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PubMed1983

Current thinking on tonsillectomy and adenoidectomy.

Tonsillectomy and adenoidectomy, though less frequently performed now than in the 1930s, remain among the most common surgical procedures in the United States. The need for and benefits of tonsillectomy and adenoidectomy have been a source of controversy for several decades. Nonetheless, there are situations in which these procedures definitely are beneficial. Tonsillectomy and adenoidectomy are two distinct procedures with separate indications, and they are performed concurrently only when the specific indications for each coexist. Tonsillectomy is indicated by recurrent tonsillitis, peritonsillar abscess, chronic tonsillitis, tonsillar neoplasm, or tonsillar hypertrophy that is obstructive to the upper aerodigestive tract (respiratory distress, dysphagia, or interference with performance of an adenoidectomy). Adenoidectomy is indicated for nasal airway obstruction due to adenoidal enlargement from hypertrophic or inflammatory processes. Although correlation exists among obstructive adenoids, mouth breathing, and dentofacial anomalies, present evidence is not sufficient to justify adenoidectomy solely on the basis of craniofacial or dentofacial abnormalities. Today, elimination of an occult source of infection (once called focal infection) in patients with disorders such as rheumatic fever or serous otitis media is not a valid indication for either operation. Contraindications to tonsillectomy and adenoidectomy include bleeding disorders, familial anesthetic intolerance, velopharyngeal insufficiency, and concurrent disease that may enhance operative risks. Like all surgical procedures, tonsillectomy and adenoidectomy entail morbidity and risk of mortality. The most frequent complication of these operations is hemorrhage. Risk of mortality is approximately 0.006%. Mortality and morbidity can be minimized by appropriate preoperative evaluation, complete control of the airway with endotracheal anesthesia, and meticulous surgical technique.

Adenoidectomy↗
PubMed2004

Management of descending necrotizing mediastinitis.

OBJECTIVE/HYPOTHESIS: Descending necrotizing mediastinitis is caused by downward spread of neck infections and constitutes a highly lethal complication of oropharyngeal lesions. This infection previously had a much worse prognosis. In recent years, more aggressive management has been recommended. The aim of this study is to evaluate the results with the association of thoracotomy and cervicotomy, medical care in an intensive care unit, and daily washing of drained cervical and thoracic tissues. STUDY DESIGN: Retrospective study of 17 patients treated from 1984 to 1998. METHOD: Descending necrotizing mediastinitis was consecutive to pharyngitis (6 cases), peritonsillar abscess (3 cases), dental abscess (6 cases), foreign body infection (1 case), and laryngitis (1 case). Corticotherapy was reported in seven cases. Twelve patients had no particular medical history. Mean age was 42 years. Mean duration of signs before diagnosis was 6 days. Thoracotomy was associated with the cervical approach in 14 cases, whereas 3 patients were treated by cervicotomy only. RESULTS: Fourteen patients of 17 (82.3%) were successfully treated. Three deaths occurred. The mean duration of hospitalization in the intensive care unit was 30 days, and the mean total duration of hospitalization was 45 days. CONCLUSION: Descending necrotizing mediastinitis must be detected as soon as possible by computed tomography (CT) scanning in patients with persistent symptomatologia after treatment for oropharyngeal infections. Prompt surgical drainage with thoracotomy and cervicotomy in all cases of mediastinal involvement below the tracheal carena, use of CT scanning to monitor the disease evolution, and medical management in an intensive care unit significantly reduces the mortality rate to less than 20%.

Adult↗
PubMed2004

Biologically active neutrophil chemokine pattern in tonsillitis.

