[Current status of laser surgery in the area of the soft palate and adjoining regions]

The amount of different clinically available lasers is increasing. The ENT surgeon can therefore use the best laser for the planned operation. As the resources of the hospital do not increase with the laser technology, a decision has to be made whether in addition to the universal CO2-laser other types must be acquired and which type is best. This paper presents the characteristics and typical tissue interactions of several lasers for the area of the soft palate. Typical operative examples are shown, e.g. partial resection of the soft palate in patients with bronchopathy and sleep apnoea syndrome, tonsillectomy, tonsillotomy and adenotomy in adults.

Microdebrider Tonsillotomy vs Electrosurgical Tonsillectomy

OBJECTIVE

To examine whether microdebrider intracapsular tonsillotomy (MT) results in less postoperative pain compared with electrosurgical extracapsular tonsillectomy (ET).

DESIGN

Prospective, randomized, double-blind, matched pair, clinical trial.

SETTING

Specialty care hospital. Patients Twelve male (48%) and 13 female (52%) children aged 5 to 15 years, with obstructive tonsillar hyperplasia were randomized to have one tonsil removed by MT and the other by ET.

INTERVENTIONS

An angled endoscopic microdebrider was used to perform MT, and ET was performed by standard monopolar cautery technique. Parents and children were blinded to the side of MT and ET. Children rated the pain 0 to 5 by side using the Faces Pain Scale-Revised. Blinded data collection was via telephone daily for 2 weeks by a study nurse.

MAIN OUTCOME MEASURES

Primary: postoperative pain as recorded by Faces Pain Scale-Revised; secondary, presence or absence of otalgia and postoperative bleeding.

RESULTS

Twenty-two children (88%) had tonsillectomy and adenoidectomy, while 3 children (12%) had tonsillectomy alone. On postoperative days 1 to 9, children reported significantly less pain on the MT side compared with the ET side (paired t test; P<.01). By postoperative days 10 to 14, the difference between sides disappeared. Twenty children (80%) reported otalgia, and it was always unilateral. For those children reporting otalgia, there was a 100% correlation between the side of otalgia and the side of ET. There was no posttonsillectomy bleeding among the 25 children.

CONCLUSION

Microdebrider intracapsular tonsillotomy is significantly less painful compared with electrosurgical ET in children undergoing surgical intervention for obstructive tonsillar hypertrophy.

Power-assisted adenoidectomy

OBJECTIVE

To quantify that the use of powered instrumentation for adenoidectomy is an improvement over traditional techniques.

DESIGN

Retrospective case series of 40 consecutive children undergoing power-assisted adenoidectomy compared with 40 consecutive children undergoing conventional transoral adenoidectomy with a curet.

SETTINGS

Tertiary care center.

MAIN OUTCOME MEASURES

Operative time, blood loss, length of hospitalization, and complications.

RESULTS

With power-assisted adenoidectomy, the mean operative time was significantly faster (11 minutes vs 19 minutes for the conventional method), mean blood loss was not significantly different (22 mL vs 32 mL for the conventional method), mean length of hospitalization after the procedure was not significantly different (2.95 hours vs 2.8 hours for the conventional method), and there were no surgical complications with either technique.

CONCLUSION

In comparison with conventional techniques, power-assisted adenoidectomy provides significant advantages that are subjectively apparent but can also be objectively measured.

Obstructive adenoid tissue: an indication for powered-shaver adenoidectomy

OBJECTIVES

To quantify the incidence of intranasal extension of adenoid tissue and residual adenoidal obstruction of the posterior choanae following traditional curette adenoidectomy to determine the efficiency of adenoid curettage and the usefulness of intraoperative endoscopic examination and powered-shaver adenoidectomy in achieving better postnasal patency.

DESIGN

Prospective intraoperative endoscopic evaluation of the posterior choanae and nasopharynx of a case series of 130 patients before and after curette and powered-shaver adenoidectomy.

SETTING

Tertiary referral center.

PATIENTS

One hundred thirty consecutive pediatric patients with obstructive adenoidal hypertrophy undergoing adenoidectomy.

MAIN OUTCOME MEASURES

The degree of residual postnasal obstruction due to adenoid tissue was assessed endoscopically (grades 0-3) after curette and adjuvant powered-shaver adenoidectomy. The presence of intranasal adenoid tissue was also recorded.

