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PubMed2006

Floating the uvula: an intraoperative method for detecting bifidity.

A bifid uvula, midline diastasis of the palatal muscles, and notching of the posterior hard palate have classically formed a triad diagnosing submucosal clefts. The uvula has thus served as a tool for clinicians to detect the earliest signs of clefting. In this case report, we discuss how mucosal lining may be held together by mucous viscosity, making it difficult to detect notching or a grossly bifid uvula. We demonstrate a simple intraoperative technique to easily overcome this force. This paper involves a case report of an 8-year-old female undergoing an adenotonsillectomy. A previously undetected bifid uvula was found only after floating the uvula in normal saline solution. This changed our surgical approach from a complete to a partial adenoidectomy. A bifid uvula may be considered the earliest form of a cleft palate, and more importantly, it has been shown in the literature to be associated with other anomalies as submucosal cleft, hyoplastic eustachian tube orifice, and absence of the salpingopharyngeal folds. The intraoperative technique of floating the uvula helps to overcome mucous viscosity and identify an otherwise missed bifid uvula.

Adenoidectomy↗
PubMed2004

Iatrogenic open globe eye injury following sinus surgery.

PURPOSE: To report a case of iatrogenic open globe eye injury occurring during endoscopic sinus surgery. DESIGN: Case report and literature review. METHODS: A 10-year-old boy presented with periorbital swelling and subconjunctival hemorrhage of the left eye following bilateral nasal adenoidectomy. Funduscopic examination showed evidence of a full-thickness open globe injury at the equator in the inferior nasal midperiphery. RESULTS: The injury most likely was secondary to inadvertent perforation of the lamina papiracea with entrance into the orbit and subsequent penetration of the globe. CONCLUSION: Sinus surgery has been reported previously in association with severe orbital complications. We are unaware of previous reports of open globe injury following sinus surgery.

Adenoidectomy↗
PubMed1998

Sleep-disordered breathing in children with achondroplasia.

OBJECTIVE: Our objective was to characterize sleep-disordered breathing in 88 children with achondroplasia aged 1 month to 12.6 years. RESULTS: At the time of their initial polysomnography, five children had previously undergone tracheostomy, and seven children required supplemental oxygen. Initial polysomnography demonstrated a median obstructive apnea index of 0 (range, 0 to 19.2 apneas/hr). The median number of central apneas with desaturation per study was 0.5 (0 to 49), the median oxygen saturation nadir was 91% (50% to 99%), and the median peak end-tidal pCO2 was 47 mm Hg (36 to 87 mm Hg). Forty-two children (47.7%) had abnormal initial study results, usually caused by hypoxemia. Two children with severe obstructive sleep apnea eventually required continuous positive airway pressure therapy, and three additional children required tracheostomies. CONCLUSIONS: (1) Children with achondroplasia often have sleep-related respiratory disturbances, primarily hypoxemia. (2) The majority do not have significant obstructive or central apnea; however, a substantial minority are severely affected. (3) Tonsillectomy and adenoidectomy decreases the degree of upper airway obstruction in most but not all children with achondroplasia and obstructive sleep apnea. (4) Restrictive lung disease can present at a young age in children with achondroplasia.

Achondroplasia↗
PubMed1998

Common topics in pediatric otolaryngology.

This article outlines the perioperative and long-term management of children undergoing tonsillectomy, adenoidectomy, tympanostomy with tube insertion, and sinus surgery. Indications for complications of each of the procedures is reviewed in this article. The authors also cover the management of children with tracheostomies. Several questions frequently asked by parents of children with a tracheostomy are addressed.

Adenoidectomy↗
PubMed2004

Otitis media.

Otitis media (OM) continues to be one of the most common childhood infections and is a major cause of morbidity in children. The pathogenesis of OM is multifactorial, involving the adaptive and native immune system, Eustachian-tube dysfunction, viral and bacterial load, and genetic and environmental factors. Initial observation seems to be suitable for many children with OM, but only if appropriate follow-up can be assured. In children younger than 2 years with a certain diagnosis of acute OM, antibiotics are advised. Surgical candidacy depends on associated symptoms, the child's developmental risk, and the anticipated chance of timely spontaneous resolution of the effusion. The recommended approach for surgery is to start with tympanostomy tube placement, eventually followed by adenoidectomy. The ideal intervention for OM, however, does not yet exist, and an urgent need remains to explore new and creative options based on modern insights into the pathophysiology of OM.

