Specific features of otorhinolaryngologic diseases in patients with hemophilia

The fact that ENT doctors infrequently diagnose hemophilia is explained by their inadequate knowledge of the disease. We examined 35 patients suffering from hemophilia A and 3 patients suffering from hemophilia B. The most frequent ENT pathology in them was relapsing nasal hemorrhages of varying intensity and duration (20 patients). Chronic tonsillitis was identified in 17 hemophiliacs. In 2 patients, angina was aggravated by hemorrhages from the tonsils and life-threatening hemorrhages to the soft tissues of the pharynx, neck and mediastinum which led to airways stenosis. In 3 patients, adenoids of the I degree and in 5 patients, adenoids of the II degree were detected. Among other ENT pathologies mention should be made of deformed nasal septum (13 cases), chronic otitis media (4 cases) and chronic suppurative mesotympanitis (1 case). In summary, the most common ENT disease in hemophiliacs is pathology of the lymphadenoid pharyngeal ring detected in more than half of the patients examined. Taking into consideration the specific and life-threatening pattern of potential complications of this pathology, it is important to choose efficient therapeutic methods.     

Microbiology of the tonsils and adenoids in a pediatric population

To investigate the microbial flora of the tonsils and adenoids, the core tissue from the tonsils and adenoids of 50 children undergoing tonsillectomy and adenoidectomy for either recurrent infection or airway obstruction was cultured aerobically and anaerobically, and the number of bacterial colonies was quantitated. The most common organisms isolated were alpha-hemolytic streptococci, nonpathogenic Neisseria species, Haemophilus species, Staphylococcus aureus, and Corynebacterium species. No anaerobes were identified. Bacterial isolates from the tonsils and adenoids were similar in number and frequency of occurrence. Potential pathogenic bacteria (Haemophilus species, S aureus, beta-hemolytic streptococci, and Streptococcus pneumoniae) were identified in 40 patients. Seventy-three percent of these patients shared a common pathogen in tonsil and adenoid tissue. Haemophilus species were recovered in 54% of patients and S aureus in 46%. No significant difference exists between the type and number of pathogens in patients undergoing adenotonsillectomy for recurrent infection or obstruction.     

How frequent are pathologic ENT findings in patients with obstructive sleep apnea syndrome?

Several studies have been reported suggesting a relationship between pharyngeal obstruction due to ENT pathology and the sleep apnea syndrome (SAS). To determine the incidence of pathological ENT findings that may present symptoms similar to SAS, we performed ENT examination, fiberoptic nasopharyngoscopy, rhinomanometry and partial audiometry and electronystagmography in 431 patients who had undergone polysomnography for clinically suspected SAS. 336 patients were referred for ENT examination; 95 patients had some kind of ENT disease and therapy before polysomnography. In the first group 31% showed one or more pathological ENT finding (ears 9%, nasopharynx 2%, nose 19%, oropharynx 5%, larynx 5%, neck 1%); 10.5% had pathology in two regions and 0.7% in three regions. An ENT operation was indicated in 23%, usually for nasal obstruction. ENT findings included chronic otitis media, adenoids, enlargement of lingual tonsil and vocal cord pathology, but no patient had a malignant tumor or severe pharyngeal obstruction. We conclude that severe anatomical abnormalities or dysplastic syndromes are rare; only 2 SAS patients had acromegaly due to hypophyseal adenoma and 1 patient without SAS had craniofacial dysplasia. However, ENT examination frequently revealed severe nasal obstruction due to septal deviation, polyposis or adenoids. These findings emphasize the need for ENT examination and therapy before application of CPAP (continuous positive air pressure) therapy.     