RESULTS

Following traditional curette adenoidectomy, 51 (39%) of 130 patients had residual obstructive adenoid with 42 patients (32%) having occlusive intranasal adenoid tissue. Having determined the presence of remaining obstructive tissue with intraoperative nasal endoscopy in these 51 patients, complete airway patency was achieved with powered-shaver adenoidectomy.

CONCLUSION

The presence of intranasal extension of adenoids obstructing the posterior choanae is common in children with adenoid hypertrophy. Traditional adenoidectomy is ineffective in removing this tissue and may also leave obstructive tissue high in the nasopharynx. Intraoperative nasal endoscopy allows assessment of the completeness of surgery. Powered-shaver adenoidectomy enables complete removal of obstructive adenoid tissue thereby ensuring postnasal patency.

Postoperative Recovery After Microdebrider Intracapsular or Monopolar Electrocautery Tonsillectomy

OBJECTIVE

To prospectively assess the postoperative recovery in patients randomly selected to receive either microdebrider intracapsular tonsillectomy (MT) or monopolar electrocautery tonsillectomy (ET).

DESIGN

A prospective, randomized, single-blinded study.

SETTING

Tertiary care children's hospital.

PATIENTS

A total of 74 patients between the ages of 3 and 7 years undergoing adenotonsillectomy for obstruction were randomly assigned to the MT and ET groups.

MAIN OUTCOME MEASURES

Families were blinded to the technique used and given a checklist to fill out daily quantifying pain, activity, diet, and the number of doses of pain medication given over a 10-day period. Other variables assessed included the time of surgery and intraoperative blood loss.

RESULTS

The average time of surgery was 16.9 minutes for ET compared with 20.9 minutes for MT (P<.001). The average blood loss was 30 mL for ET compared with 45 mL for MT (P = .01). Resumption of near-normal dietary intake was achieved 1.7 days earlier in patients receiving MT compared with ET (P = .04). There was no significant difference in the number of days taken for the resolution of pain or resumption of normal activity between the 2 groups.

CONCLUSIONS

Microdebrider tonsillectomy takes over 4 minutes longer to perform compared with ET and has slightly higher intraoperative blood loss. There appears to be a slight advantage in the resumption of normal dietary intake with MT but no significant difference in the number of days taken for the resolution of pain or resumption of normal activity.

Pediatric adenoidectomy under vision using suction-diathermy ablation

OBJECTIVES

To compare adenoidectomy using suction-diathermy ablation with adenoidectomy by way of curettage in a pediatric tertiary care setting.

STUDY DESIGN

A prospective series of 68 children undergoing adenoidectomy (without tonsillectomy) under vision using a suction-diathermy ablation technique over 2 years was compared with an historical control group of 58 children undergoing adenoidectomy (without tonsillectomy) by way of curettage over 2 years.

METHOD

Intraoperative blood loss was recorded and compared. Efficacy in improving nasal symptomatology was compared between the two groups using an ordinal "nasal symptom score" preoperatively and postoperatively. Complications were recorded and compared. Analysis was performed using two-tailed t tests.

RESULTS

The two groups were well matched for age, weight, and adenoid size (P > .4). Follow-up ranged from 4 to 48 months. Adenoidectomy using suction-diathermy resulted in significantly less blood loss (P < .001). The technique was no less efficacious in terms of reducing the nasal symptom score than conventional adenoidectomy by way of curettage (P = .07). Complication rates were no different. No recurrences were identified and no instances of nasopharyngeal stenosis were recognized.

CONCLUSIONS

Routine use of suction-diathermy ablation for adenoidectomy converts a difficult, often bloody procedure into a surgically precise operation. It is especially applicable to children. It may have additional advantages in aiding the prevention of the spread of the human form of bovine spongiform encephalopathy (variant Creutzfeldt-Jakob disease [CJD]). Compared with other recently introduced techniques for adenoidectomy, it is considerably less expensive.

Suction diathermy adenoidectomy

This technique uses a combination of monopolar diathermy and suction to perform a controlled resection of the adenoids in a near bloodless field. A clear view of the entire resection is obtained with a mirror. There is minimal blood loss and postoperative haemorrhage rate is extremely low. The authors describe the technique used and discuss their experience.