Acute Disease↗
PubMed2000

Doppler echocardiography in adenotonsillar hypertrophy.

OBJECTIVE: Adenotonsillar hypertrophy causing upper airway obstruction may lead to the pulmonary hypertension and cor pulmonale. This study aimed to clarify the diagnostic methods of this complication, besides polysomnography, to find another objective criterion for surgical intervention and to demonstrate the curative effect of adenotonsillectomy on this complication using this objective criterion. METHODS: We studied the outcomes of 17 children with pulmonary hypertension secondary to the adenotonsillar hypertrophy. Pulmonary arterial pressure measurement was performed noninvasively by Doppler echocardiography. RESULTS: Mean preoperative pulmonary arterial pressure was 29.12+/-4.41 mmHg and decreased dramatically after relief of upper airway obstruction by adenoidectomy and/or tonsillectomy to the normal level of 12.06+/-3.09 mmHg. These results were analyzed by equal variances t-test and found very significant (P<0.01). Regarding the symptoms of upper respiratory obstruction, symptom scores of these children decreased very significantly and were analyzed by equal variances t-test (P<0. 01) in the postoperative period. For all the symptoms individually (snoring, mouth-breathing during sleep and daytime, hyponasal voice, restless sleeping, daytime somnolence, enuresis nocturna), comparing percentages of preoperative and postoperative symptoms by unequal variances t-test, we obtained very significant decrease (P<0.01). CONCLUSIONS: This study illustrates that Doppler echocardiography is a safe, practical and noninvasive-method in diagnosing cardiovascular disturbances--one of the complications of adenotonsillar hypertrophy and especially for measuring the pulmonary arterial pressure. All the symptoms and disorders due to the adenotonsillar hypertrophy may be reversible by performing early adeno- and/or tonsillectomy.

Adenoidectomy↗
PubMed2002

Rhinovirus RNA in children with longstanding otitis media with effusion.

BACKGROUND: Earlier studies indicate that respiratory viruses may play a role in the pathogenesis of otitis media with effusion (OME). OBJECTIVES: To study the presence of rhinovirus RNA in middle ear mucosa in children with OME without signs of present acute infection. METHODS: Eighteen children scheduled for tympanostomy tube placement due to longstanding OME were recruited and a biopsy of the promontory mucosa was obtained. In addition, adenoidectomy was performed for eight of these children and a biopsy of adenoid tissue was taken as well. The samples were collected from December to May. Rhinovirus RNA was studied by in situ hybridization (ISH). RESULTS: Seven out of eight adenoid biopsies were positive for rhinovirus by ISH. However, rhinovirus RNA was not found in any of the 18 middle ear biopsies. CONCLUSIONS: These results show that children with longstanding OME do not have a rhinovirus infection in the middle ear mucosa, although the same children frequently harbor large amounts of rhinovirus RNA in their adenoid tissue.

Adenoidectomy↗
PubMed2003

Using a children's book to prepare children and parents for elective ENT surgery: results of a randomized clinical trial.

OBJECTIVE: We evaluated the effects of surgery preparation using a children's book on pre- and postoperative anxiety and distress in 2-10 years old children undergoing tonsillectomy and/or adenoidectomy and their mothers. METHODS: Parents of the experimental group were given the preparation book during the preoperative visit at the hospital, whilst control subjects did not receive the book. Data collection was conducted on the evening prior to surgery (T1), and the evening post surgery (T2). At these two points in time, mothers completed a self-designed feeling states checklist and the state anxiety scale of the State and Trait Anxiety Inventory to assess their perceptions of the child's distress and their own level of anxiety. At T2, nurses were asked to give ratings of patient-caregiver variables, such as level of anxiety, cooperation with care or level of information. The sample under study consisted of 160 mother/child dyads in the experimental group and 240 controls. RESULTS: We found that mothers who received the book exhibited less self-reported state anxiety prior to the operation compared to mothers who did not. Simultaneously, children of the experimental group showed less distress in 4 of 11 feeling states. Nurses assessed the mothers of the experimental group to participate more in the child's care than control mothers. CONCLUSIONS: The results demonstrated that our preparation book can provide educational and anxiety-reducing benefits. Given the relatively low production costs and its easy administration, it can be recommended as a popular, practical and cost-efficient tool to prepare children and parents for surgery and hospitalization.

