Current trends in tonsillitis and tonsillectomy

Dexamethasone Decreased Postoperative Complications in Tonsillotomy

PURPOSE

Tonsillotomy (TT) is a new and popular method with partial resection of the tonsils. Dexamethasone is often used during surgery for its anti-inflammatory, antiemetic, and analgesic properties. In this study, we aimed to explore the effect of systemic steroids use on postoperative vomiting, pain, and bleeding in TT.

DESIGN

A randomized controlled trial.

METHODS

We enrolled 240 children aged 2 to 18 years who had undergone TT or adenotonsillotomy at our center from July 2020 to July 2021. Dexamethasone or 0.9% normal saline was administered before the start of surgery. Postoperative hemorrhage, vomiting, and nausea were recorded and compared between groups.

FINDINGS

The dexamethasone group had a 2.5% (3/119) rate of postoperative bleeding, while the rate was 1.6% (2/119) in the control group. No patients required multiple operations for control of bleeding. The degree of postoperative pain (2.1 ± 0.5 vs 3.4 ± 0.9) and the occurrence of postoperative nausea (21% vs 31.9%), as well as vomiting (15% vs 24.4%) in the dexamethasone group, was significantly lower compared with the placebo group.

CONCLUSIONS

The rate of postoperative bleeding between the dexamethasone group and the control group had no significant difference, suggesting the high safety of dexamethasone use in TT. Dexamethasone use in TT improved postoperative pain, nausea, and vomiting significantly.

[Chronic tonsillitis and periodontal diseases]

INTRODUCTION

Chronic tonsillitis is a multifactorial immunopathological process that contributes to the development of tonsillitis-associated pathology. In turn, this tonsillitis-associated pathology potentiates and aggravates the course of chronic tonsillitis. In the literature, there are data on the possible influence of oropharyngeal loci of focal chronic infection on the body as a whole. One of such foci that can aggravate the course of chronic tonsillitis and maintain sensitization of the body are periodontal pockets formed during the inflammatory process in periodontal tissues. Highly pathogenic microgranisms of periodontal pockets secrete bacterial endotoxins, stimulating the immune response of the human body. Bacteria and their waste products cause intoxication and sensitization of the whole organism. A vicious circle is formed, which is quite difficult to break.

OBJECTIVE

To study the effect of chronic inflammatory process in periodontal disease on the course of chronic tonsillitis.

MATERIAL AND METHODS

70 patients with chronic tonsillitis were examined. Together with a dentist-periodontist, an assessment of the state of the dental system was carried out, according to the results of which all patients with chronic tonsillitis were divided into 2 groups: with and without periodontal diseases.

RESULTS

In patients with periodontitis, highly pathogenic flora is found in periodontal pockets. When examining patients with chronic tonsillitis, it is important to assess the condition of the dental system, to calculate dental indices, the key of which are periodontal and bleeding index. It is necessary to recommend comprehensive treatment for patients with CT and periodontitis by otorhinolaryngologists and periodontists.

CONCLUSION

It is necessary to recommend comprehensive treatment by otorhinolaryngologists and dentists to patients with chronic tonsillitis and periodontitis.

[The role of tonsillectomy in the treatment of chronic tonsillitis]

The problem of chronic tonsillitis remains one of the urgent problems of modern otorhinolaryngology. The article discusses the statistics and complications of chronic tonsillitis, provides indications for tonsillectomy and its main complications.

OBJECTIVE

Generalization and systematization of data on the impact of surgical treatment on the quality of life of patients with chronic tonsillitis.

MATERIAL AND METHODS

Search for literary sources, carried out using the search engines of the RSCI, PubMed, Web of Science, and eLibrary.

RESULTS

A review of literature sources demonstrates a significant improvement in the quality of life of patients after tonsillectomy; however, data from some studies show a trend towards a decrease in the number of planned tonsillectomies and an associated increase in the detection of local purulent-septic complications.

