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A novel electrosurgical divider: performance in a self-controlled tonsillectomy study. Eur Arch Otorhinolaryngol 2022; 279:2109-2115. [PMID: 34338876 PMCID: PMC8930875 DOI: 10.1007/s00405-021-07008-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Accepted: 07/19/2021] [Indexed: 01/05/2023]
Abstract
PURPOSE Tonsillectomies are among the most common surgeries in otorhinolaryngology. A novel electrosurgical temperature-controlled instrument (device) promises rapid tonsillectomies and might reduce postoperative pain, but comparative studies to assess performance are warranted. METHODS This randomized self-controlled clinical trial was conducted from October 2019 to October 2020 at the Department of Otorhinolaryngology, Head and Neck Surgery of the Medical University of Vienna. Forty-eight patients underwent a tonsillectomy with the device on one side and using cold-steel with localized bipolar cauterization on the other side (control). Main outcomes were the time for tonsil removal (per side) and the time to stop bleeding (per side). Secondary measurements were postoperative pain, assessed once on day 0 and five times on days 1, 3, 5, 7, and 10. Postoperative bleeding episodes and consequences were recorded. RESULTS Device tonsillectomies were performed significantly faster than controls; the mean surgical time difference was 209 s (p < 0.001, 95% CI 129; 288). Intraoperative blood loss was significantly lower on the device side (all p < 0.05). Postoperative measurements of pain and bleeding were similar for both sides. Two return-to-theatre secondary bleeding events were recorded for the control side. CONCLUSION The novel electrosurgical temperature-controlled divider reduced the tonsillectomy surgical time and intraoperative blood loss, with no apparent negative effects on postoperative pain or bleeding, compared to a cold-steel tonsillectomy with localized bipolar cauterization. In time-restricted settings, the device could be beneficial, particularly after familiarization with device handling. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03793816.
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Grasl S, Mekhail P, Janik S, Grasl CM, Vyskocil E, Erovic BM, Arnoldner C, Landegger LD. Temporal fluctuations of post-tonsillectomy haemorrhage. Eur Arch Otorhinolaryngol 2021; 279:1601-1607. [PMID: 34557959 PMCID: PMC8897317 DOI: 10.1007/s00405-021-07080-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Accepted: 09/06/2021] [Indexed: 12/25/2022]
Abstract
Purpose Although haemorrhage is a common and in some cases life-threatening complication after tonsillectomy, surprisingly little is known about the temporal fluctuations of the onset of bleeding. The purpose of this study was to assess circadian and seasonal rhythms of post-tonsillectomy haemorrhage (PTH) and potential ramifications to educate patients and health care staff. Methods This retrospective study carried out at a tertiary referral hospital included paediatric and adult patients requiring emergency surgery due to severe PTH between 1993 and 2019. Medical records were reviewed and patient demographics, details regarding the initial procedure, postoperative day of haemorrhage, and start time of emergency surgery were extracted. Descriptive statistics, Kruskal–Wallis test, Mann–Whitney U test, and Chi-square goodness of fit tests were used to detect potential differences. Results A total of 300 patients with severe PTH and subsequent emergency surgery were identified. The median postoperative duration until PTH was 6 (range: < 1–19) days. 64.7% (n = 194) of all emergency surgeries had to be performed during evening and night hours (6 pm—6 am) (p < 0.0001). Compared to diurnal incidents, the risk of a nocturnal PTH event increased, the longer ago the initial surgery was (p < 0.0001). No seasonal variations were identified. Age, sex, and details of the initial procedure had no significant influence on the start time according to the surgical protocol. Conclusion The discovered temporal fluctuations of PTH are of relevance for patient awareness and preoperative education. Due to possible life-threatening complications, management of severe PTH requires specific resources and trained medical staff on call.
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Affiliation(s)
- Stefan Grasl
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical University of Vienna, Vienna, Austria
| | - Patrick Mekhail
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical University of Vienna, Vienna, Austria
| | - Stefan Janik
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical University of Vienna, Vienna, Austria
| | - Christoph M Grasl
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical University of Vienna, Vienna, Austria
| | - Erich Vyskocil
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical University of Vienna, Vienna, Austria
| | - Boban M Erovic
- Institute of Head and Neck Diseases, Evangelical Hospital, Vienna, Austria
| | - Christoph Arnoldner
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical University of Vienna, Vienna, Austria
| | - Lukas D Landegger
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical University of Vienna, Vienna, Austria.
