Showing papers on "Tonsillectomy published in 2013"

Pain intensity on the first day after surgery: a prospective cohort study comparing 179 surgical procedures.

Abstract: Background Severe pain after surgery remains a major problem, occurring in 20-40% of patients. Despite numerous published studies, the degree of pain following many types of surgery in everyday clinical practice is unknown. To improve postoperative pain therapy and develop procedure-specific, optimized pain-treatment protocols, types of surgery that may result in severe postoperative pain in everyday practice must first be identified. Methods This study considered 115,775 patients from 578 surgical wards in 105 German hospitals. A total of 70,764 patients met the inclusion criteria. On the first postoperative day, patients were asked to rate their worst pain intensity since surgery (numeric rating scale, 0-10). All surgical procedures were assigned to 529 well-defined groups. When a group contained fewer than 20 patients, the data were excluded from analysis. Finally, 50,523 patients from 179 surgical groups were compared. Results The 40 procedures with the highest pain scores (median numeric rating scale, 6-7) included 22 orthopedic/trauma procedures on the extremities. Patients reported high pain scores after many "minor" surgical procedures, including appendectomy, cholecystectomy, hemorrhoidectomy, and tonsillectomy, which ranked among the 25 procedures with highest pain intensities. A number of "major" abdominal surgeries resulted in comparatively low pain scores, often because of sufficient epidural analgesia. Conclusions Several common minor- to medium-level surgical procedures, including some with laparoscopic approaches, resulted in unexpectedly high levels of postoperative pain. To reduce the number of patients suffering from severe pain, patients undergoing so-called minor surgery should be monitored more closely, and postsurgical pain treatment needs to comply with existing procedure-specific pain-treatment recommendations.

A Randomized Trial of Adenotonsillectomy for Childhood Sleep Apnea

Abstract: Background Adenotonsillectomy is commonly performed in children with the obstructive sleep apnea syndrome, yet its usefulness in reducing symptoms and improving cognition, behavior, quality of life, and polysomnographic findings has not been rigorously evaluated. We hypothesized that, in children with the obstructive sleep apnea syndrome without prolonged oxyhemoglobin desaturation, early adenotonsillectomy, as compared with watchful waiting with supportive care, would result in improved outcomes. Methods We randomly assigned 464 children, 5 to 9 years of age, with the obstructive sleep apnea syndrome to early adenotonsillectomy or a strategy of watchful waiting. Polysomnographic, cognitive, behavioral, and health outcomes were assessed at baseline and at 7 months. Results The average baseline value for the primary outcome, the attention and executive-function score on the Developmental Neuropsychological Assessment (with scores ranging from 50 to 150 and higher scores indicating better functioning), was ...

Nonsteroidal anti‐inflammatory drugs and perioperative bleeding in paediatric tonsillectomy

Abstract: Background Nonsteroidal anti-inflammatory drugs (NSAIDs) are used for pain relief following tonsillectomy in children. However, as they inhibit platelet aggregation and prolong bleeding time they could cause increased perioperative bleeding. The overall risk remains unclear. This review was originally published in 2005 and was updated in 2010 and in 2012. Objectives The primary objective of this review was to assess the effects of NSAIDs on bleeding with paediatric tonsillectomy. Our secondary outcome was to establish whether NSAIDs affect the incidence of other postoperative complications when compared to other forms of analgesia. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 10); MEDLINE (inception until October 2012); EMBASE (inception until October 2012); Current Problems (produced by the UK Medicines Control Agency), MedWatch (produced by the US Food and Drug Administration) and the Australian Adverse Drug Reactions Bulletins (to May 2010). The original search was performed in August 2004. We also contacted manufacturers and researchers in the field. Selection criteria We included randomized controlled trials assessing NSAIDs in children, up to and including 16 years of age, undergoing elective tonsillectomy or adenotonsillectomy. Data collection and analysis Two authors independently assessed trial quality and extracted the data. We contacted study authors for additional information, where necessary. Main results We included 15 studies that involved 1101 children in this updated review. One study was added as a result of our 2012 search, another previously included study was removed due to lack of randomization. Fourteen included studies compared NSAIDs with other analgesics or placebo and reported on bleeding requiring surgical intervention. The use of NSAIDs was associated with a non-significant increase in the risk of bleeding requiring surgical intervention: Peto odds ratio (OR) 1.69 (95% confidence interval (CI) 0.71 to 4.01). Ten studies involving 365 children reported perioperative bleeding requiring non-surgical intervention. NSAIDs did not significantly alter the number of perioperative bleeding events requiring non-surgical intervention: Peto OR 0.99 (95% CI 0.41 to 2.40) but the confidence intervals did not exclude an increased risk. Thirteen studies involving 1021 children reported postoperative vomiting. There was less vomiting when NSAIDs were used as part of the analgesic regime than when NSAIDs were not used: Mantel Haenszel (M-H) risk ratio (RR) 0.72 (95% CI 0.61 to 0.85). Authors' conclusions There is insufficient evidence to exclude an increased risk of bleeding when NSAIDs are used in paediatric tonsillectomy. They do however confer the benefit of a reduction in vomiting.

