Bacteremia during tonsillectomy

Bacterial Lymphatic Metastasis in Infection and Immunity

Lymphatic vessels permeate tissues around the body, returning fluid from interstitial spaces back to the blood after passage through the lymph nodes, which are important sites for adaptive responses to all types of pathogens. Involvement of the lymphatics in the pathogenesis of bacterial infections is not well studied. Despite offering an obvious conduit for pathogen spread, the lymphatic system has long been regarded to bar the onward progression of most bacteria. There is little direct data on live virulent bacteria, instead understanding is largely inferred from studies investigating immune responses to viruses or antigens in lymph nodes. Recently, we have demonstrated that extracellular bacterial lymphatic metastasis of virulent strains of Streptococcus pyogenes drives systemic infection. Accordingly, it is timely to reconsider the role of lymph nodes as absolute barriers to bacterial dissemination in the lymphatics. Here, we summarise the routes and mechanisms by which an increasing variety of bacteria are acknowledged to transit through the lymphatic system, including those that do not necessarily require internalisation by host cells. We discuss the anatomy of the lymphatics and other factors that influence bacterial dissemination, as well as the consequences of underappreciated bacterial lymphatic metastasis on disease and immunity.

Posttonsillectomy bacteremia and comparison of tonsillar surface and deep culture

Objective. This study aimed to identify the microorganisms of surface and depth of tonsils and whether these microorganisms bring the menace of bacteremia during tonsillectomy in the children under surgery. Materials and Methods. The culture specimens were taken from surface and depth of tonsil from the patients suffering from chronic tonsillitis at the time of operation. Also, 10 mL venous blood samples were taken 5 minutes before and after the operation for microbiological study. Results. According to the results, 112 (76.1%) and 117 (79.6%) cultures from surface and depth of tonsils represented multiple microorganisms, respectively. Besides, staphylococci coagulase positive was the most common organism in both surface and depth of tonsils. None of the preoperation blood cultures were positive, while 3 postoperation blood cultures (2.1%) were positive. Staphylococci coagulase negative and alpha hemolytic streptococcus were detected in 2 cases (1.4%) and 1 case (0.7%), respectively. Conclusion. In the present study, the two cultured sites were almost similar regarding the types of isolated microorganisms. Our results suggested that bacteremia might occur after tonsillectomy. Therefore, to avoid the possible dramatic outcomes after tonsillectomy, pre- and postoperation attendances are essential.

Malpractice claims and unintentional outcome of tonsil surgery and other standard procedures in otorhinolaryngology

BACKGROUND

Septoplasty, tonsillectomy (with and without adenoidectomy) and cervical lymph node excision are amongst the most common 50 inpatient operations in Germany. Intracapsular tonsillectomies (i.e. tonsillotomies) are increasingly performed. The aim of this study was to evaluate technical traps and pitfalls as well as alleged medical malpractice associated with tonsillectomy (TE), adenoidectomy (AE), tonsillotomy (TT), septoplasty (SP) and cervical lymph node excision (LN).

METHODS

A questionnaire was sent to the Regional Medical Conciliation Boards, Medical Services of the Health Insurance Companies (MDK) and Regional Institutes of Forensic Medicine in Germany to collect anonymized cases of complications following TE, TT, AE, LN and SP. The results were discussed in the light of the contemporary medical literature and published trials and verdicts in Germany.

