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PubMed1988

Peritonsillarlike lateral oropharyngeal abscess after tonsillectomy.

Peritonsillar abscess is a well-known sequela of acute tonsillitis. However, not so well known is the occurrence of a peritonsillarlike oropharyngeal abscess in patients with previous tonsillectomy. No case report or review exists in the American medical literature. We present four cases of abscess after tonsillectomy and a review of the world literature. A discussion of the evaluation and treatment of posttonsillectomy abscess based on these cases is included. An attempt is made to alert the practitioner to the fact that patients who have undergone tonsillectomy can develop peritonsillarlike oropharyngeal abscesses.

Abscess↗
PubMed1990

The efficacy of cefaclor vs amoxicillin on recovery after tonsillectomy in children.

Tonsillectomy and adenoidectomy continues to be one of the most commonly performed operations in the pediatric age group. The morbidity from tonsillectomy can be severe and includes throat and ear pain, fever, lethargy, and poor oral intake. A previous study at the Children's Hospital of Philadelphia (Pa) demonstrated the efficacy of amoxicillin therapy in minimizing some of these postoperative symptoms. However, some children continue to have a prolonged recovery even while receiving this antibiotic regimen. Because of these children and the high incidence of Staphylococcus found in tonsillar core tissue, a randomized, prospective study was undertaken at the Children's Hospital of Philadelphia to evaluate the efficacy of cefaclor vs amoxicillin in patients recovering from tonsillectomy. The patients received either ampicillin or cefazolin intravenously at the time of surgery and for 12 to 24 hours postoperatively. When oral intake was adequate, they received either amoxicillin or cefaclor orally for 7 additional postoperative days. Intraoperative cultures of the oropharynx and tonsillar tissue were obtained, as well as cultures of the tonsillar fossa 7 to 14 days postoperatively. The patients were evaluated for severity and duration of postoperative symptoms as well as complications. The results of this study showed no difference between the two groups of patients. We conclude that there is no justification for routine use of cefaclor over amoxicillin in the posttonsillectomy patient.

Amoxicillin↗
PubMed1995

Depression in children after tonsillectomy.

Postoperative depression has been reported in adults undergoing open heart surgery and mastectomy. Tonsillectomy is a commonly performed procedure and can be associated with significant morbidity including pain, difficulty swallowing, dehydration, and bleeding. While adults may be able to express their feelings about the postoperative course, children often are unable to express themselves. Because postoperative depression may manifest itself in unusual behavior that is dismissed as "expected," it may go unrecognized. We present three case reports in which the child demonstrated signs of depression following tonsillectomy. We believe that depression following tonsillectomy occurs more frequently than has been recognized. We describe the diagnosis and management of posttonsillectomy depression to increase the otolaryngologist's awareness of this entity.

Child↗
PubMed1995

Use of intraoperative corticosteroids in pediatric tonsillectomy.

OBJECTIVE: To determine the effects of a single dose of dexamethasone sodium phosphate on postoperative morbidity in children undergoing tonsillectomy. DESIGN: Randomized, double-blind, placebo-control clinical trial. SETTING: Academic, tertiary care children's hospital. PATIENTS: Sixty-nine children (35 boys, 34 girls), aged 3 to 18 years, undergoing tonsillectomy with or without adenoidectomy. INTERVENTION: Patients were randomized to receive a single dose of intravenous dexamethasone or saline. MAIN OUTCOME MEASURES: Pain scores, determined by a Faces Scale, were obtained at 4-hour intervals during the first postoperative day and daily for 7 days thereafter. Total use of an analgesic; type of diet; level of activity; presence of halitosis, nausea, emesis, or fever; and incidence of postoperative bleeding were also compared between the two groups. RESULTS: The two groups of children were similar in age, gender, diagnosis, and surgical time. Pain scores in the postoperative period were identical while the patients were in the hospital and for the first 7 days after discharge. No statistically significant differences were noted in pain scores, nausea, emesis, halitosis, analgesic medications required, diet, or activity levels between the two groups of patients. CONCLUSION: A single intraoperative dose of dexamethasone did not appreciably affect postoperative morbidity in children undergoing tonsillectomy.