A 2013 updated systematic review & meta-analysis of 36 randomized controlled trials; no apparent effects of non steroidal anti-inflammatory agents on the risk of bleeding after tonsillectomy.

Abstract: Background Although the literature suggests that non-steroidal anti-inflammatory drugs (NSAIDs) are effective in controlling post-operative pain in the paediatric population, physicians have been reluctant to utilise these medications after tonsillectomy due to concerns of increased bleeding rates. While many surgeons prescribe opioid analgesics postoperatively, these are associated with a number of potential adverse side-effects including nausea, vomiting, constipation, excessive sedation and respiratory compromise. Objective of review To compare bleeding rates and severity between recipients of NSAIDs versus placebo or opioid analgesics for tonsillectomy. Search strategy Two authors independently searched electronic databases including PubMed, OVID, EMBASE and Cochrane Review from inception to July 2012. The keywords used included: Adenotonsillectomy, Tonsillectomy, Analgesia, Bleeding, Perioperative and Postoperative. These were then combined in various combinations with specific NSAIDs. Evaluation method A systematic review and meta-analysis of all randomised control trials comparing bleeding rates and severity between NSAIDs versus placebo or opioids post-tonsillectomy. Results A total of 36 studies met our inclusion criteria including 1747 children and 1446 adults. When all of the studies were combined in a meta-analysis using the most severe outcome, there was no increased risk of bleeding in those using NSAIDs after tonsillectomy. Use of NSAIDs in general [1.30 (0.90–1.88)] or in children [1.06 (0.65–1.74)] was not associated with increased risk of bleeding in general, most severe bleeding, secondary haemorrhage, readmission or need of reoperation due to bleeding. Similarly, there was no increased bleeding risk for specific NSAIDs in adults. In the studies looking at paediatric subjects, the overall odds ratio of bleeding was even lower than in the general population and not significant. This result is based on 18 studies, six of which had zero outcomes in either treatment arm. Similar to the general population analysis, there was no significant difference in any of the subanalyses: bleeds treated with reoperation, readmission or bleeds in children that could be managed conservatively. There were also no significant differences in the subanalyses of individual NSAIDs. Similarly, there was no significant difference in rates of bleeding in the subanalysis of studies that gave NSAIDs multiple times, for instance, both before and after surgery. Conclusions These results suggest that NSAIDs can be considered as a safe method of analgesia among children undergoing tonsillectomy.

Mortality and major morbidity after tonsillectomy: etiologic factors and strategies for prevention.

