The admission of patients with peri‐tonsillar abscess to a general ENT ward and its influence on secondary post‐tonsillectomy haemorrhage

The admission of patients with peri‐tonsillar abscess to a general ENT ward and its influence on secondary post‐tonsillectomy haemorrhage Patients with peri‐tonsillar abscess require hospitalization. The aim of this prospective study was to determine whether the admission of patients with peri‐tonsillar abscess to the same ward as those undergoing tonsillectomy influences the incidence of secondary post‐tonsillectomy haemorrhage. We included all adult patients undergoing in‐patient tonsillectomy (n = 183) and all patients with proven peri‐tonsillar abscess (n = 46) over a 1‐year period. Both patient groups were nursed in the same general otolaryngology ward. The operation dates of those patients who developed secondary post‐tonsillectomy haemorrhage were matched to the dates when patients with peri‐tonsillar abscess were admitted. Out of the 71 patients who had tonsillectomy on days when patients with peri‐tonsillar abscess were admitted, 10 developed secondary haemorrhage. Out of the 112 patients who had tonsillectomy on days when no one in the ward had peri‐tonsillar abscess, 16 developed secondary haemorrhage. No difference was demonstrated (χ² = 0.0014, P > 0.05). In this study, admission of patients with peri‐tonsillar abscess to a general otolaryngology ward does not influence the incidence of secondary post‐tonsillectomy haemorrhage in patients undergoing elective surgery.     

Platelet-rich plasma for pediatric tonsillectomy patients

Objectives/Hypothesis: To determine if placement of autologous platelet‐rich plasma (PRP) on the tonsil beds at the time of tonsillectomy would decrease postoperative pain and complications. Study Design: Double blind, randomized, prospective study. Methods: Seventy children were recruited to participate in the study, ranging in age from 4 to 15 years. They were randomized to treatment (PRP) or control groups. The parents, patients, and nurses were blinded as to which group they were in. Postoperative pain scores were obtained using the FACES pain scale and recorded in a home diary. Results: Seventy patients were recruited to the study, and 12 did not submit their diaries and were considered to drop out of the study. Demographic data were similar for both control and treatment groups. Median pain scores, medication use, days to normal diet, and office visits did not differ between the two groups. Conclusions: PRP applied once at the time of tonsillectomy does not improve postoperative pain or recovery in pediatric patients.     

Iatrogenic hyponatremia: a cause of death following pediatric tonsillectomy

Death following pediatric tonsillectomy is very rare. If deaths occur, they are most commonly due to bleeding or aspiration. In this presentation, we would like to illustrate another potentially lethal complication following the pediatric tonsillectomy, iatrogenic hyponatremia. We have encountered 3 patients who have developed post-operative hyponatremia. This has resulted in 2 deaths. The third patient was successfully treated and developed no permanent sequela. We will discuss the etiology and pathophysiology of post-operative hyponatremia including guidelines for administering fluid and electrolytes intra-operatively and post-operatively. We expect that fatal post-operative hyponatremia can be avoided in the pediatric tonsillectomy patients.     

Increased post‐tonsillectomy secondary haemorrhage with disposable instruments: an audit cycle

The objective of the audit was to examine the increased morbidity associated with elective tonsillectomy with single‐use instruments in a district general hospital in England. Retrospective audit of consecutive case notes of 145 patients who underwent tonsillectomy in a 6‐week period after the introduction of single‐use instruments was carried out. The main outcome measure was incidence of secondary haemorrhage. In total, 9.5% of patients required re‐admission indicated by secondary haemorrhage, 4% required emergency surgery and 43% of the total group had haemostasis achieved with ties. None of these was re‐admitted. Out of the total group, 57% had haemostasis achieved with single‐use bipolar forceps; 16.8% of these patients were re‐admitted, with 7% of this group requiring emergency surgery to control the haemorrhage. Animal tissue experiments and design analysis of the single‐use bipolar diathermy highlighted the deficiencies of the initial single‐use bipolar diathermy. This was replaced by a new design of single‐use diathermy forceps. A second audit was performed which revealed a significant reduction in postoperative morbidity. Complications associated with the introduction of new instruments can be identified by repeated audit cycles.     

Comparison of treatment outcomes between intracapsular and total tonsillectomy for pediatric obstructive sleep apnea