Lactoferrin versus Long-Acting Penicillin in Reducing Elevated Anti-Streptolysin O Titer in Cases of Tonsillopharyngitis

Background

Beta-Hemolytic streptococci are the most frequent bacteria causing tonsillitis. Lactoferrin may play a role in the treatment of chronic tonsillitis due to its direct antimicrobial activity.

Objective

To assess the possible role of lactoferrin in reduction of raised serum Anti-Streptolysin O Titer (ASOT) in cases of chronic tonsillopharyngitis in comparison to long acting penicillin.

Methods

This study included 117 children with tonsillopharyngitis with high ASOT randomly divided into three groups; group 1 treated with lactoferrin, group 2 treated with long acting penicillin and group 3 treated with both drugs. For all patients ASOT was measured after three and six months of starting treatment.

Results

This study included 60 males and 57 females with the mean age (8.5 ± 2.4). There is statistically significant reduction in ASOT in all groups after three months of treatment. ASOT after 3 months was significantly lower in group1 (370±440) and group 3 (350±450) in comparison to group 2 (420±560) with p value 0.02, 0.004, respectively, with no significant difference in comparing group 1 to group 3 p value 0.4. Also, ASO titre after 6 months was significantly lower in group1 (350±420) and group 3 (340±440) in comparison to group 2 (420±550) with p value 0.02, 0.007, respectively, with no significant difference in comparing group 1 to group 3 p value 0.5. In comparing ASOT at three months and six months of treatment in the three studied groups; it decreased by 2% in group 1, and 1.6% in group 3 and no change in group 2.

Conclusion

Lactoferrin alone or in combination with long acting penicillin is safe and more effective than long acting penicillin alone in reducing ASOT. Treatment for six months with lactoferrin alone or in combination with long acting penicillin could offer a better response.

Impact of COVID-19 on nationwide pediatric otolaryngology practice: Adenotonsillectomies (TA) and tonsil-related diagnoses trends

Objectives/hypothesis

To determine the effects of the COVID-19 pandemic on Adenotonsillectomies (TA), Tonsil Related Cases (TC), and Peritonsillar Abscess (PTA) Trends.

Study design

Retrospective Cohort Study.

Methods

This is a retrospective cohort study using the Pediatric Health Information System® (PHIS) database, which consists of 51 children's hospitals. Regions were defined according to PHIS rules with at least five children's hospitals per region. We compared monthly total TA, TC, TC as a proportion of all hospital visits, and PTA from all encounters at each hospital from January 1, 2019, through December 31, 2021.

Results

Compared to 2019, April 2020 saw mean TC drop significantly from 371.62 to 68.37 (p < 0.001). Interestingly, June, September, and December 2020 had significantly higher mean TC compared to 2019. TC as a proportion of all hospital visits decreased significantly throughout the majority of 2021. Similarly, TA significantly decreased during 2020 and 2021 across all regions in the US, starting in March 2020 and this reduction in TA extended through the end of 2021 without any signs of recovery. PTA rates did not change significantly over the three years.

Conclusions

The pandemic-plagued 2020 saw a noticeable decrease in overall TC and TA but then rebounded quickly to even higher than pre-pandemic levels. However, this rebound halted for the majority of 2021 and subsequently decreased to lower than pre-pandemic levels, which differs from other communicable pathologies such as otitis media which decreased initially then recovered to pre-pandemic levels by Summer of 2021.

Defining the microbiome of the head and neck: A contemporary review

OBJECTIVE

The purpose of this paper is to define the microbiome of the head and neck by characterizing and distinguishing the commensal bacteria from pathogenic species.

STUDY DESIGN

Literature review.

METHODS

Pubmed and Google scholar databases were queried for relevant articles. Keywords such as "middle ear microbiome", "outer ear microbiome", "sinonasal microbiome", "tonsil microbiome", and "laryngeal microbiome" were utilized separately to identify articles pertaining to each topic of study. All applicable abstracts were chosen for initial review and relevant abstracts were then selected for review of the full texts. Articles that did not study the human microbiome, those not written primarily in English, those that were not readily available for full review, and case reports were excluded from the study.