A survey of postoperative nasal packing among UK ENT surgeons

Packing of the nasal cavity following routine nasal surgery is a common but controversial practice. We aimed to evaluate nasal packing practices among UK ENT consultants for common nasal operations. A questionnaire was sent to 648 consultant ENT surgeons regarding their packing practice in patients undergoing nasal surgery. Data were collected regarding rhinology subspecialty interest, number of nasal operations performed per year, likelihood of packing for six common nasal procedures, and types of pack used. In all, 282 (43.5%) replies were received. Fifty-four (78.3%) rhinologists claimed to perform >100 nasal operations per year versus 64 (31.8%) non-rhinologists (P < 0.005). For specific operations, there was a universal trend towards less routine packing (>70% frequency) in the rhinologist group (P < 0.005). Surgeons who specified a subspecialty interest in rhinology packed significantly less often than the non-rhinologists for common nasal operations. There was great variation in the type of pack favoured by different surgeons.     

Using human reliability analysis to detect surgical error in endoscopic DCR surgery

The aim of this study was to describe the nature of active skill-based errors occurring in endoscopic dacrocystorhinostomy (DCR) surgery. A human reliability analysis methodology was used to assess surgical error from observational capture data. Twelve endoscopic DCR operations performed by three different surgical trainees were video recorded. The steps (subtasks) of each operation were carefully analysed and common errors were documented. Specific errors that resulted in trauma to the nasal mucosa were noted. Execution errors were common, with errors of grasping being most frequent (67% of all execution errors). Most of these involved the Blakesley forceps. In total, there were 69 mucosal trauma hits. Inserting instruments into or withdrawing them from the nasal cavity with too much force or speed caused more than half of these. Incising with too much force resulting in 'overshoot' caused 34% of mucosal trauma. Trainee ENT surgeons should take particular care when inserting or withdrawing instruments from the nasal cavity and also when performing lacrimal sac or nasal mucosa incisions. Performance of these tasks with too much force was identified as a common and potentially avoidable cause of mucosal trauma. Further research is needed into the design and use of endoscopic sinus surgery instruments with the aim of avoiding the errors that were encountered.     

The ubiquity of asymptomatic respiratory viral infections in the tonsils and adenoids of children and their impact on airway obstruction

BackgroundAirway obstruction due to enlargement of tonsils and adenoids is a common pediatric problem resulting in sleep disordered breathing. The cause for the relatively abnormal growth of tonsils and adenoids is poorly understood.MethodsNon-acutely ill children undergoing tonsillectomy and adenoidectomy (T&A) for various reasons were enrolled prospectively in a study to determine the frequency of asymptomatic respiratory viral infections in each lymphoid tissue and to relate the number and types of virus to the degree of airway obstruction. Molecular techniques were used to detect 9 respiratory viruses while Brodsky scores and measurements of percentages airway obstruction were used to estimate the degree of airway compromise due to the tonsil and adenoid, respectively.ResultsViruses were detected in 70.9% of tonsils and 94.7% of adenoids, p < 0.001. Adenovirus was the most common virus detected at 71.1%. Adenoids had an average of 2.4 viruses compared to 0.92 for tonsils, p < 0.001. Higher Brodsky scores were only associated with EBV in tonsils, p = 0.03, while greater percentages of airway obstruction in the adenoids were associated with adenovirus, EBV, corona virus, parainfluenza virus and rhinovirus, p ≤ 0.005.ConclusionsAsymptomatic viral infections are common and directly related to the degree of airway obstruction significantly more often in adenoids than tonsils.     

Is routine histological examination of nasal polyps justified?

This study aims to assess the indications for histological examination of polypoid lesions removed from the nose. To achieve this we have performed a national survey of consultant ENT surgeons and reviewed 2866 nasal polypectomy operations. The operations were performed between 1982 and 1988 in the Radcliffe Infirmary, Oxford and the Freeman Hospital, Newcastle. One hundred and fifty questionnaires were sent to randomly selected ENT consultants in the United Kingdom. One hundred and seventeen were returned completed (return rate 78%). The questionnaire asked whether or not the surgeon sent all polyps for examination and, if not, what his indications were for so doing. A retrospective review of all nasal polypectomy operations at the two hospitals was performed. The questionnaire revealed that 38% of the surgeons who replied sent all nasal polyps for examination and 62% did not. The commonest indications for requesting histology were unilateral polyps, abnormal appearance and a history of bleeding. The review of polypectomies showed that 74% of cases in Oxford were examined histologically and 33% in Newcastle. Two per cent of polyps were tumours, of which half were malignant. There were no cases in this study in which unsuspected malignancy was found. All cases of nasal tumours, benign or malignant, were diagnosed clinically either in the Outpatient clinic or in the operating theatre. The results of this survey suggest that it is unnecessary to send all nasal polyps for histological examination.     