To gain an insight into the mechanisms of chronic and acute inflammation, the production of neutrophil chemokines in different types of tonsillitis - hyperplastic tonsillitis (HT), recurrent tonsillitis (RT) and peritonsillar abscesses (PA) - was investigated. The chemokines interleukin-8 (IL-8), growth-related oncogene-alpha (GRO-alpha), epithelial cell-derived neutrophil attractant-78 (ENA-78) and granulocyte chemotactic protein-2 (GCP-2) were detected and shown to have different biological activities. With respect to the biological properties of CXC chemokines, the biological activity of the chemokines was identified using a three-step high-performance liquid chromatography (HPLC) technique, a bioassay involving measurement of neutrophil chemotaxis in a single Boyden chamber in tissue of HT, RT and PA. Using reverse transcription-polymerase chain reaction (RT-PCR), the chemokine concentrations were determined in the different tonsillitis entities. The chemokine pattern was dominated in PA by IL-8 and GRO-alpha and in RT by GRO-alpha. Hyperplastic tonsils of patients without a history of infection generated about five times lower IL-8 than PA. A protein concentration of GCP-2 was induced in PA and RT, whereas ENA-78 remained the same in all entities. In conclusion, it would appear that IL-8 was up-regulated in acute inflammation, whereas GRO-alpha dominated in chronic inflammation. ENA-78 seems not to play a pivotal role in inflammatory processes in tonsils. GCP-2 may serve as a substitute chemokine in certain inflammatory conditions as its quantity of mRNA and protein was higher in RT and PA than in HT.

Acute Disease↗
PubMed2003

Increased diagnosis of Lemierre syndrome and other Fusobacterium necrophorum infections at a Children's Hospital.

OBJECTIVE: To assess the apparent increase in the diagnosis of Lemierre syndrome (LS) and other Fusobacterium necrophorum infections at a large children's hospital. Infections with F necrophorum ranged from peritonsillar abscess to potentially fatal LS. LS is an oropharyngeal infection characterized by septic thrombophlebitis of head and neck veins, complicated by dissemination of septic emboli to pulmonary and systemic sites. METHODS: Review of the medical and laboratory records was conducted of all patients who were seen at or admitted to the Children's Hospital of Wisconsin with the diagnosis of LS and/or isolation of F necrophorum from a clinical specimen between January 1995 and January 2002. RESULTS: During the 7-year period of the study, there was an increase in the isolation of F necrophorum from patients who were seen at Children's Hospital of Wisconsin, as well as the number of cases of LS. There was 1 isolation of F necrophorum from clinical specimens per year from 1996 to 1999, which increased to 10 isolates of the organism from January 2000 to January 2002. During the most recent period, January 2001-January 2002, 5 cases of LS were diagnosed, a distinctive entity not recognized previously at the institution. CONCLUSIONS: The cause for the recent increase in the number of serious infections caused by F necrophorum infection diagnosed at our institution is unclear but does not seem to be related to changes in microbiologic techniques or patient demography. We speculate that it could be attributable, in part, to alterations in antibiotic usage patterns in our region. Clinicians need to be aware of the increasing clinical importance of F necrophorum infections and the life-threatening nature of LS.

Adolescent↗
PubMed2003

[Peritonsillar phlegmons and abscesses. Retrospective study of 100 cases].

Our main goal was performing a retrospective study about peritonsillar cellulitis and abscess to prove the efficiency of treatment. So that we have collected 100 clinical histories of admitted patients in our ENT Service between 1990 and 2001 with such pathology and analysed a serie of variables and the treatment given in each case. It is one of the most common infectious diseases of the head and neck region. If aspiration positive, it require an incision and drainage to improve the symptoms (throat pain, fever, dysphagia and trismus). We have made no immediate tonsillectomies. All the patients were hospitalized and average stay was 3 days. 21 patients were re-admitted because of a recurrence pathology before the later programmed surgery.

Adolescent↗
PubMed1975

Peritonsillolith.

Peritonsillolith appears to be an unknown entity. Two cases of lithiasis in the peritonsillar region following spontaneous rupture of peritonsillar abscesses have been reported. The authors have speculated concerning the cause of stone formation in the peritonsillar region, which has been designated "peritonsillolith," on the basis of lithiasis in other regions of the body, such as gallbladder, kidneys, and salivary glands. Peritonsilloliths most likely form as a result of incomplete evacuation of pus, the dead bacteria and the pus cells providing the nidus for their formation. The salts of these stones are undoubtedly derived from the inflammatory exudates and saliva.