BackgroundIntracapsular tonsillectomy (IT) has been advocated as a treatment for pediatric obstructive sleep apnea (OSA). However, evidence in the literature utilizing polysomnography (PSG) is limited.ObjectiveTo examine the experience at a tertiary children's hospital to evaluate the effectiveness and risks of intracapsular tonsillectomy compared to total tonsillectomy (TT) for treating pediatric OSA.MethodsA retrospective study was undertaken of pediatric tonsillectomy cases performed for OSA at a tertiary children's hospital from 2005 to 2010. Patients with recurrent tonsillitis, craniofacial abnormalities, chromosomal abnormalities, neuromuscular disease, and congenital malformations were excluded. Main outcome measures were apnea-hypopnea index (AHI), minimum oxygen saturation (minO₂), and surgical complications.ResultsOf the 1583 patients reviewed in this study, there were 75 IT and 93 TT patients with pre- and post-operative PSG results. The IT patients were younger, had lower BMI, larger tonsil size, lower pre-operative (AHI) and lower post-operative AHI (p < 0.05). There was a similar percentage of patients that showed improvement in AHI and minimum oxygen saturation between the IT and TT groups. There were statistically similar average change in AHI and minimum oxygen saturation between the IT and TT groups at 5.6 ± 8.6 and 8.6 ± 12.9, respectively (p = 0.8) as well as similar improvement in minimum oxygen saturation between the two groups at 3.3% ± 4.3% and 3.0% ± 5.2%, respectively (p = 0.66). Of TT patients, 2.9% experienced post-operative bleeding with 1.6% requiring OR for control of hemorrhage. Of IT patients, 2.2% were found to have tonsillar regrowth with 2.0% returning to the OR for secondary tonsillectomy.ConclusionsIntracapsular tonsillectomy, like total tonsillectomy, is effective in improving polysomnogram results in appropriately selected children. Intracapsular tonsillectomy is a suitable option for the surgical treatment of pediatric OSA consequent to its demonstrated efficacy in relieving OSA and its favorable safety profile.     

Impact of the pediatric tonsillectomy and polysomnography clinical practice guidelines

Objective

To evaluate the effect of the recently published guidelines on Tonsillectomy in Children and Polysomnography for Sleep-Disordered Breathing Prior to Tonsillectomy in Children on physician practice patterns.

Study design

Cross-sectional survey.

Method

Survey of members of the American Academy of Otolaryngology—Head and Neck Surgery.

Setting

Academic tertiary referral center.

Results

A total of 280 physicians completed the survey, with a response rate of 41.7%. 93% of respondents had read the clinical practice guidelines. Many respondents had completed a pediatric otolaryngology fellowship (46%). A large group of physicians (46%) continue to prescribe antibiotics within 24 h after surgery. One-third of respondents stopped prescribing antibiotics because of the guidelines. Discord between severity of symptoms and tonsil size was the most common reason cited for ordering a polysomnogram prior to tonsillectomy (76%). The most common reason cited for admission post-tonsillectomy was age less than 3 (40%). Less than half of physicians prescribe NSAIDs for pain control (43.8%) despite its safety profile, and only 23% reported that the guidelines influenced their use of NSAIDs postoperatively. Most respondents use intra-operative steroids (90%) as recommended.

Conclusion

The guidelines are intended to provide evidence based direction in tonsillectomy practices and improve referral patterns for polysomnography prior to tonsillectomy. The majority of the surveyed otolaryngologists reviewed these guidelines and some have changed their practice secondary to the guidelines. However, many physicians continue to prescribe post-operative antibiotics and do not use NSAIDs.     

The financial impact of clinic no-show rates in an academic pediatric otolaryngology practice

Purpose

To investigate determinants of no-show rates in an academic pediatric otolaryngology practice including appointment time, age, sex, new patient status, payer mix, and median household income by zip code.

Assessment of secondary haemorrhage rates following adult tonsillectomy – a telephone survey and literature review

Assessment of secondary haemorrhage rates following adult tonsillectomy – a telephone survey and literature review Many previous studies have considered patient re‐admission rates alone as the true rate of secondary haemorrhage following adult tonsillectomy. We aimed to determine the true rate of secondary haemorrhage following tonsillectomy in adults by performing a telephone interview with 60 consecutive patients. Whilst 40% (n = 24) of our patients reported a significant episode of bleeding (blood actively flowing from their mouth for more than 1 min) following discharge, only 8% (n = 5) were re‐admitted and only 3% (n = 2) required return to theatre. Review of the current literature suggests that return‐to‐theatre rates are more consistent than hospital re‐admission rates in large studies. We would suggest that although secondary haemorrhage can occasionally be very serious, the majority is minor, and it would therefore be more useful when comparing different techniques for tonsillectomy to consider numbers of patients returning to theatre rather than re‐admission rates.     

A randomised controlled trial of the effect of regional nerve blocks on immediate post‐tonsillectomy pain in adult patients

Post‐operative pain is the main cause of morbidity following tonsillectomy. The efficacy of glossopharyngeal and lesser palatine nerve blocks in controlling postoperative pain in adult patients was investigated prospectively. Patients 16 years and older admitted for elective tonsillectomy were randomised to one of three groups to receive a pre‐incisional oropharyngeal injection of 0.5% bupivicaine, a ‘dummy’ injection of saline or no injection. Dissection tonsillectomy and general anaesthetic techniques were standardized. Postoperative pain was monitored for 24 h. anova , χ² and Fisher's exact test were used for intergroup comparisons. Ninety‐two patients (72 women and 20 men), mean age 22 years were studied. Twenty‐nine patients received 0.5% bupivicaine, 30 saline and 33 no pre‐incisional injection. The overall mean pain scores of 2.1, 1.9 and 1.9 in the bupivicaine, saline and no injection groups were similar. Glossopharyngeal and lesser palatine 0.5% bupivicaine nerve blocks are not effective in reducing early post‐tonsillectomy pain.