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Milner TD, Hilmi O, Marshall J, MacKenzie K. Pan‐Scotland tonsillectomy outcomes: A national cross‐sectional study. Clin Otolaryngol 2020; 46:138-145. [DOI: 10.1111/coa.13608] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Revised: 06/08/2020] [Accepted: 06/14/2020] [Indexed: 01/06/2023]
Affiliation(s)
- Thomas D. Milner
- Queen Elizabeth University Hospital Glasgow UK
- University of Glasgow Glasgow UK
| | - Omar Hilmi
- Queen Elizabeth University Hospital Glasgow UK
| | | | - Kenneth MacKenzie
- Queen Elizabeth University Hospital Glasgow UK
- University of Strathclyde Glasgow UK
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Vyskocil E, Baumgartner WD, Ch. Grasl M, Grasl S, Arnoldner C, Steyrer J, Erovic BM. Post-tonsillectomy hemorrhage: cost-benefit analysis of prolonged hospitalization. Acta Otolaryngol 2020; 140:597-602. [PMID: 32281464 DOI: 10.1080/00016489.2020.1746829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Background: Prolonged hospitalization after tonsillectomy up to three nights was implemented to decrease mortality due to post-tonsillectomy hemorrhage.Aims: To assess if extension of postoperative inpatient observation time from one to three nights results in potential benefits following tonsillectomy.Subjects and methods: Patients who stayed only one night post-tonsillectomy between 1994 and 2006 (Group A) were compared to 1570 patients who stayed three nights postoperatively between 2008 and 2016 (Group B). Complication rate and expense of hospitalization were compared.Results: Published data show that 114 (1.78%) out of 6400 patients in group A had post-tonsillectomy hemorrhage. In this patient group 75.4% (n = 86) of all bleedings occurred after discharge from hospital. However, in group B post-tonsillectomy hemorrhage occurred in 70 (4.5%) and of those only 0.38% (n = 6) developed bleeding episodes on the second or third postoperative day (POD). As observed in group A, the majority of hemorrhage (n = 57; 81.4%) was observed after discharge. Cost analysis reveals a difference of approximately 6 million €for all 32 ENT departments per year in Austria.Conclusions and significance: Extending postoperative hospitalization from one to three nights reveals no benefit after tonsillectomy. Comparison reveals substantial increase of costs for an extended 3 nights inpatient stay.
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Affiliation(s)
- Erich Vyskocil
- Department of Otorhinolaryngology, Head Neck Surgery, Medical University of Vienna, Vienna, Austria
| | - Wolf-Dieter Baumgartner
- Department of Otorhinolaryngology, Head Neck Surgery, Medical University of Vienna, Vienna, Austria
| | - Matthaeus Ch. Grasl
- Department of Otorhinolaryngology, Head Neck Surgery, Medical University of Vienna, Vienna, Austria
| | - Stephan Grasl
- Department of Otorhinolaryngology, Head Neck Surgery, Medical University of Vienna, Vienna, Austria
| | - Christoph Arnoldner
- Department of Otorhinolaryngology, Head Neck Surgery, Medical University of Vienna, Vienna, Austria
| | - Johannes Steyrer
- Interdisciplinary Institute for Management and Organisational Behaviour, Vienna, Austria
| | - Boban M. Erovic
- Department of Otorhinolaryngology, Head Neck Surgery, Medical University of Vienna, Vienna, Austria
- Institute for Head and Neck Diseases, Evangelical Hospital Vienna, Vienna, Austria
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Albright JT, Duncan NO, Smerica AM, Edmonds JL. Intra-capsular complete tonsillectomy, a modification of surgical technique to eliminate delayed post-operative bleeding. Int J Pediatr Otorhinolaryngol 2020; 128:109703. [PMID: 31614242 DOI: 10.1016/j.ijporl.2019.109703] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 09/29/2019] [Accepted: 09/30/2019] [Indexed: 11/17/2022]
Abstract
Pediatric tonsillectomy is a frequently performed procedure using a variety of surgical techniques. Despite decades of modern surgical experience and advances in tools and techniques, a consensus on which technique is superior for minimizing complications has not been established. In a 2014 study, the authors examined differing surgical techniques and devices to determine if there was a significant difference in the bleed rates based on technique and device [1]. In that study 7024 children were evaluated, of which a total of 1.4% (n = 99) of children experienced a postoperative hemorrhage that required a second surgery. There was no significant difference found between the four different techniques that were evaluated. Although the combined rates of post-operative hemorrhage requiring a second surgery was lower compared to many other published reports, we hypothesized that continued improvement in surgical techniques could eliminate post-operative hemorrhage completely. As follow up to that study, we decided on a collective change in technique, and subsequent analysis of our post-operative results with respect to only one outcome, post-operative hemorrhage requiring a second surgery. With a new standardized technique in place, we retrospectively evaluated one year of surgical outcomes. These procedures were performed using the technique of a modified and complete, intra-capsular Coblator tonsillectomy. Of the 783 tonsillectomies done in 12 months, we found there were 0 patients that had experienced a postoperative hemorrhage requiring a second surgery. Based on our previous study with a rate of 1.4% post-operative hemorrhage we would have expected to have 11 episodes of post-operative hemorrhage requiring a second surgery.