Trend changes in the adenotonsillar surgery

In order to evaluate possible trend changes in the epidemiological factors of adenotonsillar surgery, a total of 1,958 operations performed between 1992 and 2002 were reviewed. RESULTS: One third of the operations were to remove tonsils in comparison with the two thirds that were to remove adenoids. Three procedures were used: 59% adenoidectomies, 28% adenotonsillectomies and 13% tonsillectomies. During the study period, the percentage of adenotonsillectomies decreased, whereas the number of adenoidectomies increased. In general, this kind of surgery is mainly performed on males. CONCLUSIONS: Although we have not discovered variations regarding gender and average age for the operations, adenotonsillar surgery has increased over recent years and the percentage ratio of the various procedures has altered as a result of new indications.     

How we do it: Changes in thyroid and salivary gland surgery since 1989: who's doing it and what are they doing?

? The aim of this study was to identify changes in the provision of parotid, submandibular and thyroid gland surgery between surgical specialties since 1989, as well as changes in surgical practice. ? Data from the Department of Health's Hospital Episode Statistics (HES) was extracted from 1989/1990 and 2003/2004 records by operation and surgical specialty in England. ? The data reveals a considerable decline in the amount of parotid and submandibular surgery performed by General surgeons; with the majority of this surgery currently being performed by ENT surgeons, and to a lesser extent, Oral and Maxillo‐Facial surgeons. ? Thyroid surgery has undergone less radical change, with General surgeons continuing to perform the majority of cases; however, an increasing proportion is now provided by ENT surgeons. ? There also seems to be changes in the types of thyroid operation being performed; with large increases in total thyroidectomy and reductions in subtotal thyroidectomies.     

Comparison of the surface and core bacteria in tonsillar and adenoid tissue with Beta-lactamase production

Adenoidectomy and tonsillectomy, indicated for children with recurrent or persistent symptoms of infection or hypertrophy, are among the most frequent operations performed in children. This study was carried out for investigating the microbial flora of the tonsils and adenoids regarding to core and surface microorganisms and also pathogen microrganisms' beta-lactamase production rate. Cultures were taken from the core and surface of tonsils and adenoids of the 91 patients at the time of the surgery for tonsillectomy and adenoidectomy. Aerobic and anaerobic cultures were inoculated and identified. Beta-lactamase production was detected also. The most frequently isolated aerobic microorganisms were Streptococcus viridans and Neisseria spp. The number of the microorganisms isolated from the tonsil core compared to the surface of the tonsils was found statistically insignificant (P?>?0.05). The number of the adenoid surface aerobic microorganisms was found higher from the adenoid core (P??0.05). The togetherness of Staphylococcus aureus and other beta-lactamase producing bacteria was found statistically significant (P?相似文献   

Current indications for (adeno)tonsillectomy in children: a survey in The Netherlands

OBJECTIVE: Despite the fact that (adeno)tonsillectomy is one of the procedures most frequently performed on children, studies of current indications are scarce. The purpose of this study is to determine the indications for (adeno)tonsillectomy in children younger than 15 years of age according to Dutch ENT surgeons and general practitioners (GPs). METHODS: During a period of 8 months, 18 ENT surgeons in seven ENT practices and 210 referring GPs filled out standard questionnaires for 349 children listed for tonsil surgery. RESULTS: Apart from recurrent tonsillitis (ENT: 40%, GP: 35%), findings such as enlarged tonsils (ENT: 42%, GP: 24%) and tonsillar crypt debris (ENT: 29%, GP: 17%) and non-specific symptoms such as listlessness (ENT: 28%, GP: 19%) and poor appetite (ENT: 28%, GP: 16%) were considered important criteria for surgery. Symptoms of obstructive sleep apnea were present in 25% (ENT) and 6% (GP) of patients but were considered indicative for surgery in only 11% (ENT) and 4% (GP). In contrast to ENT surgeons, GPs considered otitis media and hearing loss relatively important for (adeno)tonsillectomy. CONCLUSIONS: Apart from the generally accepted indications such as recurrent tonsillitis and obstructive sleep apnea, other indications play an equally important role in the decision to perform tonsil surgery in The Netherlands.     