Adenoma, Pleomorphic↗
PubMed2005

Cervical necrotizing fasciitis due to bacterial tonsillitis.

Necrotizing fasciitis is a severe and potentially fatal soft tissue infection, but involvement of the head and neck is rare. We report on 4 cases of cervical necrotizing fasciitis arising from tonsillitis. One patient was diabetic and one had received steroids before disease development. One patient developed acute respiratory failure and died of septic shock. Three patients recovered, helped by early recognition, aggressive surgical intervention, appropriate broad-spectrum antibiotics, and supportive therapy. The common bacteria found in all abscess samples were Streptococcus sp., but mixed flora with anaerobic organisms was seen in all but 1 case. Tonsillitis and peritonsillar abscess must be suspected as a cause of cervical necrotizing fasciitis and a successful result can be achieved with immediate aggressive treatment.

Adult↗
PubMed2001

Deep neck abscess: a retrospective review of 210 cases.

This study was performed to review our experience with deep neck abscesses (DNAs) and compare it to the experiences in the available literature, and to study changing trends within our patient population. We retrospectively studied 210 patients who had DNAs between 1981 and 1998. Peritonsillar abscesses and limited intraoral abscesses were excluded. Demographics, presentation, etiology, site of abscess, associated systemic diseases, bacteriology, radiology, treatment, airway management, and outcome were reviewed. We compared the entire group to those in the available literature and studied changing trends within this patient population. Dental infection (43%) was the most common cause, followed by intravenous drug abuse (12%) and pharyngotonsillitis (6%). The incidences of intravenous drug abuse and mandibular fractures as causes of DNA were 19% and 8%, respectively, during the period 1981 to 1990, but were only 1% each during the period 1991 to 1998. Streptococcus viridans was the most common pathogen (39% of positive cultures), followed by Staphylococcus epidermidis (22%) and Staphylococcus aureus (22%). Lateral pharyngeal space abscess was the most common DNA (43%), followed by submandibular space abscess, Ludwig's angina, and retropharyngeal space abscess (28%, 17%, and 12%, respectively). Seventy-five percent of patients with true Ludwig's angina underwent tracheotomy. Nondental infections are no longer a significant etiologic factor in DNA. Streptococcus viridans has replaced S aureus and beta-hemolytic streptococci as the most common pathogen. Lateral pharyngeal space abscess was the most common DNA; however, its incidence has progressively decreased over the past decade. Intravenous drug abuse and mandibular fractures are no longer major etiologic factors. Tracheotomy is indicated in patients with Ludwig's angina.

Abscess↗
PubMed2006

[Post-tonsillectomy hemorrhage: incidence and risk factors].

INTRODUCTION: The aim of this study was to quantify the incidence and evaluate the risk factors of post-tonsillectomy hemorrhage (PTH). MATERIALS AND METHODS: A retrospective study was performed of all patients with PTH at the three hospital departments in Aarhus County, Denmark (650,000 inhabitants), and a random sample of one-third of all tonsillectomised patients at Aarhus University Hospital (AS) in the period 1 December 2002 to 30 November 2003, during which period 918 patients were tonsillectomised. RESULTS: Post-operative haemorrhage occured in a total of 48 patients (5.2%). Twenty-six patients (2.8%) needed re-operation: 12 (3.4%) at AS, 7 (3.7%) at Randers Centralsygehus (RCS) and 7 (1.8%) at Silkeborg Centralsygehus (SCS). The following factors correlated significantly with PTH: high age (p = 0.0093), greater perioperative blood loss (p = 0.026) and high perioperative blood pressure (p = 0.0007). In addition, we found a three times higher but insignificant (p = 0.26) risk during abscess tonsillectomy as compared to cold tonsillectomy. CONCLUSION: The three ENT departments of Aarhus County fulfil international standards, but the operation has a high complication rate, which emphasizes the importance of solid indications for operation. In light of the increased risk of PTH with higher age, the instructions at AS have been altered so that all patients over 20 years of age with peritonsillar abscess who can cooperate are treated with aspiration and incision.