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Affiliation(s)
- James T Albright
- Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, USA
| | - Newton O Duncan
- Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, USA
| | - Abel M Smerica
- Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, USA
| | - Joseph L Edmonds
- Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, USA.
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Grasl S, Janik S, Vyskocil E, Kadletz L, Grasl MC, Erovic BM. Preoperative plasma fibrinogen as a predictive factor for post‐tonsillectomy haemorrhage. Clin Otolaryngol 2019; 44:935-941. [DOI: 10.1111/coa.13404] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Revised: 06/17/2019] [Accepted: 07/07/2019] [Indexed: 12/13/2022]
Affiliation(s)
- Stefan Grasl
- Department of Otorhinolaryngology and Head and Neck Surgery Medical University of Vienna Vienna Austria
| | - Stefan Janik
- Department of Otorhinolaryngology and Head and Neck Surgery Medical University of Vienna Vienna Austria
| | - Erich Vyskocil
- Department of Otorhinolaryngology and Head and Neck Surgery Medical University of Vienna Vienna Austria
| | - Lorenz Kadletz
- Department of Otorhinolaryngology and Head and Neck Surgery Medical University of Vienna Vienna Austria
| | - Matthaeus C. Grasl
- Department of Otorhinolaryngology and Head and Neck Surgery Medical University of Vienna Vienna Austria
| | - Boban M. Erovic
- Institute of Head and Neck Diseases Evangelical Hospital Vienna Vienna Austria
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Lavin J, Lehmann D, Silva AL, Bai G, Hebal F, Manworren R, Stake C, Rychlik K, Billings KR. Variables associated with pediatric emergency department visits for uncontrolled pain in postoperative adenotonsillectomy patients. Int J Pediatr Otorhinolaryngol 2019; 123:10-14. [PMID: 31054535 DOI: 10.1016/j.ijporl.2019.04.038] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 04/24/2019] [Accepted: 04/24/2019] [Indexed: 01/18/2023]
Abstract
OBJECTIVE Returns to the emergency department (ED) for pain or dehydration after adenotonsillectomy (T&A) are frequent. Attempts to associate the specific pain regimens with these visits have been unrevealing, suggesting a need to assess for other potential factors associated with readmission. METHODS A review of a 2:1 cohort matched by age, gender and payer status compared post-T&A patients who did not return ED for pain or dehydration within 21 days to those who returned. Factors investigated included patient demographics, comorbidities, medication regimen and the presence of postoperative telephone encounters. Patients returning to the ED were further assessed for rates of medication adherence. RESULTS 7493 patients underwent T&A during the period. Of these, 144 (1.9%) returned for pain/dehydration. Comparison to 285 matched patients revealed an association between ED returns and Hispanic ethnicity (p < 0.001), Spanish language (p = 0.0002), and comorbid Down syndrome and ADHD (p = 0.011 in both). The incidence of parent telephone calls to the office was associated with ED returns (58.7 in the ED cohort, 28.4% in non-ED cohort, p < 0.0001). On multivariable analysis, Hispanic ethnicity and phone calls were associated with ED returns (p < 0.0001 and p < 0.0001, respectively). Only 64.0% of patients returning to the ED were adherent with postoperative pain regimens. CONCLUSIONS While demographic factors may be associated with rate of ED returns for pain and dehydration, post-operative phone calls were most highly associated with returns. The majority of patients returning to the ED were non-adherent with recommended pain regimens, suggesting an opportunity to investigate medication adherence in all post-tonsillectomy patients.