Instrumentation and patient characteristics that influence postoperative haemorrhage rates following tonsil and adenoid surgery

OBJECTIVES

To investigate the effect of the type instrumentation used and the age and gender characteristics of patients on postoperative haemorrhage rates following tonsil and adenoid surgery.

DESIGN

A retrospective analysis of 13 593 procedures was performed from The Patient Episode Database for Wales between 1 January 1999 and 31 March 2004.

SETTING

National health policy changes created four periods of different instrument usage (reusable, single-use with diathermy, single-use alone, specified single-use with diathermy). These and the age and gender distribution of the patients were examined against four categories of postoperative haemorrhage.

MAIN OUTCOME MEASURES

Postoperative haemorrhage rates were expressed as the number of complications per operations performed. Primary postoperative haemorrhage that occurred during the initial admission either required a return to theatre [R1] or was managed conservatively [N1]; secondary postoperative haemorrhage that required a return to hospital either returned to theatre [R2] or was managed conservatively [N2], were compared.

RESULTS

Primary haemorrhage with return to theatre doubled, from the baseline rate with reusable instruments, from 0.6% (CI 0.5-0.8) to 1.2% (CI 0.7-1.9) when single-use instruments were introduced and remained high at 1.4% (CI 0.9-2.1) after the withdrawal of single-use diathermy. This haemorrhage rate returned to the baseline rate (0.6% CI 0.3-1.0) when specified single-use instruments were introduced. None of the other haemorrhage rates changed significantly throughout the four observation periods. Adenotonsillectomy and tonsillectomy patients have different age and gender patterns. In a univariate analysis, males over the age of 12 years were twice as likely to have haemorrhage with return to theatre than girls of the same age, 3.8% (CI 3.0-4.7) versus 1.7% (CI 1.4-2.1).

CONCLUSIONS

A significant rise in serious postoperative primary haemorrhage but not secondary haemorrhage was seen following the initial introduction of single-use instruments that reverted to baseline with the introduction of specified single-use instruments. Diathermy does not appear to have affected the haemorrhage rates. There is a distinct age and gender pattern for tonsil and adenoid surgery and risk of postoperative haemorrhage. The use of arbitrary divisions of age may be misleading in studies that examine post-tonsillectomy haemorrhage.

Past and Present Instrument Use in Pediatric Adenotonsillectomy

OBJECTIVE: Examine changing trends/instrument usage for pediatric adenotonsillectomy.

STUDY DESIGN AND SETTING: Survey of 300 members of the American Society of Pediatric Otolaryngology assessing instruments used in adenotonsillectomy currently and over the past 15 years.

RESULTS: A total of 120 surveys were returned. The most common total tonsillectomy instruments for obstruction/infection were: monopolar electrocautery (ME) (53.1%/54.5%) and coblation (CT) (16.0%/16.1%). The most common subtotal tonsillectomy instrument for obstruction/infection was microdebrider (51.4%/30.8%). Over the past 15 years, ME predominated, cold utilization declined, and CT rose. The most common adenoidectomy instruments were ME (25.0%/25.0%), curette with touch-up ME (22.4%/22.4%), and microdebrider with touch-up ME (19.0%/14.7%). Over the past 15 years, curette with touch-up ME predominated early, curette utilization alone declined, and ME, microdebrider, and CT have risen.

CONCLUSION: Pediatric otolaryngologist technique/instrument use for adenotonsillectomy has changed over the past 15 years. This study may be limited by the low survey response rate.

A parallel group analysis of tonsillectomy using the harmonic scalpel vs electrocautery

OBJECTIVE

To evaluate efficiency and postoperative morbidity in tonsillectomy using the harmonic scalpel (HS) vs conventional electrocautery (EC).

DESIGN

A retrospective medical chart review of all patients who underwent tonsillectomy at a single children's hospital during a 32-month period from January 2001 to August 2003.

PATIENTS

The charts of 605 patients who underwent tonsillectomy or adenotonsillectomy were reviewed. The patients were stratified into 2 groups based on the dissecting instrument used (HS vs EC). Each group consisted of 2 subcategories based on age (< or =7 years and >7 years). Data collected included age, sex, operative indication, operative time, postanesthetic recovery room time, pain scale scores, postoperative admissions, and postoperative morbidities.