Abstract: Objective/Hypothesis To report data on death or permanent disability after tonsillectomy. Study Design Electronic mail survey. Methods A 32-question survey was disseminated via the American Academy of Otolaryngology–Head and Neck Surgery electronic newsletter. Recipients were queried regarding adverse events after tonsillectomy, capturing demographic data, risk factors, and detailed descriptions. Events were classified using a hierarchical taxonomy. Results A group of 552 respondents reported 51 instances of post-tonsillectomy mortality, and four instances of anoxic brain injury. These events occurred in 38 children (71%), 15 adults (25%), and two patients of unstated age (4%). The events were classified as related to medication (22%), pulmonary/cardiorespiratory factors (20%), hemorrhage (16%), perioperative events (7%), progression of underlying disease (5%), or unexplained (31%). Of unexplained events, all but one occurred outside the hospital. One or more comorbidities were identified in 58% of patients, most often neurologic impairment (24%), obesity (18%), or cardiopulmonary compromise (15%). A preoperative diagnosis of obstructive sleep apnea was not associated with increased risk of death or anoxic brain injury. Most events (55%) occurred within the first 2 postoperative days. Otolaryngologists who reported performing <200 tonsillectomies per year were more likely to report an event (P < .001). Conclusions This study, the largest collection of original reports of post-tonsillectomy mortality to date, found that events unrelated to bleeding accounted for a preponderance of deaths and anoxic brain injury. Further research is needed to establish best practices for patient admission, monitoring, and pain management. Laryngoscope, 123:2544–2553, 2013 Level of Evidence N/A.

New Evidence about an Old Drug — Risk with Codeine after Adenotonsillectomy

Abstract: In response to reports of respiratory depression and death in young children who had received codeine after tonsillectomy, adenoidectomy, or both, the FDA initiated a safety evaluation. The result is a boxed warning on the labels of all codeine-containing products.

Paradigm shift in Sweden from tonsillectomy to tonsillotomy for children with upper airway obstructive symptoms due to tonsillar hypertrophy

Abstract: Tonsillotomy (TT) is now used more often than tonsillectomy (TE) for tonsil obstructive symptoms in Sweden. Both TE and TT give high patient satisfaction although TT results in fewer postoperative bleedings and shorter time when analgesics are needed. The objective of this study is to analyze the current prevalence of different tonsil surgery procedures, the rates of early and late bleeding and other complications. Data from the National Tonsil Surgery Register in Sweden were analyzed. Patients 1–15 years operated for symptoms due to tonsil hypertrophy were included. Surgical procedure, technique and bleedings during hospital stay were registered. Thirty days after surgery, unplanned contacts due to bleeding, infection or pain were reported as were symptom relief after 6 months. 24,083 patients were registered. Of the 10,826 children 1–15 years operated for obstructive symptoms, 64 % were TT or TT+A, and 34 % TE, TE+A. 69 % answered the 30-day questionnaire and 50 % the 6 months. Bleeding in hospital occurred in 1.38 %, late bleedings in 2.06 %: 3.7 % after TE+A, 0.8 % after TT+A. Differences in readmissions due to bleeding, number of days using analgesics, health care contacts due to pain and nosocomial infections were significant between TT and TE, but not differences with regard to symptom relief after 6 months.

The relationship between depressive symptoms and obstructive sleep apnea in pediatric populations: a meta-analysis.

Abstract: Background:A higher incidence of depressive disorders and symptoms has been suggested among children suffering from obstructive sleep apnea (OSA). Yet, the extent to which OSA is related to increas...

Post-tonsillectomy haemorrhage more common than previously described – an institutional chart review

Abstract: Conclusions: Risk of post-tonsillectomy haemorrhage (PTH) was higher compared with previous studies and may be associated with the criteria used. Male gender and the use of haemostatic agents in the primary operation were associated with increased risk of PTH, whereas the use of non-steroidal anti-inflammatory drugs (NSAIDs) or dexamethasone was not. Objectives: The aim of the study was to investigate the risk of PTH in adult patients, and its association with the use of NSAIDs, dexamethasone, paracetamol, serotonin (5-HT3) receptor antagonists, haemostatic agents, age and gender during preceding tonsillectomy (TE). Methods: All PTH complications that resulted in an adult TE patient re-contacting the hospital were retrospectively recorded during a 12-month period. PTH types were allocated into three categories: (I) a history of bleeding, (II) bleeding requiring direct pressure or electrocautery under local anaesthesia or (III) reoperation under general anaesthesia. Results: A total of 842 adult T...