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Affiliation(s)
- Jennifer Lavin
- Ann & Robert H. Lurie Children's Hospital of Chicago, Division of Pediatric Otolaryngology-Head and Neck Surgery, Chicago, IL, USA; Northwestern University Feinberg School of Medicine, Department of Otolaryngology-Head and Neck Surgery, Chicago, IL, USA
| | - David Lehmann
- Northwestern University-Feinberg School of Medicine, Chicago, IL, USA
| | - Astrid Leon Silva
- Ann & Robert H. Lurie Children's Hospital of Chicago, Department of Surgery, Chicago, IL, USA
| | - Guangyu Bai
- Northwestern University-Feinberg School of Medicine, Chicago, IL, USA
| | - Ferdynand Hebal
- Ann & Robert H. Lurie Children's Hospital of Chicago, Department of Surgery, Chicago, IL, USA
| | - Renee Manworren
- Ann & Robert H. Lurie Children's Hospital of Chicago, Department of Surgery, Chicago, IL, USA; Ann & Robert H. Lurie Children's Hospital of Chicago, Department of Nursing, Chicago, IL, USA
| | - Christine Stake
- Ann & Robert H. Lurie Children's Hospital of Chicago, Department of Surgery, Chicago, IL, USA
| | - Karen Rychlik
- Stanley Manne Children's Research Institute, Biostatistics Research Core, Chicago, IL, USA; Northwestern University-Feinberg School of Medicine, Department of Pediatrics, Chicago, IL, USA
| | - Kathleen R Billings
- Ann & Robert H. Lurie Children's Hospital of Chicago, Division of Pediatric Otolaryngology-Head and Neck Surgery, Chicago, IL, USA; Northwestern University Feinberg School of Medicine, Department of Otolaryngology-Head and Neck Surgery, Chicago, IL, USA.
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Reusser NM, Bender RW, Agrawal NA, Albright JT, Duncan NO, Edmonds JL. Post-tonsillectomy hemorrhage rates in children compared by surgical technique. EAR, NOSE & THROAT JOURNAL 2018; 96:E7-E11. [PMID: 28719712 DOI: 10.1177/014556131709600702] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Despite the sheer number of pediatric tonsillectomies performed in the United States annually, there is no clear consensus as to which surgical technique is superior. One way to compare surgical techniques is to study the morbidity associated with each. We report postoperative hemorrhage rates, one of the frequently encountered major adverse events, as part of a retrospective chart review across four different surgical techniques. These surgeries involved either (1) Coblation, (2) Co-blation with partial suture closure of the tonsillar fossa, (3) diathermy, or (4) partial intracapsular tonsillectomy (PIT). Of the 7,024 children we evaluated, 99 (1.4%) experienced a postoperative hemorrhage that required a second surgery; hemorrhage occurred after 33 of the 3,177 Coblation-alone procedures (1.04%), 28 of the 1,633 Coblation with partial suture closure procedures (1.71%), 29 of the 1,850 diathermies (1.57%), and 9 of the 364 PIT procedures (2.47%). Statistical analysis of hemorrhage rates with each surgical technique yielded p values >0.05 in each case (Coblation alone and Coblation with partial suture closure: p = 0.29; diathermy: p = 0.47; PIT, p = 0.20). Based on these data, we conclude that none of these techniques is significantly superior in terms of decreasing the risk of post-tonsillectomy hemorrhage in children. Therefore, surgeons should continue to use the surgical procedure they are most familiar with to optimize recovery in the postoperative period.
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Affiliation(s)
- Nicole M Reusser
- Department of Dermatology The University of Texas Health Science Center at Houston, Houston, TX, USA
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Sanders JG, Cameron C, Dawes PJD. Gabapentin in the Management of Pain following Tonsillectomy: A Randomized Double-Blind Placebo-Controlled Trial. Otolaryngol Head Neck Surg 2017; 157:781-790. [PMID: 28741425 DOI: 10.1177/0194599817719883] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective To determine if a single dose of oral gabapentin given prior to tonsillectomy decreases postoperative morbidity. Study Design Prospective randomized double-blind placebo-controlled trial. Setting Southern District Health Board University Hospitals, New Zealand, over a 10-month period. Subjects and Methods Seventy-three adults undergoing tonsillectomy were randomized to receive either a single preoperative dose of oral gabapentin (600 mg) or placebo. A standard analgesic protocol was prescribed for 14 postoperative days. The primary outcome was a patient-assigned visual analog scale pain score during rest and swallow; secondary outcomes were analgesic consumption, nausea, vomiting, and return to normal diet and activities. Complications and adverse effects were also recorded. Results Thirty-seven participants were allocated to the placebo group and 36 to the gabapentin group. After withdrawals, data were analyzed from 31 in the placebo group and 27 in the gabapentin group. Pain scores between groups were not significantly different within the first 6 hours. The gabapentin group recorded significantly higher pain scores between days 5 and 10 (maximal difference, day 8: 17.6 mm; effect size, -8.87; P = .03; 95% CI, -16.883 to -0.865). There was no significant difference in swallow pain scores or early postoperative fentanyl consumption. Consumption of paracetamol ( P = .01 at day 13 and P = .004 at day 14) and codeine ( P < .05 at days 3-5, 7, 8, 10, 14) was higher in the gabapentin group. No significant difference between groups was found for the other outcomes. Conclusions Preemptive gabapentin (600 mg) was associated with greater postoperative pain scores and analgesic consumption following adult tonsillectomy when compared with placebo.