RESULTS

There were significant differences in mean age (P<.001), mean weight (P<.001), and indication for surgery (P<.001) between the 2 methods: HS patients were younger, weighed less, and more often had obstructive symptoms as their primary operative indication compared with the EC group. Average operative times were not significantly different between methods. No differences were noted with respect to recovery time (HS group, P = .10; EC group, P = .30), postoperative oxygen requirements (HS group, P = .07; EC group, P = .09), and postoperative pain scores (HS group, P = .31; EC group, P = .58). There was a significant difference in postoperative admissions between the 2 methods in patients 7 years or younger (P = .005). Finally, we noted a significant difference in postoperative bleeding between the HS (2/292) and EC (13/313) methods when the data were compared per age group (P = .006), but the overall bleeding rate was not statistically significant owing to the small number of total bleeding instances (15/605).

CONCLUSIONS

Recent prospective studies indicate that the HS provides advantages over conventional EC with respect to postoperative pain and return to normal activity. This study shows that HS tonsillectomy was as efficient as the conventional EC method. In addition, there was evidence that the rate of postoperative bleeding was significantly reduced by using the HS vs conventional EC.

Safety of powered instrumentation for adenoidectomy

A recent study established the utility of an endoscopic shaver for adenoidectomy in children by the transoral approach and showed that power assisted adenoidectomy (PAA) was significantly faster with a trend toward decreased blood loss. The purpose of this study was to demonstrate the safety of power assisted adenoidectomy in a large cohort of patients. A retrospective review was performed of 329 patients who had adenoidectomy by powered instrumentation. Postoperative complications were documented and compared with a similar group that had curette adenoidectomy. Complications watched for included prolonged recovery, postoperative hemorrhage, readmission for dehydration, velopharyngeal insufficiency, and nasopharyngeal stenosis. No postoperative complications were seen in the power assisted adenoidectomy group. This review confirms the safety of power assisted adenoidectomy.

Power-assisted adenoidectomy: total and partial resection

OBJECTIVE

To describe the surgical technique for power-assisted adenoidectomy and review the safety and effectiveness of the procedure.

STUDY DESIGN

Retrospective review.

METHODS

Power-assisted adenoidectomy uses a curved microdebrider shaver blade that conforms to the nasopharynx. The action of the shaver is controlled through visualization using a laryngeal mirror. Power-assisted adenoidectomy is started high in the nasopharynx, with resection beginning in the most superior aspect of the adenoid pad and moving inferiorly to the base of the pad. The cutting edge of the microdebrider remains in view continuously.

RESULTS

Between 1998 and 2001, we performed power-assisted adenoidectomy in 677 children and conducted both retrospective and prospective reviews of our experience. No instances of excess intraoperative blood loss (>150 mL), postoperative hemorrhage, velopharyngeal insufficiency, or other complication associated with adenoidectomy have occurred.

CONCLUSION

We have consistently demonstrated that power-assisted adenoidectomy is precise, rapid, and safe.

Coblation®: Improving outcomes for children following adenotonsillectomy

Tonsillectomy and adenoidectomy, 2 of the most common childhood surgeries, are performed for a number of indications, the most common being airway obstruction caused by adenotonsillar hypertrophy. Other indications for tonsillectomy include recurrent pharyngotonsillitis, streptococcal carriage, recurrent peritonsillar abscess, halitosis, and presumed neoplasia. Although adenotonsillar surgery is a safe and effective technique for treating disease and obstruction, parents remain concerned about postoperative morbidity, for which the potential is much greater after tonsillectomy than adenoidectomy. Postoperative pain and hemorrhage are 2 unpleasant side effects that can prolong postoperative recovery. Surgeons use a variety of surgical techniques to remove the tonsils and adenoids. When compared with older techniques, such as cold steel dissection and monopolar electrocautery, a new technique named Coblation that uses lower temperatures than electrocautery to remove tonsil tissue and achieve hemostasis, has been shown to reduce pain and decrease postoperative narcotic use, leading to shorter recovery times and a quicker return to normal in children.

Power-assisted partial adenoidectomy

OBJECTIVE

To describe partial adenoidectomy using a powered microdebrider and review the experience with the procedure.

STUDY DESIGN

Prospective study and review.