Adolescent↗
PubMed1997

Sickle cell disease and tonsillectomy. Preoperative management and postoperative complications.

BACKGROUND: Patients with sickle cell disease are recognized as having a relatively higher risk for postoperative complications, including fever, atelectasis, pneumonia, or sickle cell vas-occlusion. OBJECTIVE: To present a protocol for preoperative management of patients with sickle cell disease undergoing tonsillectomy, including the use of transfusions and intravenous hydration. DESIGN: Retrospective chart review. SETTING: Academic, tertiary care referral medical center. PATIENTS: Seventy-five patients with sickle cell disease who underwent tonsillectomy with or without adenoidectomy were included for review. Preoperative management was documented, and risk factors were assessed. Intraoperative management was reviewed, and postoperative complications were identified and compared with preoperative data and management. RESULTS: Preoperative management consisted of transfusions to a hemoglobin S ratio (hemoglobin S-total hemoglobin) less than 40% or a hemoglobin level greater than 100 g/L. Aggressive intravenous hydration of 1.5 times the maintenance fluid was given 24 hours before surgery. Increased complications were associated with a preoperative hemoglobin S ratio greater than 40% (P < .05) and an age younger than 4 years (P < .05). Operative time, technique, and blood loss were not statistically significant risk factors. The average length of hospitalization was 4.8 days. CONCLUSIONS: Children with sickle cell disease presenting for elective tonsillectomy should be given a transfusion to a hemoglobin S ratio less than 40% in an attempt to reduce postoperative complications. Additional factors, such as age and presence of obstructive sleep apnea, only increase the potential risks.

Adenoidectomy↗
PubMed2002

Harmonic scalpel for tonsillectomy.

OBJECTIVE: To describe the Harmonic scalpel and review recent studies comparing its use in tonsillectomy with standard dissection and electrocautery. STUDY DESIGN: Review. METHODS: The Harmonic scalpel uses ultrasonic technology to cut and coagulate tissues at lower temperatures than those associated with electrocautery and lasers. Studies of the use of this device have assessed its performance with respect to intraoperative blood loss, postoperative hemorrhage, and postoperative pain. RESULTS: Intraoperative blood loss and episodes of postoperative hemorrhages have been found to be minimal in patients in whom the Harmonic scalpel was used for tonsillectomy. The device also appears to be associated with a reduction in postoperative pain. CONCLUSION: Use of the Harmonic scalpel for tonsillectomy may have several advantages over standard methods.

Child↗
PubMed1996

Longitudinal analysis of human salivary immunoglobulins, nonimmune antimicrobial agents, and microflora after tonsillectomy.

In order to study the role of tonsils in the host defense in the oral region one pre- and two postoperative (1 and 6 months) whole saliva samples were collected from 25 young adults referred for tonsillectomy. Saliva samples were analyzed for selected host defense factors, representing both immune (total IgA, IgG, IgM, anti-Streptococcus mutans, anti-EBV, anti-CMV, and anti-adenovirus IgA and IgG) and nonimmunoglobulin (lysozyme, lactoferrin, salivary peroxidases, thiocyanate, hypothiocyanite, and agglutinins) mediators. Following tonsillectomy, a significant (P < 0.04) reduction was observed in specific IgG antibodies, suggesting that tonsils participate in local IgG response to oral antigens. Total IgM levels also decreased (P< 0.006), which may to some extent reflect reduced antigenic stimuli compared to preoperative status with frequent tonsillitis. Saliva-derived nonimmunoglobulin host defense factors, except lactoferrin, which declined significantly, remained normal throughout the study period. Our study indicates that tonsils play a role in local oral IgG-mediated immune response but tonsillectomy does not seem to lead to any significant long-term impairment of salivary defense capacity.

Adolescent↗
PubMed1994

Velopharyngeal insufficiency following palatine tonsillectomy.