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Affiliation(s)
- James G Sanders
- 1 Department of Otolaryngology-Head and Neck Surgery, Waikato Hospital, Hamilton, New Zealand
| | - Claire Cameron
- 2 Department of Preventive and Social Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Patrick J D Dawes
- 3 Department of Surgical Science, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
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Topal K, Aktan B, Sakat MS, Kilic K, Gozeler MS. Post-operative pain control after tonsillectomy: dexametasone vs tramadol. Acta Otolaryngol 2017; 137:618-622. [PMID: 28084857 DOI: 10.1080/00016489.2016.1269945] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
CONCLUSION Tramadol was found to be more effective than dexamethasone in post-operative pain control, with long-lasting relief of pain. OBJECTIVE This study aimed to compare the effects of pre-operative local injections of tramadol and dexamethasone on post-operative pain, nausea and vomiting in patients who underwent tonsillectomy. DESIGN Sixty patients between 3-13 years of age who were planned for tonsillectomy were included in the study. Patients were divided into three groups. Group 1 was the control group. Patients in Group 2 received 0.3 mg/kg Dexamethasone and Group 3 received 0.1 mg/kg Tramadol injection to the peritonsillary space just before the operation. Patients were evaluated for nausea, vomiting, and pain. RESULTS When the control and the dexamethasone groups were compared; there were statistically significant differences in pain scores at post-operative 15 and 30 min, whereas there was no statistically significant difference in pain scores at other hours. When the control and tramadol groups were compared, there was a statistically significant difference in pain scores at all intervals. When tramadol and dexamethasone groups were compared, there was no statistically significant difference in pain scores at post-operative 15 and 30 min, 1 and 2 h, whereas there was a statistically significant difference in pain scores at post-operative 6 and 24 h.
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Affiliation(s)
- Kubra Topal
- Department of Otorhinolaryngology, Training and Research Hospital, Erzurum, Turkey
| | - Bulent Aktan
- Faculty of Medicine, Department of Otorhinolaryngology, Ataturk University, Erzurum, Turkey
| | - Muhammed Sedat Sakat
- Faculty of Medicine, Department of Otorhinolaryngology, Ataturk University, Erzurum, Turkey
| | - Korhan Kilic
- Department of Otorhinolaryngology, Training and Research Hospital, Erzurum, Turkey
| | - Mustafa Sitki Gozeler
- Faculty of Medicine, Department of Otorhinolaryngology, Ataturk University, Erzurum, Turkey
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Do post-tonsillectomy patients who report bleeding require observation if no bleeding is present on exam? Int J Pediatr Otorhinolaryngol 2017; 95:75-79. [PMID: 28576538 DOI: 10.1016/j.ijporl.2017.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Revised: 02/01/2017] [Accepted: 02/03/2017] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Three to ten percent of tonsillectomy patients experience post-tonsillectomy hemorrhage. Examination of those patients who return to the Emergency Department (ED) with a history of hemorrhage may be found to have active bleeding, a coagulum within the fossa, or a normal post-operative exam. It is not known if those with a normal postoperative exam require inpatient observation. METHODS This is a retrospective series from 1/1/2010 to 12/31/2014 at a tertiary pediatric hospital. We evaluated outcomes in patients who presented to our ED with a history of post tonsillectomy hemorrhage, but after a thorough inspection failed to demonstrate active bleeding or clot, and were thus deemed to have a normal postoperative exam. This cohort was then evaluated for subsequent active bleeding requiring cauterization. Demographics and clinical data were extracted from the medical record. RESULTS In 337 visits with a history of bleeding, and a normal postoperative exam, 38 (11%) subsequently bled requiring cauterization. 32/38 (84%) bled within 24 h of admission to the ED. No demographic or clinical variables predicted an increased risk of bleeding during observation. CONCLUSIONS Eleven percent of patients who presented to the ED with a history of bleeding at home but a normal postoperative exam subsequently bled and required cautery, usually within 24 h. Aside from the history of bleeding at home, we found no additional predictors of subsequent bleeding and recommend this group of patients should be considered for 24 hour in-hospital observation prior to discharge.