METHODS

To perform a power-assisted partial adenoidectomy, the surgeon directs the window in the microdebrider blade tip toward the tissue, which is drawn in by suction; the rotating blade then shaves the tissue. Studies have compared this adenoidectomy technique with curette procedures.

RESULTS

In a comparative prospective study, we found that operating time and time required for hemostasis were significantly shorter (P =.001) with power-assisted partial adenoidectomy than with curettage. There was no significant difference between the two procedures in blood loss or complication rate. These results were similar to those of previous studies. Overall, we have performed more than 1000 power-assisted partial adenoidectomies. No long-term complications have occurred, blood loss remains low, and surgeons are satisfied with the technique because of its speed, improved visibility during resection, and precision.

CONCLUSION

We and other authors have found power-assisted partial adenoidectomy to provide a faster, more precise operation than curette techniques, with benefits for both patient and surgeon.

Electrocautery versus Cold Knife Technique Adenotonsillectomy: A Cost Analysis

OBJECTIVE: Much has been written about the merits of various techniques of adenotonsillectomy. Proponents of each technique tout many virtues over one another. However, cost remains one variable that has not been thoroughly addressed. In this study, we compared the surgery time, anesthesia time, bleeding, and cost between 2 well-established techniques. Electrocautery tonsillectomy/adenoid ablation was compared against traditional cold knife dissection with adenoid curette.

STUDY DESIGN AND SETTING: A retrospective chart review of 275 patients in a large tertiary teaching hospital.

RESULTS: The electrocautery group had overall savings of 8, 8, and 9 minutes in surgery, anesthesia, and operating room times, respectively. In terms of cost, the variable cost of the electrocautery group was 19% less than the cold knife dissection group.

CONCLUSION/SIGNIFICANCE: This study demonstrated that cautery ablation of adenoids, when employed as part of adenotonsillectomy, enables the surgical team to save significant amount of time, and substantial cost for patients. EBM rating: B-3.

Adenoidectomy with laser or incisional myringotomy for otitis media with effusion

OBJECTIVE

To compare the effectiveness of CO2 laser myringotomy to incisional myringotomy at the time of adenoidectomy for refractory otitis media with effusion (OME).

STUDY DESIGN

Controlled retrospective consecutive case series.

METHODS

All children undergoing myringotomy and adenoidectomy for OME in the spring of 1999 had 1.7-mm-diameter perforations created in their tympanic membranes using a CO2 laser and conventional microslad. Their ears were evaluated at first postoperative visit (mean, 16.65 days after surgery) by a validated otoscopist to determine the presence or absence of perforations and middle ear effusions. These patients were compared with historical controls comprising all children undergoing incisional myringotomy and adenoidectomy in 1998. A chi2 analysis was performed to compare the results of these two myringotomy techniques.

RESULTS

Twenty-three children (39 ears) underwent laser myringotomy and adenoidectomy in 1999, compared with 26 children (48 ears) who underwent incisional myringotomy and adenoidectomy in 1998. In the laser myringotomy group, 8 of the 39 ears had a persistent opening at first follow-up; 4 of the 39 ears showed evidence of effusion. In the incisional myringotomy group, all 48 ears had healed; 7 of these ears showed evidence of effusion.

CONCLUSION

Myringotomies created using the CO2 laser are more likely to be patent at first postoperative visit than those made with incisional technique (P < .01). However, this prolonged middle ear ventilation does not significantly decrease the prevalence of effusion (P > .1).

Adenoidectomy with the coblator: a logical extension of radiofrequency tonsillectomy

This paper describes a method of radiofrequency ablation of adenoid tissue using a coblator, comparing it with conventional and other newer methods of adenoidectomy. Its chief advantages are that it produces a bloodless field, precision of tissue removal and leads to less damage to surrounding tissues.

The nasopharyngeal prong airway: an effective post-operative adjunct after adenotonsillectomy for obstructive sleep apnoea in children

OBJECTIVES

Obstructive sleep apnoea is a common childhood disorder. Adenotonsillar enlargement is most commonly implicated, with adenotonsillectomy representing an effective treatment in the majority of cases. Such children may develop respiratory compromise post-operatively, sometimes necessitating admission to the intensive care unit. We describe insertion of a nasopharyngeal "prong" airway and evaluate its benefits after adenotonsillectomy for obstructive sleep apnoea and milder forms of sleep-disordered breathing.