Are the tonsils and adenoids a reservoir of infection in otitis media with effusion (glue ear)?

In a prospective investigation of the treatment of glue ear in children, the possible role of persistent infection in the tonsils and adenoids was assessed by comparing bacterial cultures of swabs and resected tissue from the tonsils and adenoids of patients with cultures of swabs from similar sites in control subjects without ENT abnormality. For almost all potential pathogens, including Streptococcus pneumoniae and Haemophilus influenzae, no statistically significant differences were demonstrated between patients and controls. The same was true of Streptococcus pyogenes in tonsil specimens, while in adenoid specimens rather more isolates were obtained in patients than controls. This difference was just statistically significant at the 5% level, but only when all isolations, including very scanty growths, were compared. On present evidence, persistent infection should not be invoked to explain the success of adenoidectomy in otitis media with effusion or to justify adenotonsillectomy.     

Obstructive hypertrophic adenoids and tonsils as a cause of infantile failure to thrive: reversed by tonsillectomy and adenoidectomy

Isolated failure to thrive in an infant caused by chronic hypoventilation due to hypertrophic adenoids and tonsils, has not been previously described. A 9 month-old infant presented with weight loss and mild clinical respiratory signs. Hypoxemia and CO2 retention, however, were documented by transcutaneous gas measurement, and ENT examination revealed enlarged tonsils and adenoids. Adenoidectomy and tonsillectomy at 9 1/2 months of age completely reversed the patient's hypoventilation and growth pattern. While the exact mechanism of failure to thrive secondary to upper airway obstruction in infancy is not clear, we conclude that routine ENT evaluation should be a regular part of the workup of infants under one year who suffer from failure to thrive.     

Bacteriology of adenoids and tonsils in children with recurrent adenotonsillitis

Adenoids and tonsils electively removed from 25 children with a history of recurrent group A beta-hemolytic streptococci (GABHS) adenotonsillitis were cultured for aerobic and anaerobic bacteria. Two hundred twenty-four organisms (112 aerobes and facultatives, 110 anaerobes, and 2 Candida albicans) were isolated from the tonsils, and 229 (111 aerobes and facultatives and 118 anaerobes) were isolated from the adenoids. Mixed infection was present in all instances, with an average of 9.1 isolates per specimen. The predominant aerobes were Streptococcus sp, Haemophilus influenzae, and GABHS, and the prevalent anaerobes were Peptostreptococcus, Prevotella, and Fusobacterium spp. Beta-lactamase-producing bacteria were detected in 72 isolates recovered from 22 tonsils (88%) and in 74 isolates recovered from 21 adenoids (84%). Discrepancies in the organisms recovered were found between the tonsils and adenoids. Of the aerobic isolates, 20% were isolated only in tonsils and 18% only in adenoids. Of the anaerobes, 20% were found only in tonsils and 26% only in adenoids. This study demonstrates a polymicrobial aerobic-anaerobic flora in both adenoids and tonsils, and discrepancies in recovery of pathogens such as GABHS. The adenoids may serve as a potential source of tonsillitis caused by GABHS.     