RESULTS

The response rate of our survey was 55.9%. The Institutes of Forensic Medicine contributed nine cases, 49 cases were submitted by the Regional Conciliation Boards and none by MDK. All forensic cases were associated with exsanguinations following tonsillectomy including two children (5 and 8 years of age) and seven adults (aged 20 to 69 years). The fatal post-tonsillectomy hemorrhage (PTH) had occurred 8.7 days on average; four patients experienced the bleeding episode at home (day 5, 8, 9 and 17, respectively). Repeated episodes of bleeding requiring surgical intervention had occurred in 6 patients. Three Conciliation Boards submitted decicions associated with TT (1), AE (4), LN (3), SP (16) and TE (25). Cases with lethal outcome were not registered. Only three of the 49 cases were assessed as surgical malpractice (6.1%) including lesion of the spinal accessory nerve, wrong indication for TE and dental lesion after insertion of the mouth gag. The review of the medico legal literature yielded 71 published verdicts after AE and TE (29), LN (28) and SP (14) of which 37 resulted in compensation of malpractice after LN (16; 57%), TE (10; 37%), SP (8; 57%) and AE (2; 100%). There were 16 cases of PTH amongst 27 trials after TE resulting either in death (5) or apallic syndrome (5). Bleeding complications had occurred on the day of surgery in only 2 patients. 16 trials were based on malpractice claims following SP encompassing lack of informed consent (6), anosmia (4), septal perforation (2), frontobasal injury (2) and dry nose (2). Trials after LN procedures were associated exclusively with a lesion of the spinal accessory nerve (28), including lack of informed consent in 19 cases. 49 cases (69%) were decided for the defendant, 22 (31%) were decided for the plaintiff with monetary compensation in 7 of 29 AE/TE-trials, 9 of 28 LN-trials and 6 of 14 SP-trials. Lack of informed consent was not registered for AE/TE but LN (11) and SP (2).

CONCLUSION

Complicated cases following TE, TT, ATE, SP and LN are not systematically collected in Germany. It can be assumed, that not every complicated case is published in the medical literature or law journals and therefore not obtainable for scientific research. Alleged medical malpracice is proven for less than 6% before trial stage. Approximately half of all cases result in a plaintiff verdict or settlement at court. Proper documentation of a thourough counselling, examination, indication, informed consent and follow-up assists the surgeon in litigation. An adequate complication management of PTH is essential, including instructions for the patients/parents, instructions for the medical staff and readily available surgical instruments. Successful outcome of life-threatening PTH is widely based on a proper airway management in an interdisciplinary approach. Electrosurgical tonsillectomy techniques were repeatedly labeled as a risk factor for bleeding complications following TE. Institutions should analyse the individual PTH rate on a yearly basis. Contradictory expert opinions and verdicts of the courts concerning spinal accesory nerve lesions following LN are due to a lack of a surgical standard.

Bacteremia during quinsy and elective tonsillectomy: an evaluation of antibiotic prophylaxis recommendations for patients undergoing tonsillectomy

AIMS

Bacteremia during elective tonsillectomy is well recognized, whereas bacteremia during quinsy tonsillectomy has never been studied. The aim of the present study was to explore the incidence of bacteremia during elective and quinsy tonsillectomy in order to evaluate the antibiotic prophylaxis recommendations to patients at high risk of infective endocarditis who are undergoing tonsillectomy.

METHODS

A prospective study was conducted on 80 patients undergoing elective tonsillectomy and 36 patients undergoing acute tonsillectomy due to peritonsillar abscess. Blood cultures, tonsillar swabs, core tissue, and pus aspirates were analyzed by standard microbiological techniques.

RESULTS

Bacteremia was detected in 73% of patients during elective tonsillectomy compared to 56% during quinsy tonsillectomy (P = .089, Fishers exact test). Significantly more blood culture bottles were positive for each isolate obtained from elective tonsillectomy cases compared to quinsy tonsillectomy cases (P < .001, Spearman rank correlation). In all, 59% and 42% of electively and acutely tonsillectomized patients, respectively, had bacteremia with microorganisms that are predominant in bacterial endocarditis. Ninety-three percent of the isolated strains were sensitive to amoxicillin, and all were sensitive to amoxicillin with clavulanic acid.

DISCUSSION

Our results challenge the distinction made by the European Society of Cardiology between elective and quinsy tonsillectomy, with regard to antibiotic prophylaxis recommendation only to patients undergoing procedures to treat an established infection. To provide full empiric coverage, including coverage for Staphylococcus aureus, we advocate the use of amoxicillin with clavulanic acid in patients at high risk of infective endocarditis.

The comparison of bacteremia and amount of bleeding during adenotonsillectomy

OBJECTIVE

Adenoidectomies and/or tonsillectomies are among the most frequently performed otolaryngological surgical procedures.The goals of this study were to investigate the relationship between the amount of bleeding and bacteremia during adenoidectomy and/or tonsillectomy procedures.

