Twenty-year observational study of paediatric tonsillitis and tonsillectomy

INTRODUCTION

Tonsillectomy is now only indicated in the UK when specific criteria are met, as outlined by the Scottish Intercollegiate Guidelines Network (SIGN) and The National Institute for Health and Care Excellence (NICE). As a result, fewer numbers of tonsillectomy are being performed. Tonsillectomy is the primary treatment for recurrent tonsillitis; therefore, we hypothesise that acute admissions to hospital with tonsillitis and infective complications will have risen since criteria were introduced. Our aim was to assess the rates of acute hospital admissions with tonsillitis in children and the factors associated with this.

METHODS

Data were provided by Information Service Division for all under 16s in Scotland between 1996/1997 and 2016/2017. Socioeconomic background was determined from the Scottish Index of Multiple Deprivation (SIMD) score. Poisson regression analysis was used to model predictors of surgery and correlation analysis to study the relationship between tonsillitis and other factors.

RESULTS

60 456 tonsillectomies were performed. The number of tonsillectomies dropped significantly following the introduction of SIGN guidelines, and the rates of tonsillitis increased; however, admissions with tonsillitis were already on an upward trajectory. Children from the most deprived areas were 72.0% (95% CI 60% to 85%, p<0.001) more likely to receive tonsillectomy and were also more likely to be admitted with tonsillitis than the least deprived areas.

CONCLUSION

Tonsillectomy and tonsillitis rates are highest in the most deprived; postulated reasons include antibiotic stewardship and difficulty accessing primary care. Current guidelines on tonsillectomy may be disproportionately harmful in children from deprived households.

Concurrent subglottic and carotid sheath haemangiomas in a paediatric patient – an extremely rare clinical entity

Multiple haemangiomas of the head and neck area have been reported sporadically in the literature. Concurrent subglottic and carotid sheath haemangiomas have not been reported before in the paediatric population. The authors present the case of a 13-week-old child admitted under the paediatric ENT team with stridor. Diagnostic micro-laryngoscopy identified a subglottic haemangioma as the cause of stridor and subsequent magnetic resonance imaging demonstrated an incidental 7 cm carotid sheath lesion extending from the skull base to the superior mediastinum. Subsequent biopsy confirmed a benign infantile haemangioma. To our knowledge, this is the first reported case of concurrent subglottic and carotid sheath infantile haemangiomas in a paediatric patient. Here we discuss the clinical features and management of infantile haemangioma.

Feasibility of ovine and porcine models for simulation training in parotid surgery and facial nerve dissection

PURPOSE

To assess and compare the feasibility of using ovine and porcine models as surgical simulation training tools for otolaryngology trainees performing parotid surgery and facial nerve dissection.

METHODS

Trainees performed parotid surgery (total parotidectomy, retrograde facial nerve dissection and facial nerve grafting) on an ovine and porcine model. Participants completed a 22-item, five-point Likert scale questionnaire on each model, assessing three validation domains; face validity (FV), global content validity (GCV) and task-specific content validity (TSCV). Data were prospectively collected and analysed using descriptive and non-parametric statistics.

RESULTS

Twelve trainees completed two consecutive parotidectomies and facial nerve dissections on an ovine and porcine model. Twenty-four dissections were completed. Validation questionnaires were completed for each model by all trainees. The ovine model achieved median validation threshold scores (≥ 4/5) for all aspects of FV, GCV and TSCV. The porcine model did not achieve validation threshold scores for any aspect of the validation questionnaire. Comparison of the ovine and porcine model demonstrated that the ovine model was statistically superior to the porcine model across most validation criteria excluding realistic appearance of skin, identification and ligation of the trans-oral parotid duct and facial nerve grafting.

CONCLUSION

Adequate experience with facial nerve dissection during parotid surgery is vital to ensuring good outcomes and avoiding complications. This study is the first to compare validity of two animal models for simulation training in parotid surgery and facial nerve dissection. We have validated the ovine model as a useful tool for simulation training and advocate its incorporation into otolaryngology training programmes.

Validation of Animal Models for Simulation Training in Pediatric Laryngotracheal Reconstruction

OBJECTIVES

To assess and compare the face (FV) and content validity (CV) of three ex vivo animal models for simulation training in pediatric laryngotracheal reconstruction (LTR).

METHODS

Feasibility of performing LTR was assessed on the head and neck of three different animals (lamb/suckling-pig/rabbit) and laryngeal dimensions and qualitative observations were recorded. A 19-item five-point Likert scale questionnaire was completed for each model to assess FV and CV. Data was prospectively collected and analyzed using descriptive and nonparametric statistics.

RESULTS

All three models were suitable for LTR simulation with laryngeal dimensions corresponding to 0-2 years (rabbit), 5-10 (pig) and >10 years (lamb model). Five trainees and five expert pediatric otolaryngologists performed LTR on each model. The overall median FV score was 5 for the lamb model (IQR 4-5), 3 for the rabbit (IQR 2-3), and 4 for the pig (IQR 4-4). The overall median CV score was 5 for the lamb (IQR 5-5), 2 for the rabbit (IQR 2-3), and 4 for the pig model (IQR 4-4). Comparison of the models demonstrated the lamb to be favored as the most realistic and practical model for simulation training in pediatric LTR, with both the lamb and the porcine model attaining validation thresholds.

CONCLUSION

Our study is the first comparative validation assessment of animal models for use in pediatric LTR simulation and it supports the use of ex vivo lamb and porcine models for use in LTR surgical skills training. The lamb model was the favored simulation model while the rabbit was considered inferior for simulation training in pediatric LTR.

LEVEL OF EVIDENCE

3b.