Adenoidectomy↗
PubMed2003

Analysis of the causes of immediate unanticipated bleeding after pediatric adenotonsillectomy.

OBJECTIVES: To assess the incidence of unexpected postoperative bleeding in children undergoing adenoidectomy and/or tonsillectomy (T&A), and to investigate its possible undetected haematological causes. METHODS: We prospectively collected all patients under 14 years of age with a normal preoperative haematologic work-up (activated partial thromboplastic time, prothrombin time, fibrinogen, and platelet count), who underwent surgery of adenoids and/or tonsils at our institution between January 1997 and November 2000. RESULTS: There were 1516 cases that accomplished the inclusion criteria in the period of survey. Thirteen patients bled after surgery. This represents an incidence of 0.8% of immediate postoperative haemorrhage among the 1516 procedures analyzed. No statistical differences were found between bleeding and non-bleeding patients according to age, sex, and type of procedure (P>0.05). In 6 of the 13 bleeding patients (46.1%) an alteration of the coagulation system was subsequently found: 5 von Willebrand's disease, and 1 releasing thrombopathy. CONCLUSIONS: The incidence of bleeding after adeno and/or tonsillectomy at our institution is comparable with series previously reported in the current medical literature. In nearly one half of the cases, undetected coagulation diseases (mainly von Willebrand's disease) are diagnosed after surgery in the haematological study.

Adenoidectomy↗
PubMed2003

Complications of adenotonsillectomy in children with OSAS younger than 2 years of age.

The most common sleep disorder in children is obstructive sleep apnea syndrome (OSAS). The majority of children with OSAS improve following tonsillectomy and adenoidectomy (T&A). T&A as an outpatient procedure in children is very common. Young age in considered risk factors for postoperative respiratory complications. The purpose of this study is to analyze our experience with postoperative T&A complications in patients younger than 2 years of age. A total of 39 T&A were performed in children younger than 2 years of age. OSAS diagnosis was confirmed by overnight polysomnography (PSG). All the patients were hospitalized and monitored by overnight pulse oximetry monitoring. Post-operatively there was marked improvement in respiratory function in all the patients comparing pre- and post-operative nadir oxygen saturation (P<0.05). Complications were documented in seven patients (20%). Five of the complications occurred in children older than 1 year of age. Bleeding occurred in two patients (5.7%). Three patients (8.6%) had dehydration, one patient (2.9%) had hypercarbia and one patient had laryngospasm. In this study there was a low incidence of peri- and post- operative respiratory complications in children younger than 2 years of age who undergo T&A for OSAS. Identification of OSAS severity may be an important factor in determining the risk of T&A in a young child.

Adenoidectomy↗
PubMed2003

Otitis media with effusion and histopathologic properties of adenoid tissue.

OBJECTIVE: Adenoidectomy is being generally used for the treatment of otitis media with effusion (OME). The purpose of current study was to determine objectively the significance of the histopathology of adenoid tissue on the development of otitis media with effusion. METHODS: The records of all the patients operated on with the diagnosis of adenoid enlargement with or without OME were reviewed and pathologic specimen were re-evaluated regarding histopathological properties by one pathologist unfamiliar with the diagnosis. Sixty-one patients with adenoid hyperplasia were enrolled in the study group, 38 males and 23 females. Age ranged between 3 and 13 years (mean age was 7.03+/-3.26 years). All the patients of study group were those operated on due to the adenoid hyperplasia and uni- or bilateral OME. Control group was composed of 39 male and 26 female patients (age range was between 3 and 13 years, and mean age was 7.06+/-3.04 years) with solely adenoid hyperplasia. RESULTS: The squamous metaplasia was present in 47 (77%) and 14 (22%) patients of study and control groups, respectively. The fibrosis of connective tissue interspersed follicles of adenoid was present in 29 (48%) and 6 (9%) patients of study and control groups, respectively. The statistical analysis revealed a significant prevalence of squamous metaplasia (P<0.001) and fibrosis of connective tissue interspersed follicles of adenoid (P<0.001) for a surgical indication of adenoid hyperplasia with OME than for without OME. The prevalence of other parameters was not significantly different between two groups. CONCLUSIONS: Adenoid tissue not only exerts an obstructive influence on the eustachian tube lumen when enlarged, but also impedes (hinders) mucociliary drainage of the middle ear by the way of non-ciliated metaplastic epithelium and fibrosis of connective tissue.