METHODS

Seventy-eight patients who underwent tonsillectomy with or without adenoidectomy and adenoidectomy with or without tube insertion were included in the study. Patients with severe chronic underlying diseases (including cardiovascular disorders, renal or hepatic disease, or immunodeficiency) were excluded from study, as were those who had suffered an acute episode of respiratory infection or had received antibiotics for any reason within three weeks prior to the operation. The amount of bleeding was measured and recorded for each patient during the surgery. Preoperative blood cultures immediately after the induction of anesthesia and postoperative blood cultures 20 min after the operation were collected.

RESULTS

While none of the blood cultures taken preoperatively was positive for any organisms, the cultures obtained postoperatively were positive in 16 (20.5%) of 78 patients who underwent tonsillectomy with or without adenoidectomy and adenoidectomy with or without tube insertion, and bacteremia was more frequent among those with greater amount of bleeding during the surgery.

CONCLUSION

The results of this study suggest that although bacteremia had no clinical consequences in patients, it should be kept in mind that patients with greater amount of bleeding are at higher risk for developing bacteremia and it may produce vital results in patients at risk.

Bacteremia during Adenoidectomy: A Comparison of Suction Diathermy Adenoid Ablation and Adenoid Curettage

Objectives:

Transient bacteremia is induced by adenoidectomy when the integrity of the nasopharyngeal membrane is broken. The aim of this study was to determine the incidence of bacteremia in patients undergoing adenoidectomy, to identify the causative organisms, and to compare the incidences of bacteremia between the two techniques suction diathermy and curettage.

Methods:

A prospective single-blind randomized trial was performed. Sixty-four patients between the ages of 2 and 13 years who were undergoing adenoidectomy were included in the study. Exclusion criteria included antimicrobial therapy in the immediate preoperative period and concurrent respiratory tract infection or pyrexia. Patients were randomized in the anesthetic room to either suction diathermy or curettage. Venous blood samples for culture were obtained 30 seconds after the procedure began (intraoperative sample) and 2 minutes after removal of the adenoid tissue (postoperative sample). Postoperative complications were recorded, and all patients were followed in the outpatient department.

Results:

Twenty-six patients underwent adenoidectomy by suction diathermy, and 38 underwent adenoidectomy by curettage. In the suction diathermy group, 38.5% of intraoperative and 19.2% of postoperative blood cultures had a positive result for bacteremia. In the curettage group, 31.6% of intraoperative and 23.6% of postoperative blood cultures had a positive result for bacteremia. There was no significant difference between the two groups. The techniques were equivalent in terms of postoperative complications. Gram-positive cocci were the most commonly isolated organisms.

Conclusions:

A transient bacteremia exists after pediatric adenoidectomy, but does not correlate with symptoms or signs. Neither suction diathermy adenoidectomy nor curettage adenoidectomy offers a particular advantage in terms of decreasing the incidence of bacteremia.

The comparison of tonsillar surface and core cultures in recurrent tonsillitis

OBJECTIVE

This study was conducted to investigate whether there is any difference between tonsillar surface and deep tissue cultures in patients who underwent tonsillectomy for recurrent tonsillitis.

METHODS

Tonsillar surface and core tonsillar cultures were taken in all patients. The samples were inoculated into 5% sheep blood, chocolate, and MacConkey agar. The bacteria isolated were identified by using standard methods as well as API kits (Bio Mérieux) if necessary.

RESULTS

Pathogenic bacteria were isolated in 77 patients, and no pathogenic bacteria were recovered in 39 of 116 patients included in the study. Of these 77 patients, in 52 patients, different types of bacteria were recovered from the surface and deep tissue cultures, whereas in 25 patients, the same types of bacteria were isolated from both surface and deep tissue cultures. The estimated probabilities of tonsillar bacteriology via surface swabs for Haemophilus influenzae, Staphylococcus aureus, Streptococcus pneumoniae, and group A beta-hemolytic streptococci were 27.2%, 38.4%, 66.6%. and 62.5%, respectively. H influenzae was less frequently predicted by surface culture than others.

CONCLUSIONS

We think that the swab cultures taken from the tonsillar surface may not always reveal the real pathogen of the tonsils. In addition, the estimated probability of tonsillar bacteriology by surface swabs varies with the type of the pathogen. If medical therapy is planned on the basis of the tonsillar surface culture, then antibiotics also effective against H influenzae besides the target microorganisms may be chosen.