METHODS

The prong is easily fashioned from a paediatric endotracheal tube. It is inserted once surgery is complete, remaining in situ overnight. We retrospectively examine its elective use over an 18-month period in selected children considered to be at high risk of post-operative respiratory compromise. Existing practice over the preceding 18-month period is also examined, by way of comparison.

RESULTS

Forty-three children underwent adenotonsillectomy for sleep-disordered breathing/OSAS in the 18 months prior to introduction of the prong. Ten were considered "high risk" cases: post-operative intensive care beds were pre-booked for these, but none were eventually required. During the subsequent 18 months, 60 children underwent adenotonsillectomy for the same indication. Seventeen "high risk" cases received the prong post-operatively. No intensive care beds were pre-booked and all children were managed safely on the ENT ward, with minimal intervention.

CONCLUSIONS

Use of a nasopharyngeal prong significantly improves the post-operative course of selected children who are at high risk of respiratory compromise after adenotonsillectomy. This largely avoids the need for medical intervention and intensive care admission.

Pediatric endoscopic transnasal adenoid ablation

We describe a technique in which suction diathermy is used for adenoid ablation through a solely endoscopic transnasal approach in the older pediatric population. This procedure has proved to be both effective and convenient during other transnasal endoscopic procedures, as it provides excellent visualization of both the superior and inferior parts of the nasopharynx and results in minimal to no bleeding in the adenoid bed. In all cases to date, there has been complete resolution of preoperative problems of infection, pain, and bleeding. All patients had good control of postoperative pain. There has been no evidence of postoperative nasopharyngeal stenosis and no velopharyngeal insufficiency. Although transnasal adenoid ablation is not appropriate for the entire pediatric population, this procedure has multiple benefits when another endoscopic sinonasal procedure is planned, when there is neck instability, or when enhanced visualization of the nasopharynx is desired.

Telescopic-Assisted Radiofrequency Adenoidectomy: A Prospective Randomized Controlled Trial

OBJECTIVES/HYPOTHESIS

The objective was to conduct a prospective randomized controlled trial describing and investigating the efficacy and safety of transoral telescopic-assisted radiofrequency adenoidectomy in young children.

STUDY DESIGN

Prospective randomized controlled trial.

METHODS

One hundred twenty patients who were 36 months of age or less and planned to undergo adenoidectomy or adenoidectomy with insertion of tympanostomy tubes were included in the study. Children were prospectively and randomly assigned into two equal treatment groups: the telescopic-assisted adenoidectomy using radiofrequency curette and the conventional adenoid-curette adenoidectomy. The main parameters included visual analogue scale score for nasal breathing, amount of blood loss, operating time, completeness of adenoid resection, smoothness of postoperative recovery, and complications.

RESULTS

Both groups had a significant improvement in the visual analogue scale score after surgery with no evidence for a significant difference between the conventional adenoid-curette and radiofrequency groups. The amount of blood lost during radiofrequency adenoidectomy was minimal, with a mean difference of 31 mL and a median difference of 26 mL. There was a tendency for shorter operative time in the radiofrequency group, but this did not reach a statistical significance. No evidence for a significant difference was noticed in the smoothness of postoperative recovery or complication rate.

CONCLUSION

Telescopic-assisted radiofrequency-curette adenoidectomy allows removal of huge adenoids completely in a precise, easy, and cost-effective procedure, with minimal blood loss and short operating time. The use of transoral telescopes provides a clear visualization that helps complete removal of the adenoids, reduction of unnecessary trauma, and effective control of bleeding.

Randomized study comparing inflammatory response after tonsillectomy versus tonsillotomy

To determine if there was a difference in the inflammatory reaction after tonsil surgery with "traditional" techniques (tonsillectomy and adenoidectomy or TA) compared to partial intracapsular tonsillectomy and adenoidectomy (PITA).

DESIGN

Randomized, double-blind study.

SETTING

tertiary care academic hospital. Children under the age of 16 years with a diagnosis of obstructive sleep disordered breathing were randomly allocated into three study groups: TA with electrocautery (n = 34), PITA with CO₂ laser (n = 30) and PITA with debrider (n = 28). All of the children underwent adenoidectomy with a current at the same surgical procedure.