Pediatric adenoid surgery in Sweden 2004–2013: Incidence,indications and concomitant surgical procedures

ObjectivesTo describe the incidence and indications of adenoid surgery and concomitantly performed ENT surgical procedures in a nationwide cohort covering several years of practice.MethodsA retrospective study based on data from the National patient registry in Sweden. All children born from 1st of January 2004 to December 31st, 2013 who underwent adenoidectomy for the first time in Sweden during 2004–2013 were included in the study. Patient characteristics (age and gender), indications for surgery and performed ENT surgery were evaluated.Results40,829 children underwent adenoid surgery during the studied period. Of these, 24,537 (60%) were boys. Mean and median age at surgery in the studied population was 4 years and 3.5 years respectively for both boys and girls. The most frequently performed surgical procedure was adenotonsillar surgery 43% (n = 17,434) followed by solitary adenoid surgery 26% (n = 10,749). The most frequent registered indication was hypertrophy 60% (n = 24,422) followed by hypertrophy and otitis media 21% (n = 8425). The highest age related incidence for all types of adenoid surgery taken together was 2–4 years of age for both genders. Boys had higher incidence rates than girls for all ages and all types of surgery except at eight years of age.ConclusionsThe main findings were that adenoidectomy most commonly was performed together with surgery of the tonsils on the indication hypertrophy, that adenoid- and adenoid related ENT surgery were most commonly performed between 2 and 5 years of age and that the incidence in surgical rates was higher for boys than girls. There seem to be large unwarranted variations between countries regarding incidence rates and we believe that there is a need for further studies in order to establish recommendations for best practice regarding adenoid and related ENT surgeries.     

Who performs thyroid surgery: a review of current otolaryngological practice

Thyroid surgery has been traditionally a general surgical practice, but recently more otolaryngologists have been offering a thyroid service. We have quantified thyroid surgery performed by the different specialties, and looked more closely at the practice of otolaryngologists. Data was obtained from the Department of Health for UK thyroid surgery in all specialties for the year 1998-99 and validated against a survey of members of the British Association of Otolaryngologists-Head & Neck Surgeons (BAO-HNS). The use of investigations of a simple clinical case (solitary thyroid nodule) was compared with best practice. General surgeons still perform the majority of thyroid surgery (83%) but ENT surgeons now perform significant numbers (15.4% of all cases), which translates to 1499 cases per annum. A total of 102 BAO-HNS members were performing thyroid surgery with an average case-load of 19.1 per year. In total, 35% of ENT surgeons see thyroid patients in multidisciplinary clinics. The choice of investigation is consistent with European guidelines. ENT surgeons are doing significant amounts of thyroid surgery and the numbers appear to be increasing. The formation of multidisciplinary teams including general surgeons and otolaryngologists who are committed to subspecialization can only improve both training and treatment outcomes.     

Distribution characteristics of immunoglobulin-secreting cells in adenoids. Relationship to age and disease.

Forty-four adenoids and 52 palatine tonsils from 71 children and adolescents (age 3-21 years) undergoing surgery because of adenoidal hypertrophy or recurrent tonsillitis were examined for the presence of immunoglobulin-secreting cells (ISC) employing an enzyme-linked immunospot assay (ELISPOT). ISC constituted less than 2% of the mononuclear cell population. Adenoids contained IgG, IgA, and IgM ISC in significantly lower numbers than palatine tonsils. The predominant isotype of the ISC was IgG, in adenoids accounting for 62% of the ISC and in palatine tonsils for 73%. The relative numbers for IgA and IgM ISC were similar. A significant correlation existed between autologous adenoids and palatine tonsils for the numbers of IgA and IgM ISC, but not for the numbers of IgG cells. These observations suggest that, adenoid and palatine tonsils display similar immunoglobulin distribution patterns within a single individual. However, individuals with hypertrophied adenoids exhibited a numeric decrease in IgG ISC with increasing age (P less than 0.01). Both lymphoid tissues may be involved in mucosal immune defense.     