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Barrett G, Williams R, Elias-Jones W, Bennett W, Ronan N, Ricks R, Potter C. A multicentre 2-cycle retrospective audit of postoperative haemorrhages from 2169 tonsillectomies. Clin Otolaryngol 2016; 42:458-461. [PMID: 26732609 DOI: 10.1111/coa.12616] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/28/2015] [Indexed: 11/28/2022]
Affiliation(s)
- G Barrett
- Department of ENT Head and Neck Surgery, Royal Devon and Exeter Hospital, Exeter, UK
| | - R Williams
- Department of ENT Head and Neck Surgery, Derriford Hospital, Exeter, UK
| | - W Elias-Jones
- Department of ENT Head and Neck Surgery, Royal Devon and Exeter Hospital, Exeter, UK
| | - W Bennett
- Department of ENT Head and Neck Surgery, Musgrove Park Hospital, Exeter, UK
| | - N Ronan
- Department of ENT Head and Neck Surgery, Royal Devon and Exeter Hospital, Exeter, UK
| | - R Ricks
- Department of ENT Head and Neck Surgery, Royal Cornwall Hospital, Exeter, UK
| | - C Potter
- Department of ENT Head and Neck Surgery, Torbay Hospital, Exeter, UK
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Sproat R, Radford P, Hunt A. Hemostatic glues in tonsillectomy: A systematic review. Laryngoscope 2015; 126:236-42. [PMID: 25946391 DOI: 10.1002/lary.25256] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/18/2015] [Indexed: 11/08/2022]
Abstract
OBJECTIVES/HYPOTHESIS The aim of this study was to compare use of hemostatic glues to conventional techniques of intraoperative hemostasis for tonsillectomy. STUDY DESIGN A systematic review of the literature and meta-analysis. METHODS All published prospective controlled trials that compared hemostatic glues to conventional techniques of hemostasis were identified. We performed a meta-analysis of articles comparing fibrin sealant to electrocautery, and of those comparing electrocautery to electrocautery plus fibrin hemostasis. RESULTS Seven studies were identified that made qualifications for review, with a total of 748 patients. Outcome measures were postoperative hemorrhage recorded by investigators, and visual analogue scores of pain for day 1, day 3, and day 10 postoperatively. Use of fibrin sealant was not associated with a reduction in hemorrhage rates following tonsillectomy when compared to electrocautery (pooled relative risk [RR] 0.315; 95% confidence intervals [CI]: 0.047-2.093, 224 patients). No statistical difference in bleeding rate was seen between electrocautery hemostasis alone, compared to electrocautery with fibrin sealant (pooled RR 1.742; 95% CI: 0.433-7.005, 108 patients). No statistically significant difference in pain was identified. CONCLUSIONS Pain and bleeding are significant causes of morbidity post-tonsillectomy. We conclude that there is no significant evidence to support hemostatic glues over current techniques for reducing severity of these outcomes. Consequently, we do not recommended hemostatic glues for routine use in current clinical practice. Studies were generally of low quality and inadequately powered to detect a statistical difference, even when pooled. We advocate further research to facilitate future meta-analysis.
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Affiliation(s)
- Rhona Sproat
- Ear, Nose, and Throat Department, Royal National Throat Nose and Ear, London
| | - Peter Radford
- Ear, Nose, and Throat Department, Wexham Park Hospital, Slough
| | - Alison Hunt
- Ear, Nose, and Throat Department, Milton Keynes NHS Foundation Trust, Standing Way, Milton Keynes, United Kingdom
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Edmonson MB, Eickhoff JC, Zhang C. A population-based study of acute care revisits following tonsillectomy. J Pediatr 2015; 166:607-12.e5. [PMID: 25524315 DOI: 10.1016/j.jpeds.2014.11.009] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2014] [Revised: 09/08/2014] [Accepted: 11/04/2014] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To describe the clinical spectrum and frequency of acute care revisits after tonsillectomy in a population-based sample from a single state in the US. STUDY DESIGN We used California state discharge databases from 2009 to 2011 to retrospectively identify retrospectively routine tonsillectomy discharges in residents <25 years of age and to establish record linkage to revisits within 30 days at ambulatory surgery, inpatient, and emergency department facilities statewide. Percentages and descriptive statistics were sample-weighted, and revisit rates were adjusted for demographic factors, expected payer, chronic conditions, surgical indication, facility type, and clustering. RESULTS Records were available for 35 085 index tonsillectomies, most of which were performed at hospital-owned ambulatory and inpatient facilities. There were 4944 associated revisits: 3761 (75.9%) treat-and-release emergency room visits, 816 (17.1%) inpatient admissions, and 367 (7.0%) ambulatory surgery visits. Most revisits (3225 [67.7%]) were unrelated to bleeding; these typically occurred early (mode, day 2) and were commonly associated with diagnosis codes indicating pain, nausea/vomiting, or dehydration. Crude all-cause revisit and readmission rates were 10.5% and 2.1%, respectively. Adjusted all-cause revisit rates (range, 8.6%-24.5%) were lowest in young children, increased in adolescents, and peaked in young adults. Adjusted bleeding-related revisit rates increased abruptly in adolescents and reached 13.9% in males (6.8% in females, P < .001) ages 20-24 years. CONCLUSIONS Acute care revisits after tonsillectomy performed at predominantly hospital-owned facilities in California are common and strongly age-related. Most revisits are early treat-and-release outpatient encounters, and these are usually associated with potentially preventable problems such as pain, nausea and vomiting, and dehydration.