MAIN OUTCOME MEASURE

c-reactive protein level (CRP) was the primary endpoint. In addition, the following were assessed: white blood cells (WBC), neutrophils (NEU), interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-α). Pre- and post-procedure measurements were compared between the groups. Parents filled out a questionnaire daily during the first postoperative week assessing pain, swallowing and snoring. CRP levels ascended higher in the PITA groups after surgery (p = 0.023), WBC and NEU showed the same pattern, IL-6 levels were higher in PITA group and there was no difference in TNF-alpha levels between the two types of procedures. Postoperative pain and postoperative hemorrhage were significantly lower in the PITA groups as compared to the TA group (p = 0.01 and 0.048). PITA in comparison to TA is associated with lower morbidity; however, the inflammatory response does not differ significantly in the first 24 h after surgery. Additional long-term studies assessing efficacy of PITA are warranted.

LEVEL OF EVIDENCE

Level 1, prospective randomized controlled trial.

A laboratory and clinical evaluation of single-use instruments for tonsil and adenoid surgery

OBJECTIVES

To compare the quality and consistency of single-use adenotonsillectomy instruments available in the UK with reusable instruments and examine their performance in a clinical setting.

DESIGN

A laboratory assessment of each reusable instrument created a detailed specification for the respective single-use equivalent. A surveillance system monitored the performance of a selected set of specified single-use instruments.

SETTING

Single-use instruments were withdrawn shortly after their introduction in 2001. Persisting concerns from the Spongiform Encephalopathy Advisory Committee led to an investigation into the feasibility of continuing to use such instruments.

MAIN OUTCOME MEASURES

The numbers of instruments from each set judged as unacceptable or as good as the original. The number and cause of instrument failure during clinical surveillance.

RESULTS

Between 40% and 93% of the instruments on each set were as good as the original and between 0% and 40% of the instruments were unacceptable from six sets of steel and one set of polymer instruments. 4151 procedures were monitored between 1 February 2003 and 31 March 2004 using a total of 41 376 instruments. Problems were reported with 335 (0.8%) instruments, 46% attributable to instrument design, 14% to poor design control and 13% to instruments escaping quality control systems. Following correction of the faults, between 1 January 2004 and 31 March 2004 the problem rate fell to 0.4%.

CONCLUSIONS

High quality single-use instruments for tonsil and adenoid surgery are available in the UK. Some companies offered inferior instruments not fit for their purpose. The procurement, introduction and subsequent clinical approval of single-use instruments requires a radically different approach to that currently applied to the purchase of reusable surgical equipment. Careful monitoring of their introduction is essential.

Powered instrumentation for transnasal endoscopic partial adenoidectomy in children with submucosal cleft palate

OBJECTIVES

Partial adenoidectomy is the selective removal of the obstructing part of adenoid tissue, thus relieves obstruction symptoms and preserves the velopharyngeal valve action. Patients with palatal dysfunction are candidates for the technique. This study describes the use of microdebrider, transnasally (guided by the nasal endoscope) to perform partial adenoidectomy in patients with submucosal cleft palate, who presented with adenoidal hypertrophy and also it discusses its effects on nasal obstruction and speech.

SUBJECTS AND METHODS

This prospective study was carried out on twenty-three submucosal cleft palate patients who were referred to the ORL-HN department; Zagazig University Hospitals complaining of respiratory obstruction and sleep disturbances due to adenoids hypertrophy. After preoperative nasoendoscopic and speech evaluation, transnasal endoscopic, power-assisted partial adenoidectomy was done for all patients. All patients were followed up at regular visits including nasoendoscopy and speech evaluation.

RESULTS

The procedure insured fast, safe, reliable, under vision and well controlled steps. Intraoperatively no major complications were recorded. During follow up, nasal obstruction and respiratory obstruction symptoms were improved. Speech outcome results were reported.

CONCLUSION

The study demonstrates the feasibility of using the microdebrider for performing transnasal partial adenoidectomy (under endoscopic guidance). The procedure is precise, rapid, safe and well-tolerated with the advantage of direct visualization of a traditionally difficult-to-expose area. The study reported improvement of respiratory obstruction symptoms with good speech results.