RESULTS

Limited studies that investigate the microbial environments of isolated anatomic subsites in the head and neck exist, however the comprehensive microbiome of the head and neck has yet to be completely defined. Based on this review, various studies of the ears, larynx, tonsils and sinus microbiomes exist and yield valuable information, however they are limited in scope and anatomic subsite. In this literature review, these studies are compiled in order to create a comprehensive text inclusive of the known microbial elements of the major anatomic subsites of the head and neck, namely the tonsils, larynx, sinus, outer ear and middle ear.

CONCLUSIONS

The significance of the human microbiome in identifying and preventing disease has been established in various physiologic systems, however there is limited research on the microbiome of the head and neck. Understanding the microbiome of the head and neck can help differentiate disease-prone patients from normal patients and guide treatment regimens and antibiotic usage, to aid in resistance control and limit adverse effects of antibiotic overuse. Understanding the elements that lead to dysbiosis can help treat and even prevent common conditions as tonsillitis and rhinosinusitis. In this review, we provide a comprehensive review to serve as an initial background for future studies to define the head and neck microbiome distinguished by all relevant subsites.

Ambulatory management of common ENT emergencies - what's the evidence?

OBJECTIVES

The global pandemic of coronavirus disease 2019 has necessitated changes to 'usual' ways of practice in otolaryngology, with a view towards out-patient or ambulatory management of appropriate conditions. This paper reviews the available evidence for out-patient management of three of the most common causes for emergency referral to the otolaryngology team: tonsillitis, peri-tonsillar abscess and epistaxis.

METHODS

A literature review was performed, searching all available online databases and resources. The Medical Subject Headings 'tonsillitis', 'pharyngotonsillitis', 'quinsy', 'peritonsillar abscess' and 'epistaxis' were used. Papers discussing out-patient management were reviewed by the authors.

RESULTS

Out-patient and ambulatory pathways for tonsillitis and peritonsillar abscess are well described for patients meeting appropriate criteria. Safe discharge of select patients is safe and should be encouraged in the current clinical climate. Safe discharge of patients with epistaxis who have bleeding controlled is also well described.

CONCLUSION

In select cases, tonsillitis, quinsy and epistaxis patients can be safely managed out of hospital, with low re-admission rates.

Obstructive sleep apnoea in adult patients post-tonsillectomy

BACKGROUND

The impact of removing the upper airway lymphoid tissue and in particular, tonsillectomy, in adults with OSA has not been demonstrated in large populations.

AIMS

To compare the severity of OSA and the prevalence of cardiovascular, metabolic and respiratory co-morbidities between patients with OSA who had undergone previous tonsillectomy and those who had not.

METHODS

The 19,711 participants in this study came from the European sleep apnea database (ESADA) which comprises data from unselected adult patients aged 18-80 years with a history of symptoms suggestive of OSA referred to sleep centers throughout Europe.

RESULTS

There were no differences between the two groups in terms of sex ratio and age (146 patients with previous tonsillectomy vs. 19565 patients without). Patients who had undergone tonsillectomy had a lower body mass index (29.3 ± 5.2 kg/m² vs 32.2 ± 6.6 kg/m², p < 0.001), lower subjective sleep latency (17.1 ± 17.8 min vs 25.5 ± 30.4 min, p = 0.001), lower ODI (15.7 ± 18.3 events/hour vs 30.7 ± 26.1 events/hour, p < 0.001), and SpO₂<90% time during sleep (21.8 ± 47.5 min vs 52.6 ± 80.8 min, p < 0.001). OSA patients with tonsillectomy had a lower prevalence of Type II diabetes mellitus (p = 0.001), hypertension (p < 0.001) and a higher prevalence of hyperlipidemia (p < 0.001) and were less likely to be commenced on CPAP (p < 0.001).

CONCLUSION

In a large population of almost 20,000 OSA patients from across Europe, patients who had undergone tonsillectomy presented with less severe OSA at time of diagnosis, and had a lower prevalence of Type II diabetes mellitus and cardiovascular co-morbidities.