Adenoidectomy↗
PubMed1989

[Acute tonsillectomy in infectious mononucleosis].

Enlargement of the pharyngeal tonsils in infectious mononucleosis (MI) is frequently an important component of the clinical picture but pronounced obstruction of the upper respiratory passages is rare. An analysis of 11 cases of infectious mononucleosis with varying degrees of pharyngeal obstruction is presented. During the acute phase of the disease, tonsillectomy was performed and also adenoidectomy in four of the cases. The patients improved rapidly after the operation and were discharged after an average of four days. No noteworthy complications of the operation occurred. An unexpectedly great number of cases of abscess formation were found at operation. Histological examination of the tonsils revealed changes in the lymphoid tissue which were characteristic but not specific for infectious mononucleosis together with extensive necrosis of the tonsillar surface. On the basis of this investigation, the authors consider that acute tonsillectomy is indicated in infectious mononucleosis with threatening occlusion of the upper airway and in cases of suspected peritonsillar abscess. In cases of slight or moderate respiratory obstruction, acute tonsillectomy may be considered in the therapeutic deliberations if the course of the condition is protracted and steroid treatment does not have the desired effect.

Adenoidectomy↗
PubMed2005

Ligasure versus cold knife tonsillectomy.

OBJECTIVE: To assess parameters related to ligasure tonsillectomy (LT) versus cold knife tonsillectomy (CKT) procedure. STUDY DESIGN: Prospective randomized study. METHODS: A prospective study was conducted on 200 consecutive adult patients undergoing tonsillectomy. Indications included chronic tonsillitis and obstructive sleep apnea syndrome. Patients undergoing adenoidectomy, or any procedure together with tonsillectomy, and patients with peritonsillar abscess history or bleeding disorders were excluded. Patients were randomly assigned to either the LT or CKT group. Intraoperative bleeding, operative time, postoperative pain using a visual analogue scale, and complication rates were evaluated. RESULTS: The LT and CDT groups consisted of 108 and 92 individuals, respectively. In the LT group, there was no measurable intraoperative bleeding, whereas mean bleeding for CKT group was 125 mL. The mean operative time was 15 +/- 1.43 minutes for the LT group and 21 +/- 1.09 minutes for the CKT group (P < .001). The overall mean pain score for the LT group was 3.63, whereas for the CKT group it was 5.09 (P < .001). Primary hemorrhage occurred in one subject of the CKT group. Secondary postoperative hemorrhage was noticed two subjects of the LT group and two subjects of the CKT group. In 21 subjects of the LT group, limited peritonsillar edema was noticed. No other complication occurred in both groups. CONCLUSION: LT procedure provides sufficient hemostasis, lower postoperative pain, and reduced operative time, as well as safety against Creutzfeld Jakob disease transmission.

Adolescent↗
PubMed2004

Fusobacterium necrophorum as the cause of recurrent sore throat: comparison of isolates from persistent sore throat syndrome and Lemierre's disease.