Utility of prophylactic antibiotics in pediatric adenoidectomy

OBJECTIVE

To determine the utility of prophylactic antibiotics in non-risk pediatric patients undergoing adenoidectomy.

METHODS

We performed a prospective, controlled, randomized, and double-blind study on patients under 14 years of age, scheduled for adenoidectomy who accomplished the following criteria: absence of immunosuppressive and/or cardiovascular risk factors, no antimicrobial therapy for at least 15 days prior to operation, and no fever 1 week before surgery. Venous blood samples for culture were obtained at 30s and 20 min after the curettage of adenoidal tissue. Likewise, immediate and delayed complications were registered in all cases. The usefulness of prophylaxis was analyzed according to three major standpoints: bacteremia, immediate complications, and delayed complications.

RESULTS

One-hundred one patients fulfilled the inclusion criteria and were included in the study. Fifty-one children received prophylaxis and the remainder did not. In the non-prophylactic group incidence of bacteremia at 30s was significantly higher than in the prophylactic group (32.7% versus 4.0%) (p<0.001). Neither bacteremia at 20 min, nor immediate or delayed complications showed statistical differences between both treatment groups.

CONCLUSIONS

Preoperative antimicrobial prophylaxis in pediatric adenoidectomy did not offer advantages preventing complications in non-risk patients. Only bacteremia that occurs 30s after the curettage of adenoid tissue is reduced with the employment of prophylactic antibiotics.

[Tonsillectomy in 2005]

During the past years, the number of tonsillectomies (only palatine tonsils are taken off) has decreased, indications for surgery have changed. A multi-disciplinal group of paediatricians tried to elaborate the state of the art in the field. Tonsils are the first line defense of high respiratory tract. The immune functions of their lymphoid tissue are multiple: mucosal antigens capture, presentation to lymphocytes, antigens specific proliferation of lymphocytes T and B, differentiation of lymphocytes in effectors lymphocytes and immune lymphocytes. Epithelial cells on the tonsils' surface express non-specific defense. These facts explain partly tonsils' hypertrophy. Tonsillectomy has no general immune consequences. In 2002, in France, 75,000 tonsillectomies were realized, of which 90% were in children. Tonsil's hypertrophy is the major indication, mandatory when sleep apnoeas exist. The main historical tonsillectomy indication for recurrent tonsillitis should decrease due to a more precise diagnostic (rapid test at bed site), an efficient antibiotics therapy and better care for pain. Other indications are scarce. Surgery, feasible from 9 months of age, requires a brief general anaesthesia and has very few contra-indications. The technique, operator dependent, relies on his experience. The only potentially severe complication is an haemorrhage due to scab fall between the eighth and twelfth days. It requires explanation and a written note given to parents. The possibility of lack of feeding and voice modification, usually transitory, should be known. Multiple consequences of tonsillectomy especially allergy have been alleged. Since the years 1980, it is well established that pre-existing allergy or asthma are not a contraindication. More, its deleterious impact on allergic children has not been demonstrated. Last, a gain of weight post-tonsillectomy is possible and could become a risk if excessive.

Bacteremia following pediatric adenoidectomy

OBJECTIVE

Adenoidectomy is frequently performed in children. The goals of this work were to determine the incidence of bacteremia during the adenoidectomy, to identify the microorganisms implicated, and to analyze the possible association of bacteremia with postoperative complications.

METHODS

One hundred pediatric patients operated of adenoidectomy without preoperative antibiotic prophylaxis were prospectively included in this study. They had no immunosuppressive and/or cardiovascular risk factors, no antimicrobial therapy for at least 15 days prior to operation, and no fever 1 week before surgery. Venous blood samples were obtained 30 s and 20 min after the curettage of adenoidal tissue.

RESULTS

The 33 and 14% of the samples were positive at 30 s and 20 min. The organism more commonly isolated was the streptococcus viridans. Bacteremia was only related to postoperative acute otitis media (p=0.012).