Effect of intravenous fluid therapy on postoperative vomiting in children undergoing tonsillectomy

Abstract: Background Postoperative vomiting (POV) is one of the most frequent complications of tonsillectomy in children. The aim of this study was to evaluate the antiemetic effect of super-hydration with lactated Ringer's solution in children undergoing elective otorhinolaryngological surgery. Methods One hundred ASA I–II children, aged 1–12 yr, undergoing elective tonsillectomy, with or without adenoidectomy, under general anaesthesia were studied. Induction and maintenance of anaesthesia were standardized with fentanyl, mivacurium, and sevoflurane in N2O/O2. Subjects were assigned to one of the two groups: 10 ml kg−1 h−1 lactated Ringer's solution or 30 ml kg−1 h−1 lactated Ringer's solution. A multivariable logistic regression was used for assessing the effects of super-hydration on POV (defined as the presence of retching, vomiting, or both). A value of P Results During the first 24 h postoperative, the incidence of POV decreased from 82% to 62% (relative reduction of 24%, P=0.026). In the adjusted logistic regression model, subjects in the 10 ml kg−1 h−1 group had an odds ratio of POV that was 2.92 (95% confidence interval: 1.14, 7.51) for POV compared with subjects in the 30 ml kg−1 h−1 group. Conclusions Intraoperative administration of 30 ml kg−1 h−1 lactated Ringer's solution significantly reduced the incidence of POV during the first 24 h postoperative. Our results support the use of super-hydration during tonsillectomy, as an alternative way to decrease the risk of POV in children.

Post Tonsillectomy Pain: Can Honey Reduce the Analgesic Requirements?

Abstract: Background Tonsillectomy with or without adenoidectomy is one of the most common surgical procedures performed worldwide, especially for children. Oral honey administration following tonsillectomy in pediatric cases may reduce the need for analgesics via relieving postoperative pain. Objectives The aim of this study was to evaluate the effects of honey on the incidence and severity of postoperative pain in patients undergoing tonsillectomy. Patients and methods A randomized, double blind, placebo controlled study was performed. One hundred and four patients, who were older than eight, and were scheduled for tonsillectomy, were divided into two equal groups, honey and placebo. Standardized general anesthesia, and postoperative usual analgesic, and antibiotic regimen were administrated for all patients. Acetaminophen plus honey for the honey group, and acetaminophen plus placebo for the placebo group were given daily. They began to receive honey or placebo when the patients established oral intake. Results The difference between acetaminophen and acetaminophen plus honey groups was statistically significant both for visual analogue scale (VAS), and number of painkillers taken within the first three postoperative days. The consumption of painkillers differed significantly in every five postoperative days. No significant difference was found between groups regarding the number of awaking at night. Conclusions Postoperative honey administration reduces postoperative pain and analgesic requirements in patients after tonsillectomy. As the side effects of honey appear to be negligible, consideration of its routine usage seems to be beneficial along with routine analgesics.

Risk factors for desaturation after tonsillectomy

Abstract: Objectives/Hypothesis To identify clinical risk factors for oxygen desaturation in the first 24 hours post-tonsillectomy, thus permitting the identification of those patients who warrant inpatient monitoring. Study Design A retrospective analysis of 4092 consecutive patients undergoing tonsillectomy over a two-year period. Methods Detailed clinical data were recorded for all patients who desaturated in the postoperative period (n = 294) and randomly selected controls (n = 368). Univariate and Multivariate analysis was performed in order to identify independent risk factors for desaturation. Results There were 294/4092 patients (7.2%) who experienced desaturations (defined as sustained saturations <90%) in the first 24 hours postoperatively (mean nadir, 78.7%). Multivariate analysis identified seven independent clinical risk factors for desaturation in the initial 24 hours post-tonsillectomy: trisomy 21, weight, coexistent cardiac disease, a coexistent syndromic diagnosis, a clinical diagnosis of obstructive sleep apnea (OSA), a coexistent neurologic diagnosis, and a prior diagnosis of pulmonary disease. A policy that admits all patients exhibiting any one of these risk factors except OSA would have identified 92% of the patients who subsequently desaturated. However, such a policy would also have required admission of 60% of the patients in our control group. Conclusions These findings are generally consistent with the Clinical Practice Guidelines recently published by the American Academy of Otolaryngology. In a tertiary care center, it may not be possible to identify an algorithm that admits all children at risk of desaturation while permitting the discharge of a high percentage of patients. Level of Evidence 3b. Laryngoscope, 123:2554–2560, 2013