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Affiliation(s)
- M Bruce Edmonson
- Division of General Pediatrics and Adolescent Medicine, Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Jens C Eickhoff
- Department of Biostatistics and Medical Informatics, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Chong Zhang
- Department of Biostatistics and Medical Informatics, University of Wisconsin School of Medicine and Public Health, Madison, WI
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Bellis JR, Pirmohamed M, Nunn AJ, Loke YK, De S, Golder S, Kirkham JJ. Dexamethasone and haemorrhage risk in paediatric tonsillectomy: a systematic review and meta-analysis. Br J Anaesth 2014; 113:23-42. [PMID: 24942713 DOI: 10.1093/bja/aeu152] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Summary In children undergoing tonsillectomy, dexamethasone is recommended to reduce the risk of postoperative nausea and vomiting while non-steroidal anti-inflammatory drugs (NSAIDs) are used for pain relief. We aimed to determine whether children who receive dexamethasone or dexamethasone with NSAID are more likely to experience haemorrhage post-tonsillectomy. Randomized and non-randomized studies in which children undergoing tonsillectomy received dexamethasone or dexamethasone and NSAID were sought within bibliographic databases and selected tertiary sources. The risk of bias assessment and evaluation of haemorrhage rate data collection and reporting were assessed using the Cochrane Risk of Bias Tool and McHarm tool. Synthesis methods comprised pooled estimate of the effect of dexamethasone on the risk of haemorrhage rate using the Peto odds ratio (OR) method. The pooled estimate for haemorrhage rate in children who received dexamethasone was 6.2%, OR 1.41 (95% confidence interval 0.89-2.25, P=0.15). There was risk of bias and inconsistent data collection and reporting rates of haemorrhage in many of the included studies. Clinical heterogeneity was observed between studies. The pooled analysis did not demonstrate a statistically significant increase in the risk of post-tonsillectomy haemorrhage with dexamethasone with/without NSAID use in children. However, the majority of the included studies were not designed to investigate this endpoint, and thus large studies which are specifically designed to collect data on haemorrhage rate are needed.
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Affiliation(s)
- J R Bellis
- Research and Development, University of Liverpool, Alder Hey Children's NHS Foundation Trust, Eaton Road, Liverpool L12 2AP, UK
| | - M Pirmohamed
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Ashton Street, Liverpool L69 3GE, UK
| | - A J Nunn
- Department of Women's and Children's Health, Institute of Translational Medicine (Child Health), University of Liverpool, Alder Hey Children's NHS Foundation Trust, Eaton Road, Liverpool L12 2AP, UK
| | - Y K Loke
- Norwich Medical School, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich NR4 7TJ, UK
| | - S De
- Department of Paediatric Otolaryngology, Head and Neck Surgery, University of Liverpool, Alder Hey Children's NHS Foundation Trust, Eaton Road, Liverpool L12 2AP, UK
| | - S Golder
- Centre for Reviews and Dissemination, University of York, York YO10 5DD, UK
| | - J J Kirkham
- Department of Biostatistics, University of Liverpool, Shelley's Cottage, Brownlow Street, Liverpool L69 3GS, UK
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Goldman JL, Baugh RF, Davies L, Skinner ML, Stachler RJ, Brereton J, Eisenberg LD, Roberson DW, Brenner MJ. Mortality and major morbidity after tonsillectomy: etiologic factors and strategies for prevention. Laryngoscope 2013; 123:2544-53. [PMID: 23595509 DOI: 10.1002/lary.23926] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2012] [Revised: 10/03/2012] [Accepted: 11/08/2012] [Indexed: 12/14/2022]
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. LEVEL OF EVIDENCE N/A.