CONCLUSIONS

Bacteremia exists after pediatric adenoidectomy, although it seldom correlates with clinical signs or symptoms. Postoperative acute otitis media is the only complication related to postsurgical bacteremia.

Cold dissection versus bipolar cauterizing tonsillectomy for bacteriemia

OBJECTIVE

The purpose of this study is to compare transient bacteriemia ratios between cold dissection tonsillectomy and bipolar cauterizing tonsillectomy, and also to analyze the bacteria detected with superficial/central tonsillar cultures.

METHODS

A total of 86 patients that were grouped as 46 patients of cold dissection tonsillectomy and 40 patients of bipolar cauterizing tonsillectomy were included in this study. Preoperative surface swab cultures, intraoperative central swab cultures of tonsils, and preoperative and postoperative blood culture samples were obtained. Antibiotic sensitivity tests were determined. Fischer exact chi 2 test was performed to compare the results of postoperative bacteriemia of both techniques statistically.

RESULTS

Postoperative bacteriemia was detected in 6 (13%) patients of cold dissection tonsillectomy group. In 5 (83.3%) of the 6 postoperative bacteriemia patients of cold dissection tonsillectomy group, isolated microorganism was confirmed both in the blood cultures and in the central swab cultures of tonsils, and resistance to penicillin was established. No patient of bipolar cauterizing tonsillectomy group appeared with postoperative bacteriemia. There was a statistically significant difference (P=.028) for postoperative bacteriemia between cold dissection tonsillectomy group and bipolar cauterizing tonsillectomy group.

CONCLUSION

We recommend bipolar cauterizing tonsillectomy for high-risk patients.

Macroscopic oropharyngeal signs indicating impaired defensive function of palatine tonsils in adults suffering from recurrent tonsillitis

The present study explored in adults suffering from recurrent tonsillitis the association between macroscopic oropharyngeal signs of recurrent inflammation, immunomorphology of palatine tonsils (counts of neutrophils by CD4 and macrophages by CD68 monoclonal antibodies in tonsillar microcompartments) and the occurrence of post-tonsillectomy bacteremia. The study involved 50 adults (31 females and 19 males) with recurrent tonsillitis. According to predominance of either inflammatory changes or evidence of sclerotic process in palatine tonsils and surrounding tissue macroscopic at oropharyngeal examination, the patients were divided into groups with 'inflammatory-type' and 'sclerotic-type' tonsils. Biochemically detected mean collagen content was significantly higher in 'sclerotic-type' tonsils than in 'inflammatory-type' tonsils (p=0.001). Post-tonsillectomy bacteremia was found in 22 patients (44%). A noteworthy finding was the higher recovery of anaerobes from blood cultures than in previous studies. A logistic regression analysis revealed that the post-tonsillectomy bacteremia was strongly associated with 'sclerotic-type' tonsils (p=0.0015) and with low counts of neutrophils in tonsillar tissue (p=0.047). We conclude that macroscopic oropharyngeal signs of sclerotic process in palatine tonsils indicate impaired tonsillar defense, in terms of lowered counts of neutrophils, increasing the risk of post-tonsillectomy bacteremia.

Invasive group A streptococcal infection after tonsillectomy

Tonsillectomy is a very common procedure in childhood. Infectious complications after tonsillectomy are infrequently reported. We describe two children with severe group A beta-hemolytic streptococcal infection after tonsillectomy, and we review the literature about bacteremia and infectious complications after tonsillectomy.

Bacteremia during adenoidectomy

OBJECTIVE

Although adenoidectomy is one of the most commonly performed surgical procedures in children, there is no satisfactory information about the risk of bacteremia during adenoidectomy and necessity of antibiotic use. The aim of this study was to determine the incidence of bacteremia during adenoidectomy and identify the organisms leading to bacteremia.

METHODS

Thirty two patients who had undergone adenoidectomy at ENT Clinic of Sutcu Imam University were included in the study. They had received no antimicrobial therapy for at least 20 days before surgery. Adenoidal surface and deep tissue cultures were taken and venous blood samples were obtained for cultures before and immediately after adenoidectomy in which adenoid was removed with a curette.

RESULTS

While none of the blood cultures taken preoperatively was positive for any organisms, the cultures obtained postoperatively were positive in only two of 32 patients included in the study.