Comparative efficacy of ancillary drugs in sevoflurane-related emergence agitation after paediatric adenotonsillectomy: A Bayesian network meta-analysis

WHAT IS KNOWN AND OBJECTIVE

The comparative efficacy of ancillary drugs on sevoflurane-related emergence agitation (EA) in paediatric anaesthesia for adenotonsillectomy remains unclear. The purpose of this Bayesian network meta-analysis was to investigate the efficacy of ancillary drugs on sevoflurane-related EA in paediatric anaesthesia for adenotonsillectomy.

METHODS

MEDLINE, Embase, the Cochrane Library and Web of Science databases were electronically searched to identify randomized controlled trials (RCTs) of different ancillary drugs used in adenotonsillectomy from inception to April 2019. Two reviewers independently screened the literature, extracted data and assessed the risk of bias in included studies. Subsequently, a network meta-analysis was performed using the R software and RevMan 5.3 software.

RESULTS AND DISCUSSION

We included 25 RCTs, involving 2151 participants. The proportion of patients with sevoflurane-related EA was significantly lower in the dexmedetomidine, ketamine, propofol, fentanyl, midazolam, sufentanil, remifentanil and clonidine groups than in the placebo group (P < .05). Fentanyl was superior to sufentanil (P < .05), whereas dexmedetomidine was superior to fentanyl (P < .05). Among ancillary drugs, dexmedetomidine (90.04%) showed the highest possibility of reducing the risk of EA, followed by fentanyl (87.45%), remifentanil (63.85%), ketamine (52.07%), midazolam (51.27%), clonidine (49.94%), propofol (29.89%), sufentanil (21.38%) and placebo (4.09%).

WHAT IS NEW AND CONCLUSION

Evidence suggests that the effects of dexmedetomidine in reducing the risk of sevoflurane-related EA in paediatric anaesthesia for adenotonsillectomy were better than the effects of other drugs. However, large, high-quality RCTs are required to further confirm this.

[Surgical interventions on the pharynx in the structure of otorhinolaryngological care to the population of the city of Moscow]

The authors studied the reporting documentation of otorhinolaryngological hospitals of the city of Moscow on the surgical treatment of pharyngeal pathology in adults from 2002 to 2017. It was found that for 16 years surgical treatment of 290 362 patients with ENT-diseases was performed: 181.206 (62.4%) patients with diseases of the nose and paranasal sinuses, 24.981 (8.6%) patients with ear pathology, 60.346 (20.8%) patients with diseases of the pharynx and 23.829 (8.2%) - with diseases of the larynx. The assessment of the overall dynamics of the studied indicators was carried out on the 'trend lines'. For the considered period, the number of patients with surgical pathology of the pharynx increased by 33.2%. The proportion of tonsillectomies increased by 1.85 times to 56.5%, drainage of peritonsillar abscesses and abscesses-tonsillectomies decreased by 19%, uvulopalatoplastic increased 4.1 times, removal of neoplasms of the pharynx increased 2.2 times, adenotomies decreased by 2.4 times. Analysis of the data allowed to establish that, against the background of an ever-increasing number of surgical interventions for diseases of the pharynx in adults, a descending trend was noted only in the treatment of complicated forms of chronic tonsillitis and hypertrophy of the pharyngeal tonsil.

Association between tonsillitis and newly diagnosed ankylosing spondylitis: A nationwide, population-based, case-control study

Objectives

To investigate the association between tonsillitis and the risk of newly diagnosed ankylosing spondylitis (AS).

Methods

We used 2003–2012 data from Taiwan’s National Health Insurance Research Database to conduct this nationwide, population-based, case-control study. We identified AS patients newly diagnosed between 2005 to 2012 as the study group and selected age, sex and index-year matched (1:6) non-AS individuals as controls. The association between tonsillitis and risk of newly diagnosed AS was determined by calculating odds ratios (ORs) with 95% confidence intervals (CIs) using conditional logistic regression analysis.