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Affiliation(s)
- Julie L Goldman
- Division of Otolaryngology, Department of Surgery, University of Louisville, Louisville, Kentucky
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Walner DL, Karas A. Standardization of Reporting Post-Tonsillectomy Bleeding. Ann Otol Rhinol Laryngol 2013; 122:277-82. [DOI: 10.1177/000348941312200411] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Abstract
Pediatricians play an important role in the perioperative care of hospitalized children after tonsillectomy and are often called upon to manage posttonsillectomy problems in the outpatient setting. The tonsillectomy operation has changed in recent years. More children are operated upon for sleep disordered breathing and fewer for recurrent pharyngitis. New instruments now permit less invasive surgery. Systematic reviews by the Cochrane Collaboration and others have helped define best practices for preoperative assessment and postoperative care. This article will outline these practices as defined in the 2011 American Academy of Otolaryngology-Head and Neck Surgery Foundation clinical practice guideline "Tonsillectomy in Children." It will describe the different tonsillectomy operations, discuss patterns of normal healing, and review management of pain and posttonsillectomy hemorrhage to form a foundation for improved pediatric care.
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Affiliation(s)
- Glenn Isaacson
- Department of Otolaryngology-Head & Neck Surgery, Temple University School of Medicine, 1077 Rydal Rd, Suite 201, Rydal, PA 19046, USA.
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Sutters KA, Holdridge-Zeuner D, Waite S, Paul SM, Savedra MC, Lanier B, Mahoney K, Miaskowski C. A descriptive feasibility study to evaluate scheduled oral analgesic dosing at home for the management of postoperative pain in preschool children following tonsillectomy. PAIN MEDICINE 2012; 13:472-83. [PMID: 22313591 DOI: 10.1111/j.1526-4637.2011.01324.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES The purpose of this study, in a sample of preschool children (ages 3-5 years; N = 47), was to evaluate the feasibility of scheduled analgesic dosing following outpatient tonsillectomy in order to optimize pain management. METHODS Parents were instructed to give their child acetaminophen with hydrocodone (167 mg/5 mL) every 4 hours around the clock for the first 3 days following surgery. Parents recorded ratings of their child's pain with/without swallowing using the Faces, Legs, Activity, Cry, and Consolability (FLACC) behavioral pain scale, pain relief ratings, and severity of analgesic side effects in a home diary. Audiotaped interviews were conducted with parents to document descriptions of their experiences in managing their child's pain at home. RESULTS Mean FLACC scores with/without swallowing were less than two at each measurement time and pain relief scores increased over time. Total analgesic dose decreased, and the number of missed doses increased over the first 3 days after surgery. Moderate-to-severe daytime sedation, nausea, vomiting, and constipation were reported by parents. DISCUSSION Study results suggest that acetaminophen with hydrocodone is effective in relieving preschool children's pain following tonsillectomy and that parental adherence to a scheduled analgesic regimen decreases over time. Time-contingent dosing was associated with moderate to severe side effects and should be addressed in discharge teaching with parents. Findings provide insight into parents' perspective of pain management at home following tonsillectomy and methods for relieving their child's pain.
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Affiliation(s)
- Kimberly A Sutters
- Surgical Services, Pain Management, Children's Hospital Central California, Madera, California 93636-8761, USA.
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Sarny S, Habermann W, Ossimitz G, Schmid C, Stammberger H. Tonsilar haemorrhage and re-admission: a questionnaire based study. Eur Arch Otorhinolaryngol 2011; 268:1803-7. [DOI: 10.1007/s00405-011-1541-y] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2011] [Accepted: 02/16/2011] [Indexed: 12/23/2022]
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Simonsen AR, Duncavage JA, Becker SS. A review of malpractice cases after tonsillectomy and adenoidectomy. Int J Pediatr Otorhinolaryngol 2010; 74:977-9. [PMID: 20708128 DOI: 10.1016/j.ijporl.2010.05.029] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2010] [Revised: 05/23/2010] [Accepted: 05/25/2010] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To examine sources of litigation following tonsillectomy and/or adenoidectomy. STUDY DESIGN Analysis of malpractice claims filed after tonsillectomy or adenoidectomy provided by 16 medical liability insurance companies. SETTING Not applicable. SUBJECTS AND METHODS Data was obtained from 16 members of the Physician Insurers Association of America. All claims were either filed or closed between 1985 and 2006. Claims were evaluated and categorized according to the type of complication. RESULTS One hundred and fifty-four claims were identified between 1985 and 2006. Six categories were created based on frequency of claims (bleeding complication n=27 [17.5%], airway fire n=2 [1.5%], burns n=28 [18.2%], consent related n=9 [5.8%], medication related n=9 [5.8%] and residual tissue/recurrence n=9 [5.8%]). Other less frequent claims were grouped as miscellaneous n=70 [45.5%]. CONCLUSIONS A significant portion of malpractice claims following tonsillectomy or adenoidectomy are related to complications not commonly discussed in the literature.
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Common Postoperative Complications in Otolaryngology Presenting to the Pediatric Emergency Department. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2010. [DOI: 10.1016/j.cpem.2010.04.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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