. This was attributed to the hemorrhagic compression of the nerve in the cavernous sinus. This is the first report of pupil-involving oculomotor nerve palsy following adenotonsillectomy. [J Pediatr Ophthalmol Strabismus. 2019;56:e76-e78.].
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50
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Katundu DR, Shija PS, Nyombi B, Semvua H, Oussoren FK, van Heerbeek N. The effect of antibiotics on post-adenotonsillectomy morbidity in Tanzanian children: study protocol for a randomized, double-blind, placebo-controlled trial. Trials 2019; 20:683. [PMID: 31815643 PMCID: PMC6902588 DOI: 10.1186/s13063-019-3830-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Accepted: 10/22/2019] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Adenotonsillectomy is the most frequently performed operation in children worldwide. For decades, prophylactic antibiotics have been prescribed to limit postoperative complications. The effect of this antibiotic use has been refuted in a Cochrane Review. However, all reviewed studies were carried out in developed countries. In Tanzania, like many other developing countries with limited resources and a high burden of infectious diseases, postoperative antibiotic prescription is still very common to decrease the supposed higher postoperative morbidity. However, as a consequence of this widespread use of postoperative antibiotics, cross-resistance and risk of allergic side effects rise. Well-designed randomized controlled trials are needed to limit unnecessary antibiotic prescription and secondary antibiotic resistance. AIM The aim of this study is to analyse the prophylactic role of postoperative antibiotics on morbidity following adenotonsillectomy in children in Tanzania. DESIGN The double-blinded, randomized, placebo-controlled trial was set in northern Tanzania. Participating centres are the Department of Otolaryngology at Kilimanjaro Christian Medical Centre in Moshi and the Department of Paediatric Surgery at the Arusha Lutheran Medical Centre in Arusha. METHODS Around 270 children aged 2-14 years, all scheduled for elective (adeno)tonsillectomy, will be included and assigned to receive either a standard regimen of 5 days of antibiotic prophylaxis or placebo after surgery. The primary outcomes are postoperative haemorrhage, fever and pain. Secondary outcomes are the time until normal diet is resumed, the time until normal activities are resumed and the occurrence of adverse events and microbial recolonization of the tonsillar beds. DISCUSSION This study will enhance an increase of proper antimicrobial prescription in Tanzanian institutions as well as other resource-limited countries where prescription of antibiotics is still very common. In addition, it might augment current knowledge about surface and core tonsillar micro-organisms and sensitivity patterns. TRIAL REGISTRATION Pan African Clinical Trials Registry, PACTR201905466349317. Retrospectively registered on 15 May 2019. https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=8119.
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Affiliation(s)
- Denis R. Katundu
- Department of Otolaryngology, Kilimanjaro Christian Medical Centre, Kilimanjaro, Tanzania
- Department of Otolaryngology, Kilimanjaro Christian Medical University College, Kilimanjaro, Tanzania
| | - Peter S. Shija
- Department of Otolaryngology, Kilimanjaro Christian Medical Centre, Kilimanjaro, Tanzania
| | - Baltazari Nyombi
- Department of Microbiology, Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Hadija Semvua
- Department of Pharmacy, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Fieke K. Oussoren
- Department of Otolaryngology, Head and Neck Surgery, Radboudumc, Nijmegen, The Netherlands
| | - Niels van Heerbeek
- Department of Otolaryngology, Kilimanjaro Christian Medical Centre, Kilimanjaro, Tanzania
- Department of Otolaryngology, Head and Neck Surgery, Radboudumc, Nijmegen, The Netherlands
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