CONCLUSION

The results of this study suggest that there is an extremely low incidence of bacteremia during adenoidectomy. As a result, it may be concluded that the use of prophylactic antibiotics to prevent bacteremia or its complications is unnecessary unless the patient has a predisposing factor for cardiac infection like prosthetic valve replacement.

Bacteremia during tonsillectomy

OBJECTIVE

To investigate bacteremia in patients who underwent tonsillectomy with a dissection method due to chronic tonsillitis, which may lead to dramatic results in patients that have a cardiovascular infection risk. In this study, it was explored whether the tonsil surface and the tonsil tissue interior microorganisms are different or not, and whether these microorganisms carry bacteremia development risk.

METHODS

Forty patients were enrolled in the study in ENT Clinic, Firat University. A bacteriological research was performed on patients with no treatment with antibiotics for a month before the operation. Tonsil surface and deep tissue cultures were performed, and venous blood samples were taken for cultures before and after the operation.

RESULTS

Surface and deep tissue cultures of tonsils of the cases represented a different result in 27.5% of the patients. No reproduction was observed regarding the blood cultures taken before tonsillectomy. Bacteremia was found in blood samples of ten patients (25%) taken immediately after tonsillectomy.

CONCLUSION

Hence, it has been concluded that different microorganisms may be present among the tonsil surface and tonsil deep tissue cultures and that bacteremia may develop after tonsillectomy. Therefore, to prevent the possible dramatic outcomes after tonsillectomy the required measures during the preoperative period should be taken into consideration, especially in patients that have chronic tonsillitis with cardiovascular disease.

A study of postoperative fever following paediatric tonsillectomy

The aetiology of post-tonsillectomy fever is obscure. Bacteraemia during surgery, anaesthetic agents and the inflammatory response of tissue to injury have been implicated. A prospective study was undertaken in 100 consecutive children to evaluate the occurrence and severity of fever in the 24 h after tonsillectomy and its relationship to bacteraemia during surgery and qualitative and quantitative cultures (colony counts) of organisms in tonsil core tissue. Fifty-four patients had a fever (> 37.5 degrees C) postoperatively, of whom, 30 had a fever greater than 38 degrees C. Blood cultures during tonsillectomy were positive in 22 patients. There was no statistically significant difference between the occurrence of fever and the techniques of tonsillectomy and haemostasis. There was also no association between positive blood, core or surface cultures and the incidence or severity of fever nor any association between colony count in core cultures and fever. Our results suggest that postoperative fever in the 24 h following tonsillectomy is not caused by infection.

Necrotizing fasciitis of the pharynx following adenotonsillectomy

Necrotizing fasciitis is a rare clinical entity in the head and neck region. We report a case of necrotizing fasciitis following adenotonsillectomy in a previously healthy 2-year-old girl. The child presented in a septic state with impending airway compromise. Computed tomography (CT) showed massive soft tissue widening with air in the retropharyngeal, parapharyngeal and retromandibular spaces. Intraoperative exploration showed necrosis of the posterior pharyngeal wall from the skull base to the cricoid, with extension into the parapharyngeal and retropharyngeal spaces. Cultures from the debrided tissues grew two aerobes and three anaerobes. Management involved airway support, surgical debridement, broad spectrum antibiotic coverage and nutritional support. The patient ultimately developed nasopharyngeal and oropharyngeal stenosis requiring tracheostomy and gastrostomy tube placement. This case report highlights an extremely rare complication of adenotonsillectomy.

Meningitis after adenoidectomy: an anatomic explanation

Meningitis is a rare complication of adenoidectomy. During a 5-month period, two children at St Christopher's Hospital for Children developed meningitis within days following this surgical procedure. The potential causes of this complication that we investigated include coincidence, systemic hematogenous spread of bacteria to the central nervous system, and direct or indirect contamination of the cerebrospinal fluid by bacteria introduced by retropharyngeal injection of lidocaine hydrochloride and epinephrine. Based on statistical analysis of the available literature and anatomic studies of the pediatric nasopharyngeal region, we conclude that a retrograde flow of bacteria via a newly described anastomotic network of veins was the most likely cause of this sequela.