OBJECTIVE: Fusobacterium necrophorum is a well established cause of Lemierre's disease (LD); a syndrome characterised by severe sore throat, septicaemia, multiple abscesses and jugular vein thrombosis. There is no published data concerning the role of F. necrophorum in recurrent sore throats. As the result of an index case of persistent sore throat attributable to this organism being diagnosed in our laboratory, a subsequent case controlled study (not yet published) isolated F. necrophorum from 21% (P=0.0001) of cases of persistent, recurrent and chronic sore throats. The object of this study was to compare isolates of F. necrophorum from cases of systemic disease with isolates from cases of persistent sore throat syndrome (PSTS) to ascertain whether strains of similar type were responsible for both throat and systemic disease or whether different strains were involved in these presentations. METHODS: Throat swabs were cultured on GN anaerobe medium (Oxoid) and incubated at 37 degrees C for 5 days. Seventeen PSTS isolates were identified phenotypically. These were compared to 17 strains isolated from blood cultures which were referred to the Anaerobe Reference Unit, (ARU) cardiff, using enterogenic repetitive intergenic consensus-polymerase chain reaction (ERIC-PCR). The control strains Fusobacterium necrophorum ssp. necrophorum (JCM 3718(T)) and Fusobacterium necrophorum ssp. funduliforme (JCM 3724(T)) from the Japanese Collection of Microrganisms (JCM) were tested in parallel with the clinical isolates. RESULTS: At least 12 separate types were identified. Four of 17 PSTS isolates and seven of 17 blood culture isolates grouped together with the F. necrophorum ssp. funduliforme control strain. There were also similarities between other proposed strains and clinical types but no comparison with the F. necrophorum ssp. necrophorum control. CONCLUSION: These results show that clinical disease caused by F. necrophorum has a wider spectrum than first anticipated. Similar strains are able to cause either chronic local or acute systemic disease suggesting that genetic factors such as those relating to major histocompatibility complex (MHC) class may be influencing the outcome of the disease in each patient. Further work is required to produce a more accurate typing scheme and to ascertain the mechanisms of disease caused by this organism. An age correlation between the high risk groups for onset of infectious mononucleosis (IM), peritonsillar abscess (PTA), LD and PSTS has been noted in adolescents and young adults. Further work is required to investigate whether IM is associated with the onset of PTA caused by F. necrophorum which may lead to either PSTS or LD.

Adolescent↗
PubMed2006

Antibiotics for sore throat.

BACKGROUND: Sore throat is a very common reason for people to present for medical care. Although it remits spontaneously, primary care doctors commonly prescribe antibiotics for it. OBJECTIVES: To assess the benefits of antibiotics for sore throat. SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) and the Database of Abstracts of Reviews of Effects (DARE) (The Cochrane Library, Issue 1, 2006), MEDLINE (January 1966 to March 2006) and EMBASE (January 1990 to December 2005). SELECTION CRITERIA: Trials of antibiotic against control with either measures of the typical symptoms (throat soreness, headache or fever), or suppurative or non-suppurative complications of sore throat. DATA COLLECTION AND ANALYSIS: Potential studies were screened independently by two authors for inclusion, with differences in opinion resolved by discussion. Data were then independently extracted from studies selected by inclusion by two authors. Researchers from three studies were contacted for additional information. MAIN RESULTS: There were 27 studies with 2835 cases of sore throat. 1. Non-suppurative complications: There was a trend for antibiotics to protect against acute glomerulonephritis, but there were insufficient cases to be sure. Several studies found antibiotics reduced acute rheumatic fever by more than two thirds (relative risk (RR) 0.22; 95% CI 0.02 to 2.08). 2. Suppurative complications: Antibiotics reduced the incidence of acute otitis media (RR 0.30; 95% CI 0.15 to 0.58); of acute sinusitis (RR 0.48; 95% CI 0.08 to 2.76); and of quinsy (peritonsillar abscess) compared to those taking placebo (RR 0.15; 95% CI 0.05 to 0.47). 3. SYMPTOMS: Throat soreness and fever were reduced by antibiotics by about one half. The greatest difference was seen at about 3 to 4 days (when the symptoms of about 50% of untreated patients had settled). By one week about 90% of treated and untreated patients were symptom-free. The overall number need to treat to prevent one sore throat at day 3 was just under six (95% CI 4.9 to 7.0); at week 1 it was 21 (95% CI 13.2 to 47.9). 4. Subgroup analyses of symptom reduction: Analysis by: age; blind versus unblinded; or use of antipyretics, found no significant differences. Analysis of results of throat swabs showed that antibiotics were more effective against symptoms at day 3, RR 0.58 (95% CI 0.48 to 0.71) if the swabs were positive for Streptococcus, compared to RR 0.78 (95% CI 0.63 to 0.97) if negative. Similarly at week 1, RRs 0.29 (95% CI 0.12 to 0.70) for positive, and 0.73 (95% CI 0.50 to 1.07) for negative swabs. AUTHORS' CONCLUSIONS: Antibiotics confer relative benefits in the treatment of sore throat. However, the absolute benefits are modest. Protecting sore throat sufferers against suppurative and non-suppurative complications in modern Western society can only be achieved by treating many with antibiotics, most of whom will derive no benefit. In emerging economies (where rates of acute rheumatic fever are high, for example), the number needed to treat may be much lower for antibiotics to be considered effective. Antibiotics shorten the duration of symptoms by about sixteen hours overall.