Otological surgery in paediatric photosensitive patients

There are a wide range of genetic and auto-immune conditions where UV light exposure poses a threat of UV irradiation to the external auditory canal, tympanic membrane and surrounding skin. Preoperative Ultraviolet Light (UV) measurements were taken in the operating theatre with standard operating microscope and an approved UV light meter prior to surgery on a patient with xeroderma pigmentosa. UV light meter readings of UV index 75 were taken at an operating distance of 290mm. Proceeding with otological surgery with a high UV index would result in a significant UV radiation burn. Utilising a Dermagard and a specific UV filter applied to the microscope resulted in acceptable UV light readings. We highlight the potential morbidity of otological surgery in paediatric photosensitive conditions. We also recommend a management plan to avoid damage by UV radiation in photosensitive patients.

A systematic review of simulated laryngotracheal reconstruction animal models

OBJECTIVES

Review of the literature to identify practical, high-fidelity, commercially available animal models for simulation training and surgical skills maintenance in laryngotracheal reconstruction (LTR).

METHODS

A systematic review of PubMed and Embase databases was conducted independently by two authors, according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Search terms included "laryngotracheal reconstruction," "laryngotracheoplasty," "pig and larynx," "sheep and larynx," and "rabbit and larynx." Articles were then assessed, identifying model cost and availability, model validation, feasibility as a training tool, and verisimilitude to pediatric LTR.

RESULTS

In total, 79 articles were considered suitable for inclusion in the study, incorporating both in vitro and in vivo models. Models utilized included rabbit (n = 69), pig (n = 7), sheep (n = 1), and goat (n = 2). The rabbit model was similar in size to the neonate, but differences in laryngeal anatomy and cartilage texture made graft insertion difficult. The anatomy of the pig, sheep, and goat larynges more closely resembled the pediatric patient, allowing improved grafting, but corresponded more in size to that of an older child. Commercial availability of the pig and sheep was considered greatest, and was reflected in cost. None of the animal models identified in the literature have been validated as a simulation tool.

CONCLUSIONS

The rabbit, sheep and pig models seemed to demonstrate the greatest potential for use as advanced pediatric airway surgery simulation models, with the rabbit model being most utilized in the literature. However, as yet there have been no models formally validated as a simulation training tool. Laryngoscope, 129:235-243, 2019.

Childhood Epistaxis: Naseptin and Cautery vs Naseptin Alone

Objective

Establish whether selective application of combined silver nitrate cautery and 4 weeks of Naseptin cream is superior to Naseptin treatment alone in the management of recurrent paediatric epistaxis.

Methods

We performed a prospective randomised controlled trial. All children referred with recurrent epistaxis were seen in a research clinic. Patients with visible anterior septal vessels were invited to participate and were randomised to receive either treatment or control. Allocation was made using opaque, sealed and shuffled sequentially numbered envelopes. Treatment patients received silver nitrate cautery followed by 4 weeks of Naseptin. Control patients received sham cautery (using the inactive end of the caustic applicator) followed by Naseptin for 4 weeks. The patients were reviewed after 8 weeks and the outcome measure was ‘no reported bleeding’ in the preceding 4 weeks. Any reported bleeding was defined as treatment failure. A power calculation was made based on a previous study by the department: 108 participants were required.

Results

229 children attended and 109 met the inclusion criteria and were randomised. Complete data is currently available for 80. Of those receiving cautery and Naseptin, 18/38 (47.4%) had no bleeding in the preceding 4 weeks and of those receiving only Naseptin, 12/42 (28.6%) had no bleeding. (Chi-squared=3, p=0.08). This gives a relative risk reduction of 26% and a number needed to treat of 5.5.

Conclusions

Silver nitrate cautery and 4 weeks of Naseptin cream is superior to Naseptin treatment alone in the management of recurrent paediatric epistaxis.

Columella stabilising suture

Caudal septal deformities if uncorrected can lead to poor functional and cosmetic outcomes. Adequate fixation of the septum to the maxillary spine is paramount in correcting these deformities. We describe a simple technique for securing the caudal septum to the maxillary spine that stabilises it in all three planes.

Reduced response of the hypothalamo-pituitary-adrenal axis to alpha1-agonist stimulation during lactation

To determine whether altered noradrenergic activation of the hypothalamo-pituitary-adrenal (HPA) axis contributes to the attenuated neuroendocrine response to stress observed during lactation, the effect of intracerebroventricular injection of the alpha1-agonist methoxamine (100 microg) was compared between virgin and lactating rats. Virgin rats showed significant increases in plasma corticosterone after methoxamine, reaching 317 +/- 44 ng/ml at 10 min and remaining significantly elevated for more than 120 min, but lactating rats showed no significant increase in corticosterone levels. Furthermore, methoxamine induced an increase in paraventricular nucleus (PVN) CRF messenger RNA expression in virgin, but not lactating, animals. Both groups of rats exhibited comparable elevations in plasma PRL after methoxamine treatment. Arginine vasopressin messenger RNA expression within the parvocellular PVN was greater in the lactating animals than in the virgin controls, but methoxamine injection was without further effect. Studies performed on ovariectomized virgin rats and ovariectomized rats receiving estradiol or progesterone replacement failed to reproduce the attenuated HPA responses seen after methoxamine treatment, although methoxamine-induced PRL levels were greatly increased by estradiol, probably arising from an effect on hormone synthesis. In vitro electrophysiological recordings of PVN neurons in hypothalamic slices from proestrous virgin and lactating rats showed that 45-52% of neurons in both groups exhibited excitatory responses to 10(-4) M methoxamine, but there was a differential response to 10(-5) M methoxamine, with PVN neurons from lactating animals failing to show a response. These data show a selective down-regulation of alpha1-mediated activation of the HPA axis in lactating animals. This may contribute to the attenuated stress-induced activation of the HPA axis during lactation.