A randomized clinical trial of a nurse telephone follow-up on paediatric tonsillectomy pain management and complications.

Abstract: Aims To determine the effect of a nurse telephone follow-up on paediatric post-tonsillectomy pain intensity, complications, and use of other healthcare services. Background After tonsillectomy, children experience moderate-to-severe pain for days. Parents tend to give insufficient analgesia, with resulting increases in pain and postoperative complications. In adults, nurse telephone follow-up for ambulatory surgeries reduces postoperative pain. Design The study design was a randomized clinical trial. Methods In this trial, children aged 4–12 years undergoing elective tonsillectomy in June–October 2010 were assigned to a nurse telephone follow-up with parents on postoperative days 1, 3, 5 and 10, or standard care with no follow-up but data collection. Outcomes included pain intensity, analgesics administered, complications, and healthcare use. Results Of 45 participants, the intervention group (n = 24) received more analgesics on postoperative days 1 and 3, increased their fluid intake at days 1 and 3, but had more constipation at day 3 than the control group (n = 21). There was no significant difference regarding pain intensity or use of healthcare resources. Conclusion Nurse telephone follow-up was beneficial for some pain management and prevention of complications, although better analgesic treatments are needed. The intervention was simple, safe, and appreciated by parents.

Comparison of topical tramadol and ketamine in pain treatment after tonsillectomy.

Abstract: Summary Objectives/Aim The primary objective of this study is to evaluate the effects of topically applied ketamine or tramadol on early postoperative pain scores in children undergoing tonsillectomy. The secondary aim of the study is to assess nausea, vomiting, difficulty in swallowing, and sore throat characteristics of the patients. Background Tonsillectomy surgery is frequently associated with postoperative pain, which usually requires substantial consumption of analgesics including opioids. Safe and effective post-tonsillectomy pain control is still a clinical dilemma, in spite of the use of various surgical and anesthetic techniques. Methods A total of 60 children, aged between 4 and 10 years, scheduled for tonsillectomy, were randomly assigned to one of three groups. Study drugs were administered to both tonsillar fossae for 5 min. In 5 ml artificial saliva, Group K (n = 20) received 0.4 ml (20 mg) ketamine and Group T (n = 20) received 0.8 ml tramadol HCl solution. Group C (n = 20) received only 5 ml saline as a control. Ramsay Sedation Scale and FACES PRS Score, nausea, vomiting, difficulty in swallowing, and sore throat were evaluated. Results There was no difference among the groups in terms of baseline characteristics, including age, sex, and ASA profile (P > 0.05 for all). Systolic blood pressure, diastolic blood pressure, mean blood pressure, heart rate, respiratory rate, and saturation of peripheral oxygen (SpO2) values were not significantly different among the groups in all time points (P > 0.05 for all). There was a statistically significant difference among the groups according to Ramsay Sedation Scales in 40th minute (P < 0.001). There were statistically significant differences among the groups in terms of Wong-Baker FACES Pain Rating Scale Score in all time points (P < 0.004 for all). There was a statistically significant difference among the groups in terms of rescue analgesia necessity in 5th and 10th minute (P < 0.001 and P = 0.003). There was a statistically significant difference among the groups in terms of sore throat in 5th and 10th minute (P < 0.001 for both). Neither rescue analgesia necessity nor sore throat characteristics was different between the Group T and Group K in all time points. Conclusion Topical tramadol and ketamine seem to be safe, effective, and easy analgesic approach for decreasing tonsillectomy pain.