Although adenotonsillectomy is usually considered a minor operation, numerous uncommon but severe complications have been described. Even tonsillectomy alone can cause velopharyngeal insufficiency (VPI). We describe two cases in which severe VPI was noted after palatine tonsillectomy was performed because of recurrent peritonsillar abscesses. The patients underwent clinical examination, nasalance measurements, videonasopharyngoscopy and videofluoroscopy. Findings in both patients were consistent with lesions of branches of the vagus and glossopharyngeal nerves through lingual rami, while one of the patients probably also had a lesion of the hypoglossal nerve. Endoscopic and videofluoroscopic examinations demonstrated essential differences in the patients' preoperative state of velopharyngeal anatomy. Findings demonstrate the value of careful postoperative endoscopic and videofluoroscopic examination in cases with VPI after tonsillectomy to identify factors affecting subsequent VPI and to design possible treatment.

Cineradiography↗
PubMed1994

Tonsillectomy and the immune system: a long-term follow up comparison between tonsillectomized and non-tonsillectomized children.

Immunological functions of the tonsils and possible effects of their removal are still controversial. One reason for this is the lack of long-term follow-up investigations after tonsillectomy. In the present study selected parameters of the cellular and humoral immune systems of 160 children 0.5-11 years after tonsillectomy (mean 6.6 +/- 2.1 years) were compared to those of 302 age-matched non-tonsillectomized children. In tonsillectomized children the incidence of infections of the upper respiratory tract was not increased compared to the non-tonsillectomized control group. Slightly increased percentages of CD 21 + cells, raised counts of CD4+ cells, absolute and relative increases in DR+ cells and a raised CD4+ DR count was found mainly in tonsillectomized boys, while lymphocyte subpopulations of tonsillectomized girls remained unaffected. Tonsillectomized children had lower IgA levels, but the complement system was not altered in either sex. These findings show that while tonsillectomy may lead to certain changes in the cellular and humoral immune systems, these alterations are clinically insignificant and no increased frequency of immunomodulated diseases should be expected.

Adolescent↗
PubMed1994

Rheumatoid arthritis is not associated with prior tonsillectomy or appendectomy.

To re-evaluate a reported association of rheumatoid arthritis (RA) with antecendent tonsillectomy or appendectomy, questionnaires were sent by post to 3673 patients who had been diagnosed as having either RA or osteoarthrosis (OA). Of those who responded 1524 were RA and 1194 OA patients. No significant differences were found between these groups with regard to the frequency of prior lymphoid surgery. This was also the case when the RA group was replaced by its rheumatoid factor (Rf) positive or Rf negative subgroup. A separate analysis of a subgroup consisting of 671 Rf positive RA patients for whom OA control subjects matched for sex and year of birth were available again showed no statistical differences in frequencies of tonsillectomy and appendectomy. Neither did partitioning the group according to the age at which lymphoid surgery was performed bring any association with an increased occurrence of RA to light. We therefore reject the hypothesis that RA is associated with antecedent tonsillectomy or appendectomy.

Adolescent↗
PubMed1995

Midazolam reduces vomiting after tonsillectomy in children.

The purpose of this study was to assess the effect of midazolam on vomiting after tonsillectomy in children. We compared 215 children aged 1.5-14 yr undergoing tonsillectomy or adenotonsillectomy under general anaesthesia with nitrous oxide and halothane. In a double-blind fashion the subjects were administered either placebo or midazolam 75 micrograms.kg-1 iv after induction of anaesthesia. After the operation, the number of emetic episodes and the length of stay in hospital were recorded. The groups were similar with respect to age, weight, sex, mode of induction, duration of anaesthesia, surgical procedure, opioid administration and length of stay in the PAR and the Day Care Surgical Unit. The 108 midazolam-treated children had a lower incidence (42% vs 57%) of vomiting than the placebo group, P < 0.02. The placebo group had a higher incidence (9% vs 2%) of unscheduled admissions to hospital due to nausea and vomiting, P < 0.05. It is concluded that midazolam administered intravenously to children intraoperatively reduces vomiting after tonsillectomy.