Implication of immunological abnormalities after adenotonsillotomy

The adenoids and tonsils are thought to be essential parts of the system protecting organism against pathogens invading the upper respiratory tracts. Human adenoids and tonsils are known to be immunologically reactive lymphoid organs, which manifest specific antibodies and B and T cells activity in response to variety of antigens carrying out the functions of humoral and cellular immunity. The purpose of the study was to observe the changes in systemic immunity in children with hypertrophy of adenoids and tonsils treated in Department of Laryngology, Children's Hospital in Warsaw in period 1994-1999. The study comprised 80 patients (33 girls and 47 boys, aged from 3 to 14 years, mean age 6.8 years) with diagnosed hypertrophy of adenoids and tonsils. The diagnosis of hypertrophy of adenoids and tonsils was based on characteristic history and laryngological examination. All patients were scheduled for adenotonsillotomy. The control group comprised 40 people (14 girls and 26 boys, aged from 3 to 15 years, mean age 7.6 years) without history of the recurrent upper tract infections. In all patients we carried out following examinations: serum levels of immunoglobulins A, G, M (humoral immunity); percentage of T lymphocytes (CD3); percentage of T helper (CD4) and T cytotoxic (CD8) lymphocytes (cellular immunity) and delayed cutaneous hypersensitivity-Multitest CMI (cell mediated immunity). Our study demonstrate that in children with hypertrophy of adenoids and tonsils exist changes in the immunological parameters. The observed changes appear not only locally but also generally. In the early period after adenotonsillotomy there was statistically significant decrease of the values of humoral and cellular immunity parameters. However, 6 months after operation we observed normalization of examined immunological parameters. We think that the examinations of parameters of immunological system (humoral and cellular) are necessary before planned adenotonsillotomy.     

One-stage revision surgery for pediatric cholesteatoma: long-term results and comparison with primary surgery

OBJECTIVE: Few studies report on revision surgery for pediatric cholesteatoma, even if most studies of primary surgery show high recurrence rates. We present independently evaluated long-term results of revision surgery and compare the results with those of primary surgery. METHODS: The series consisted of 42 consecutive pediatric (age <16 years) cholesteatoma revision operations in the Helsinki University ENT Department. The primary and revision surgery was non-staged, all mastoids were obliterated and the bony ear canals were reconstructed. The preoperative, surgical and annual control data were recorded in a database. The last control was independently performed (J.S.) with an average follow-up of 4.3 years and 87% attendance. RESULTS: The recurrence rate for revision operations was 38%. A retraction process developed in 38% of the ears and 67% of these retractions turned into active cholesteatomas. There was a non-significant difference for these figures as compared with primary surgery. Postoperative discharge and poor middle ear ventilation were associated with recurrence. The following factors showed significant differences between primary and revision surgery: increased number of bare facial nerve in the revision group, lower recurrence rate for experienced surgeons (as for both groups together) and improved hearing results for ears without recurrence in the revision group. CONCLUSIONS: Recurrent disease after revision surgery appears either in the attic or in the mesotympanum, or develops from a retraction pocket in a similar manner as was seen in patients receiving primary surgery. Recurrence is associated with discharging and poorly ventilated ears. Pediatric cholesteatoma surgery should be done or be supervised by experienced surgeons. The present operation methods result in many recurrences after primary and revision surgery. New surgical methods are needed to create additional aeration pathways to the epitympanum in order to improve middle ear aeration and to prevent some of the retractions.     

Snoring: surgical vs. nonsurgical management

Eighteen children were treated for snoring. Surgical removal of enlarged tonsils and/or adenoids resulted in prompt and total elimination of snoring in 17 of these patients. One child required nasal and sinus surgery to gain relief from snoring. Eighty-three adults were interviewed, examined, and treated for snoring. Correction of anatomical abnormalities in the nose, soft palate, uvula, and pharynx achieved elimination of snoring in 72% of surgically treated cases. By contrast, nonsurgical remedies achieved snoring elimination in only 5% of patients (controls). Tracheostomy was required in 10% of snoring adults--those who proved to have severe obstructive sleep apnea syndrome. Snoring is due to the combined effect of several anatomic and physiologic abnormalities in the nasal and pharyngeal segments of the airway. It may be amenable to surgical therapy when the severity of the problem warrants it.