Coblation vs. Electrocautery Tonsillectomy: A Prospective Randomized Study Comparing Clinical Outcomes in Adolescents and Adults

Abstract: Objectives. Coblation is operated in low temperature, so it is proposed that tonsillectomy with coblation involves less postoperative pain and allows accelerated healing of the tonsillar fossae compared with other methods involving heat driven processes. However, the results of the previous studies showed that the effect of coblation tonsillectomy has been equivocal in terms of postoperative pain and hemorrhage. Though, most of the previous studies which evaluated coblation tonsillectomy were performed in children. Recently, electrocautery tonsillectomy has been used most widely because of the reduced intraoperative blood loss and shorter operative time compared to other techniques. This prospective study compared intraoperative records and postoperative clinical outcomes in adolescents and adults following coblation and electrocautery tonsillectomies. Methods. Eighty patients over 16 years of age with histories of recurrent tonsillitis were enrolled. The patients were randomly allocated into coblation (n=40) and electrocautery tonsillectomy groups (n=40). All operations were performed by one surgeon who was skilled in both surgical techniques. Intraoperative parameters and postoperative outcomes were checked. Results. Postoperative pain and otalgia were not significantly different between the two groups; however, there was a tendency towards reduced pain and otalgia in the coblation group. More cotton balls for swabbing the operative field were used introoperatively in the electrocautery group (P=0.00). There was no significant difference in postoperative hemorrhage, wound healing, commencement of a regular diet, and foreign body sensation between the groups. Conclusion. Only cotton use, which represented the amount of blood loss, was less in the coblation tonsillectomy group. Coblation tonsillectomy warrants further study with respect to the decreased postoperative pain and otalgia.

Regrowth of the adenoids after coblation adenoidectomy: cephalometric analysis.

Abstract: Objectives/Hypothesis To analyze the prevalence of adenoid regrowth at 1 year after coblation adenoidectomy using cephalometric radiography. Study Design Retrospective analysis. Methods One hundred eighty-eight children who underwent adenoidectomy from June 2006 through September 2010 were included. Demographic data, preoperative size of palatine tonsils, presence of allergic rhinitis, concurrent operation of recurrent middle ear effusion, and preoperative and postoperative Korean version of Obstructive Sleep Apnea-18 (KOSA-18) scores were analyzed. The size of the adenoids was measured three times in all the children by lateral cephalometry; preoperatively, at 1 month after adenoidectomy to observe adenoid residual; and at 1 year after surgery to observe adenoid regrowth. Results The adenoid regrowth at 1 year after adenoidectomy was observed in 25 children (13.3%), and the adenoid residual at 1 month after surgery was observed in 11 children (5.9%) in the cephalometry. Seven of the 11 children with residual disease (63.6%) had adenoid regrowth at 1 year. The regrowth group was significantly younger than no regrowth group, and the preoperative adenoids were larger in regrowth group than in no regrowth group. The symptoms of sleep disordered breathing recurred in two patients and they had revision adenoidectomy. Conclusion The regrowth rate of the adenoids at 1 year was not low. However, most of the patients were asymptomatic. The adenoid residual at 1 month contributed to regrowth at 1 year, and the risk factors of the adenoid regrowth were younger age and larger initial size of the adenoids. Level of Evidence 2b. Laryngoscope, 123:2568–2573, 2013

A randomized study of surgical site infiltration with bupivacaine or ketamine for pain relief in children following cleft palate repair.