Adenoidectomy↗
PubMed1995

Ondansetron is a better prophylactic antiemetic than droperidol for tonsillectomy in children.

Both intravenous ondansetron (OND) and droperidol (DROP) have been observed to reduce vomiting after tonsillectomy in children. This randomized, double-blind investigation compared the effect of OND and DROP on vomiting after outpatient tonsillectomy in 276 healthy children age 2-12 yr. All subjects received a standardized anaesthetic, which consisted of induction with either propofol or halothane/N2O, vecuronium 0.1 mg x kg(-1) on an as needed basis, maintenance with halothane/N2O, midazolam and codeine, and reversal of neuromuscular blockade with neostigmine and atropine on an as needed basis. Subjects were given either OND 150 micrograms x kg(-1) or DROP 50 micrograms x kg(-1)iv after induction of anaesthesia. Rescue antiemetics in the hospital were administered to patients who vomited X 2 and X 4, respectively. Postoperative pain was treated with morphine, codeine and/or acetaminophen. For 24 hr following surgery, emesis was recorded by nursing staff while subjects were in the hospital, and by parents following discharge from hospital. The two groups were similar with respect to demographic data, induction technique and anaesthesia time. The frequency of in-hospital emesis was 16% in the OND-patients and 30% in the DROP-group, P <0.05. The OND-subjects required fewer rescue antiemetics, 5% vs 13%, P <0.05. The overall incidence of emesis was 45% in the OND-group and 57% in the DROP-group, P <0.05. In conclusion, ondansetron was a superior prophylactic antiemetic for tonsillectomy in children when compared to droperidol.

Antiemetics↗
PubMed1996

Preoperative ketorolac increases bleeding after tonsillectomy in children.

PURPOSE: To compare the incidence of vomiting following codeine or ketorolac for tonsillectomy in children. METHODS: We had planned to enrol 240 patients, aged 2-12 yr undergoing elective tonsillectomy into a randomized, single-blind study in University Children's Hospital. The study was terminated, after 64 patients because interim analysis of the data by a blinded non-study scientist concluded that the patients were at undue risk of excessive perioperative bleeding. After induction of anaesthesia by inhalation with N2O/halothane or with propofol 2.5-3.5 mg.kg-1 i.v., the children were administered 150 micrograms.kg-1 ondansetron and 50 micrograms.kg-1 midazolam. Maintenance of anaesthesia was with N2O and halothane in O2. Subjects were administered either 1.5 mg.kg-1 codeine im or 1 mg.kg-1 ketorolac i.v. before the commencement of surgery. Intraoperative blood loss was measured with a Baxter Medi-Vac Universal Critical Measurement Unit. Postoperative management of vomiting and pain was standardized. Vomiting was recorded for 24 hr after anaesthesia. Data were compared with ANOVA, Chi-Square analysis and Fisher Exact Test. RESULTS: Thirty-five subjects received ketorolac. Demographic data were similar. The incidence of vomiting during the postoperative period was 31% in the codeine-group and 40% in the ketorolac-group. Intraoperative blood losses was 1.3 +/- 0.8 ml.kg-1 after codeine and 2.2 +/- 1.9 ml.kg-1 after ketorolac (mean +/- SD) P < 0.05. Five ketorolac-treated patients had bleeding which led to unscheduled admission to hospital, P < 0.05, Exact Test. CONCLUSION: Preoperative ketorolac increases perioperative bleeding among children undergoing tonsillectomy without beneficial effects.

Analgesics, Non-Narcotic↗
PubMed1997

Perphenazine decreases vomiting by children after tonsillectomy.