Anti-Bacterial Agents↗
PubMed2002

Spontaneous parathyroid adenoma hemorrhage.

We report a case of spontaneous parathyroid adenoma hemorrhage. A 50-year-old man with a sore throat, and swelling and ecchymosis of the entire anterior neck was found in cervical and chest computed tomography revealed to have a low-density area extending from the parapharyngeal region to below the carina, Suspecting descending necrotizing mediastinitis secondary to a peritonsillar abscess, we conducted mediastinal and cervical drainage, but found no abscess. No evidence was found, either, in bacteriological culture of sputum and pleural effusion. After the hematoma disappeared, cervical ultrasonography indicated parathyroid adenoma. Serum calcium was marginally increased, indicating that serum calcium should be determined if cervical or mediastinal hematoma develops without an obvious cause.

Adenoma↗
PubMed2002

[Laser tonsillectomy in tonsillar hyperplasia of early childhood].

Tonsillotomy, the partial resection of hyperplastic tonsils, is generally rejected in Germany as a treatment option for obstructions of the isthmus faucium in early childhood. We think this approach merits consideration. The favorable results obtained with tonsillotomy in the University Hospital Benjamin Franklin (n = 637), a private clinic, and an ENT practice with surgical facilities (n = 189) showed that there is no justification for adhering to literature reports of severe late complications with scarred tonsillar crypts and peritonsillar abscesses. No patient has developed any of these complications thus far. Following tonsillotomy, preoperative complaints (snoring, respiratory obstruction, dysphagia, and failure to grow) decreased considerably. Thus, tonsillotomy proved to be a suitable modality for treating tonsillar hyperplasia in early childhood. The prerequisite for long-term success is strict limitation of this intervention to the diagnosis of tonsillar hyperplasia.

Airway Obstruction↗
PubMed2007

[Tonsillectomy technique: bipolar scissors vs raspatory: results of a case control study in 138 patients].

BACKGROUND: Postoperative bleeding is the major complication in tonsillectomy, and pain the most common side effect. The use of bipolar scissors versus blunt dissection tonsillectomy were compared in this study in order to evaluate postoperative bleeding and pain, as well as operative time. METHODS: In this case control study, 138 patients with the diagnosis of chronic tonsillitis, mononucleosis or a peritonsillar abscess were divided into two groups. A total of 78 patients were operated using bipolar scissors while 60 patients underwent tonsillectomy by blunt dissection. Operating time, frequency of postoperative bleeding and the postoperative pain score were compared between these two groups. RESULTS: The average operating time in the bipolar scissor group showed a tendency to be shorter than in the blunt dissection group (mean 4.1 min), although this did not reach a level of statistical significance. No differences were seen in pain scores or in the incidence of postoperative bleeding. CONCLUSION: The data documented in this study show that tonsillectomy with bipolar scissors might represent a surgical option to reduce surgical time in a larger patient group. Postoperative pain and the incidence of postoperative bleeding did not show any statistical difference between the two surgical techniques.

Adolescent↗