Abstract: Summary Background Wound infiltration with ketamine reduces postoperative pain after tonsillectomy by NMDA receptor blockade and local anesthetic effect. Objectives To evaluate the postoperative analgesia after surgical site infiltration with bupivacaine or ketamine in children undergoing cleft palate surgery. Materials and methods After institutional ethics committee approval and parental consent, 50 ASA-1 children of age 1–6 years undergoing palatoplasty were included in this prospective randomized double-blind study. A standardized technique of general anesthesia was used. The surgical site was infiltrated with either 2 mg·kg−1 of bupivacaine (Group B) or 0.5 mg·kg−1 of ketamine (Group K). Pain (Children Hospital Eastern Ontario Pain Score), sedation, dysphagia, nausea, vomiting, and sleep pattern were assessed postoperatively up to 24 h. Results CHEOPS scores were similar in both the groups up to 12 h but were lower with ketamine compared with bupivacaine at 24 h postoperatively (P = 0.01). Fewer children required rescue analgesics in Group K (28%) than in Group B (64%; P < 0.01). The time to first rescue analgesic and the amount of analgesics used in 24 h were similar in the two groups. Fewer children suffered from dysphagia in Group K (52%) than in Group B (88%; P < 0.01). More children in Group B had disturbed sleep than in Group K at 6 (88% vs 56%; P = 0.012) and 12 h (60% vs 24%; P = 0.01) postoperatively. None of the children had deep sedation, desaturation or respiratory depression. Conclusion Surgical site infiltration with either bupivacaine or ketamine provides adequate analgesia and is devoid of major side effects. Ketamine is superior to bupivacaine in terms of requirement of rescue analgesic, peaceful sleep pattern and early resumption of feeding.

Tonsillotomy: it's time to clarify the facts

Abstract: Finger nails, wires, specialized knives, slings and guillotines in the 19th and 20th century were used for subtotal tonsillectomy to reduce the risk of serious bleeding complications associated with complete removal of tonsillar tissues. Therefore, success of tonsil procedures at that time was widely based on revision surgery to cure patients suffering from diseases associated with tonsillitis. Complete, i.e., extracapsular, tonsillectomy (TE) was conceived in the first decade of the 20th century but became widespread only with safer anesthesiological techniques, particularly orotracheal intubation and introduction of halothan in the 1950s [1, 2]. In 1990, Rosenfeld registered a dramatic rise in obstructive sleep apnea (OSA) as a significant indication for TE. He assumed that this phenomenon is due to the increasing awareness of the prevalence and seriousness of adenotonsillar hypertrophy as a cause of sleep apnea, particularly in children [3]. His statement and findings were confirmed recently by Parker and Walner [4]. OSA belongs to the category of sleep-disordered breathing (SDB), characterized by abnormal respiratory patterns or the inadequate ventilation during sleep in terms of snoring, mouth breathing, or interrupted breathing. The patients may become symptomatic with excessive sleepiness, inattention, poor concentration, or hyperactivity during daytime. According to the latest statement of the American Academy of Otolaryngology-Head and Neck Surgery, TE still plays a major role to resolve SDB related to tonsillar hypertrophy in children [5]. Morbidity following TE is widely determined by pain and significant limitations in activity and diet. Return to normal diet and activity, intake of analgesics and type of consumed analgesics are therefore common endpoints of studies evaluating the benefit of newer surgical TE instruments. Complications like hemorrhage and dehydration eventually occur with the potential of a devastating outcome [6, 7]. While the best method to avoid surgical complications is not to operate, this is not an option for upper airway obstruction caused by tonsillar hypertrophy. TE, however, is acknowledged to control SDB in only 60–70 % of children with significant tonsillar hypertrophy, emphasizing the multifactorial background of this disease [5]. In the light of the limited success rate and the potential complications of TE alternative surgical procedures such as a Bochon loop have been suggested in 1993 [8], cited after [2]. In 1994, Krespi and Ling [9] recommended the CO2LASER for ‘‘serial tonsillectomy’’ to treat recurrent infection, sore throat, and halitosis in adults. In children, a considerably reduced morbidity after ‘‘tonsillotomy’’ with modern techniques was first reported in 1999 by Linder et al. [10] and Hultcrantz et al. [11], followed by Densert et al. [12], and Helling et al. [13] in 2001 and 2002, respectively. The results were confirmed with the first large retrospective study in 2003 by Koltai et al. [14] who used a microdebrider as surgical instrument. However, in a small pediatric patient population, a significant impact of ‘‘intracapsular tonsillectomy’’ on OSA—albeit not successful in all patients—was proven by means of polysomnographic J. P. Windfuhr (&) Department of Otorhinolaryngology, Plastic Head and Neck Surgery, Kliniken Maria Hilf Monchengladbach, Sandradstr 43, 41061 Monchengladbach, Germany e-mail: jochen.windfuhr@mariahilf.de