PURPOSE: To test the hypothesis that perphenazine decreases the incidence of vomiting by children after tonsillectomy. METHODS: Healthy children (n = 260) aged 2-12 yr undergoing elective tonsillectomy on a day care surgical basis were studied in this randomised. stratified, blocked, double-blind investigation. General Anaesthesia was induced intravenously with propofol or by inhalation with halothane and N2O. Perphenazine 70 micrograms.kg-1 up to 5 mg or placebo i.v. was administered before surgery. Management of perioperative fluids, emesis and pain were all standardised. RESULTS: The groups were similar with respect to demographic data. There was less vomiting after perphenazine during the first 24 hr after surgery 42% (95% CI = 34%-50%) vs 57% (95% CI = 48%-66%, placebo), P < 0.01. On the day of surgery, both in and out-of hospital emesis were decreased by perphenazine. The perphenazine treated patients required fewer rescue antiemetics than the control group, P < 0.05. Each episode of in-hospital vomiting delayed discharge by 20 +/- 7 min (mean +/- SD), P = 0.007. CONCLUSION: The prophylactic administration of perphenazine decreases vomiting by children after tonsillectomy.

Antiemetics↗
PubMed2003

Dexamethasone reduces postoperative vomiting and pain after pediatric tonsillectomy.

PURPOSE: Previous studies on dexamethasone's antiemetic and analgesic potential in children undergoing tonsillectomy have produced conflicting results. The aim of this study was to evaluate the effects of a single dose of dexamethasone on the incidence and severity of postoperative vomiting and pain in children undergoing electrocautery tonsillectomy under standardized general anesthesia. METHODS: In a double-blinded study, 120 patients were randomly allocated to receive either dexamethasone 0.5 mg.kg(-1) (maximum dose 8 mg) iv or an equivalent volume of saline preoperatively. The incidence of early and late vomiting, need for rescue antiemetics, time to first oral intake, time to first demand of analgesia and analgesic consumption were compared in both groups. Pain scores used included Children's Hospital Eastern Ontario Pain Scale, "faces", and a 0-10 visual analogue pain scale. RESULTS: Compared with placebo, dexamethasone significantly decreased the incidence of early and late vomiting (P < 0.05, P < 0.001 respectively). Fewer patients in the dexamethasone group needed antiemetic rescue (P < 0.01). The time to first oral intake was shorter, and the time to first dose of analgesic was longer in the dexamethasone group (P < 0.01). Pain scores 30 min after extubation were lower (P < 0.05) in the dexamethasone group. At 12 and 24 hr postoperative swallowing was still significantly less painful in the dexamethasone group than in the control group (P < 0.01). CONCLUSION: Preoperative dexamethasone 0.5 mg.kg(-1) iv reduced both postoperative vomiting and pain in children after electrocautery tonsillectomy.

Anesthesia, General↗
PubMed1999

[Pre-emptive analgesia with ropivacaine in adult tonsillectomy].

AIM OF INVESTIGATION: We examined whether a pre-emptive analgesic effect could be achieved with ropivacaine, which has less cardiovascular and central nervous system toxicity than bupivacaine, in adults undergoing tonsillectomy. METHODS: The study was carried out in 80 patients in a randomised, double-blind fashion. The patients were randomly assigned to one of four groups. In group I, 3 ml ropivacaine 7.5 mg/ml were injected pre-operatively 5 minutes before the start of OR into each tonsil bed. In group II, 3 ml ropivacaine 7.5 mg/ml were injected post-operatively into each tonsil bed. In group III, 3 ml NaCl were injected pre-operatively 5 minutes before the start of OR into each tonsil bed. In group IV, 3 ml NaCl were injected post-operatively into each tonsil bed. The analgesic effectiveness was measured post-operatively by the use of a visual analogue scale, a numeric rating scale (at rest and during activity) and by measuring the total analgesic consumption (mefenamic acid) in the first 192 hours. In addition the time of first analgesic request was noted. Vital parameters and side-effects were documented. RESULTS: There was no significant difference between the groups in the time of first analgesic request. Likewise, there was no significant difference in the post-operative cumulative analgesic consumption between the four groups. The post-operative administration of ropivacaine resulted in significantly lower pain scores at certain time points compared with the other groups as measured both with the visual analogue scale and the numeric rating scale (at rest). It must be emphasized, that the pain scores both at rest and with exertion remain high and that the net analgesic consumption (per day) remains constant for the first 8 post-operative days. CONCLUSIONS: We could demonstrate no significant pre-emptive analgesic effect with ropivacaine in adults undergoing tonsillectomy in our study. One can, however, recommend the administration of ropivacaine post-operatively after tonsillectomy, since a reduction of pain scores can thereby be achieved. For post-operative analgesia we recommend the combination of a non-opioid analgesic with a weak opioid.