Results

We identified 37,002 newly diagnosed AS cases and 222,012 matched non-AS controls. Patients with AS were more likely to have tonsillitis (aOR 1.46, 95% CI 1.43–1.50), appendicitis (aOR 1.29, 95% CI 1.13–1.48) and periodontitis (aOR 1.35, 95% CI 1.31–1.38) than non-AS control subjects. The association between tonsillitis and AS was consistent using varying definitions for tonsillitis, and we further found that a high frequency of visits for tonsillitis, a high medical cost for tonsillitis and a long interval between diagnosis were associated with newly diagnosed AS in a dose-response manner. Furthermore, the association between tonsillitis and AS appeared to be stronger in females (aOR 1.59, 95% CI 1.53–1.65) than those in males (aOR 1.39, 95% CI 1.35–1.44).

Conclusions

The present study revealed an association between AS risk and prior tonsillitis and indicates the need for vigilance of AS-associated symptoms in patients who had been diagnosed with tonsillitis, particularly in females.

Implementing a guideline for acute tonsillitis using an ambulatory medical unit

OBJECTIVE

Acute tonsillitis represents a significant proportion of admissions to ENT departments nationally. Given current hospital pressures, it is vital to look for safe alternatives to admission. This study explores the safe management of patients in an ambulatory medical unit, without the need for admission.

METHODS

A retrospective review of 48 patients' notes was carried out. Following the development and implementation of a guideline for acute tonsillitis, a prospective re-audit of 41 patients was carried out, measuring length of stay, overnight admissions and re-admissions.

RESULTS

The rate of overnight admission following implementation of the guideline fell from 0.75 to 0.29, and average length of stay dropped from 19.2 to 9.5 hours. There were two re-admissions in each cycle of the audit, which represents a non-significant increase.

CONCLUSION

The tonsillitis guideline has significantly reduced admissions and length of stay. Re-admissions remain low, demonstrating that this is a safe and cost-effective intervention.

Post-tonsillectomy dietary advice: systematic review

Objective:

To determine if there is evidence that post-tonsillectomy dietary advice affects post-operative morbidity.

Method:

A systematic review was conducted of Embase, Medline, the Cumulative Index to Nursing and Allied Health Literature and PsycInfo, to November 2014.

Results:

Seventeen articles were included; their heterogeneous nature prevented meta-analysis. Of these, all three small, randomised studies showed no statistical difference in morbidity between restricted and non-restricted diets.

Conclusion:

Most post-tonsillectomy dietary advice is based on historical anecdotes and not rigorous scientific testing. The existing small-scale, randomised studies show no statistical difference in morbidity between non-restricted and restricted diets.

Stakeholders' views of recurrent sore throat, tonsillitis and their management: a qualitative interview study for the NAtional Trial of Tonsillectomy IN Adults (NATTINA Part 1)

OBJECTIVES

To determine the impact of recurrent sore throats and tonsillitis in adults and stakeholder views of treatment pathways.

DESIGN

Qualitative semistructured interview design reporting novel data from a feasibility study for a UK national trial of tonsillectomy in adults.

SETTING

Nine study sites linked to ear, nose and throat departments in National Health Service hospitals located across the United Kingdom.

PARTICIPANTS

Fifteen patients, 11 general practitioners and 22 ear, nose and throat staff consented to in-depth interviews, which were analysed using a framework analysis approach.

MAIN OUTCOME MEASURES

Views of stakeholder groups.

RESULTS

Recurrent sore throats were reported to severely impact patients' family, work and social life. Ear, nose and throat staff stated that patients faced increasing barriers to secondary care service access. General practitioners were under pressure to reduce 'limited clinical value' surgical procedures.

CONCLUSIONS

The findings from this study suggest that there is a disconnect between the attitudes of the stakeholders and the reality of recurrent sore throat, tonsillectomy procedures and service provision. More evidence for the role of tonsillectomy is needed from randomised controlled trials to determine whether it should continue to be ranked as a procedure of limited clinical effectiveness.