Evaluating the Management of Obstructive Sleep Apnea in Neonates and Infants

Abstract: Objectives To investigate interventions used in treating obstructive sleep apnea in neonates and infants and to report their efficacies. Design Retrospective medical record review. Setting Tertiary care children's hospital. Patients Neonates and infants aged 0 to 12 months at the time of obstructive sleep apnea diagnosis by polysomnography. Main Outcome Measures Demographic data, comorbidities, polysomnography data, and intervention data. Results In total, 126 patients (86 [68.3%] male and 40 [31.7%] female) were included in the study. The most common interventions (and the mean age at the time of intervention) were anti–gastroesophageal reflux disease treatment (88 patients [69.8%] at age 7 months), observation (33 patients [26.2%] at age 6 months), supplemental oxygen (31 patients [24.6%] at age 4 months), adenoidectomy (30 patients [23.8%] at age 15 months), other surgical (25 patients [19.8%] at age 7 months), continuous positive airway pressure/bilevel positive airway pressure (CPAP/BiPAP) (18 patients [14.3%] at age 16 months), supraglottoplasty (11 patients [8.7%] at age 6 months), tonsillectomy and adenoidectomy (9 patients [7.1%] at age 24 months), tracheostomy (7 patients [5.6%] at age 10 months), and other nonsurgical (7 patients [5.6%] at age 15 months). Among neonates and infants, nonsurgical interventions were performed in most cases, although those aged 0 to 3 months underwent more surgical interventions (19.7%) than those aged older than 3 to 9 months (11.7%). The mean objective improvement, measured as a percentage decrease in preintervention to postintervention apnea-hypopnea index, was greatest in neonates and infants receiving CPAP/BiPAP, followed by those undergoing tracheostomy. Conclusions Anti–gastroesophageal reflux disease treatment is the most common intervention in each age group. Although adenoidectomy is the most common surgical intervention overall, the prevalence increases with age. Supraglottoplasty is the most common surgical intervention in neonates and infants aged 0 to 3 months and offers the greatest objective improvement in this age group. Overall, the use of CPAP/BiPAP is associated with the greatest objective improvement.

Randomized comparison between the combination of acetaminophen and ibuprofen and each constituent alone for analgesia following tonsillectomy in children.

Abstract: Purpose Combined acetaminophen and ibuprofen may be more effective than either constituent alone for pain in adults. The combination was compared with the individual constituents for analgesia following tonsillectomy in children.

The effectiveness of a storybook in lessening anxiety in children undergoing tonsillectomy and adenoidectomy in northern ireland

Abstract: Aim: This study aimed to assess the effectiveness of a storybook, entitled, The Tale of Woody’s Tonsils, written by Anne Marie Tunney, on reducing the level of anxiety of children aged 5–11 years who were undergoing tonsillectomy and adenoidectomy in one hospital in Northern Ireland. Background/Literature Review: Psychological preparation of children for surgery impacts coping. There is evidence, in both adult and pediatric studies, that effective psychological preparation for a surgical procedure has an impact on the individuals’ coping ability with reduced levels of anxiety leading to better post-operative outcome, faster recovery and a reduction in long term sequelae associated with admission to hospital. A storybook, as a method of preparation, has been recommended by a number of researchers but the effectiveness of this in reducing anxiety has not yet been investigated in the UK. Previous studies have mainly used only one research instrument for anxiety measurement and child self-report is not a comm...