Adult↗
PubMed2000

[Tropisetron for prevention of nausea and vomiting in children undergoing tonsillectomy and/or adenoidectomy].

BACKGROUND: Postoperative nausea and vomiting (PONV) after tonsillectomy is a common problem in children. Tropisetron is a new 5HT3 receptor antagonist and is successfully used in paediatric patients receiving cancer therapy. The aim of the study was to assess efficacy and safety of a single intravenous dose of tropisetron for prevention of PONV in paediatric patients at risk for postoperative vomiting. METHODS: In a randomised, double-blind, placebo-controlled trial, we studied 98 children aged 2-12 years undergoing tonsillectomy or adenotonsillectomy. Patients received placebo or tropisetron 0.1 mg (= 0.1 ml)/kg body weight immediately after induction of anesthesia. A standard general anesthetic technique (Sevoflurane/N2O/O2 without neuromuscular blockers or opioids) was used. Perioperative vital signs, grade of sedation and episodes of postoperative nausea and vomiting were recorded. RESULTS: No vomiting episodes occurred in 65.3% of the tropisetron treated patients compared to 34.7% of the placebo group (p = 0.0024). Only 10.2% of the tropisetron treated patients vomited more than 3 times compared to 22.4% of the control patients (p = 0.0004). The need for antiemetic rescue medication was significantly lower in the study group (10.4%) compared to 28.6% (p = 0.025). No significant adverse effects of the study medication were shown. CONCLUSION: A single intravenous prophylactic dose of tropisetron effectively reduces the incidence of PONV during the first 24 postoperative hours after tonsillectomy and/or adenoidectomy. Because of the low incidence of adverse effects, the prophylactic use of tropisetron seems to be safe and justified in paediatric surgical patients at high risk for postoperative vomiting.

Adenoidectomy↗
PubMed2005

[Postoperative pain therapy after tonsillectomy in children. An observational study for 7 days].

OBJECTIVE: We investigated the efficacy and side-effects of a concept for pain therapy after tonsillectomy in children. PATIENTS AND METHODS: A total of 100 children aged between 6 and 14 years were treated according to the following protocol for pain therapy after tonsillectomy: after induction of anaesthesia the children received 35-40 mg/kg acetaminophen rectally and 0.1 mg/kg piritramide i.v.. Additionally, boluses of 0.05 mg/kg pitritramide i.v. were allowed in the recovery room and 2 doses of 20 mg/kg acetaminophen were given rectally every 6 h on the day of surgery. On the following day the children received 30 mg/kg acetaminophen 3 times per day and from the second postoperative day onwards 1 mg/kg diclofenac was given 3 times a day. The rescue therapy was 5 mg/kg metamizol orally. The severity of the postoperative pain was evaluated by a visual pain scale (VAS) (0-100), side-effects such as vomiting and postoperative haemorrhage were documented. The Friedman test was used for testing the time course of pain intensity. RESULTS: The median of the VAS was 42 on the day of surgery, 35 on the first postoperative day and fell continuously to 10 by the 6th postoperative day. The decrease of pain severity was statistically significant (p <0.05). A rescue therapy was necessary in 6 patients on the day of surgery and in 9 patients on the first postoperative day. 7 patients suffered a postoperative haemorrhage, 4 out of the 7 needed a surgical revision and 2 out of 100 patients vomited. CONCLUSION: We conclude that this protocol for pain therapy after tonsillectomy was effective. The incidence of postoperative haemorrhage and vomiting was low.

Acetaminophen↗