Adenoidectomy↗
PubMed1983

The prognostic significance of the air volume in the middle ear for the tendency to recurrence of secretory middle ear condition.

The incidence of recurrence of secretory middle ear conditions (SMEC) in the course of the first 3 months after extrusion of a grommet was evaluated in 172 tubulated patients in relation to a number of background variables in a stepwise logistic regression analysis. The background variables were: treatment period, 3-month period (season) of extrusion, sex, age, air volume in the middle ear, diagnosis (unilateral/bilateral, suppurative/non-suppurative and consequently antibiotics), other treatment apart from a grommet (paracentesis and/or adenoidectomy), and a history of allergy. There was a definite correlation between the incidence of recurrence and the air volume in the middle ear, as determined by physical volume test, after correction for age, recurrences being most common in ears with a small middle ear volume. In addition, there was a relationship, but not as marked, between the incidence of recurrence and age after correction for the middle ear volume, recurrences being less common in older patients. None of the other background variables played a statistically significant role when correction was made for age and middle ear volume. It is recommended to practise an expectant therapeutic strategy in SMEC in order to eliminate cases with spontaneous remission. In the event of recurrence, a more liberal reinsertion of grommets is recommended for patients with small middle ear volumes, while in those with larger volumes a different aetiology should possibly be considered.

Adenoidectomy↗
PubMed1985

Total actual speaking time in infants and children with otitis media with effusion.

For the purpose of supporting the premise that remarkable improvements in the child's attitude and performance rendered by improving the hearing impairment after aspiration of effusion and insertion of ventilating tubes in infants and children causes the increase in actual speaking time, an apparatus for measuring the time of vibration of the vocal cords was newly devised. Using this instrument, the duration of speaking time of children with otitis media with effusion was measured preoperatively and postoperatively. Preoperative and postoperative mean speaking times (speaking minutes/measured hours) were found to be 8 min 24 s per hour and 10 min per hour, respectively (number of patients: 30). These variable means were significant when examined by a Student's t-test. Pre- and postoperative speaking times showed no significant differences (10 min 24 s preoperatively and 10 min 54 s postoperatively) in the control group for surgery, consisting of 5 children having adenoidectomy and/or tonsillectomy.

Adenoidectomy↗
PubMed1997

The utility of preoperative hemostatic assessment in adenotonsillectomy.

Routine preoperative coagulation screening in patients undergoing tonsillectomy and/or adenoidectomy (T and A) is considered by some to be mandatory. T and A is often the first hemostatic challenge in children; therefore, screening is thought to be useful in predicting patients who may experience postoperative hemorrhage. On the other hand, in today's cost-conscious medical environment, routine screening is considered by some to be an unnecessary added expense. At our institution, among 4373 patients who underwent T and A between 1989 and 1994, 43 returned with postoperative bleeding (0.98%). We retrospectively evaluated the usefulness of prothrombin time (PT) and activated partial thromboplastin time (PTT) in predicting intraoperative and postoperative bleeding. All children had extensive bleeding histories taken; however, preoperative laboratory screening was left to the discretion of the attending physician. Preoperative PT/PTT did not predict intraoperative or postoperative bleeding. In our experience, laboratory screening has a very low positive predictive value in detecting occult bleeding disorders or perioperative hemorrhage; thus, we feel it should be used selectively. Routine preoperative PT/PTT is not recommended to screen T and A patients and does not appear to be cost-effective.

Adenoidectomy↗
PubMed1999

Evaluation of factors affecting outcome of surgery for otitis media with effusion in clinical practice.

In discussing surgery for otitis media with effusion (OME), tympanostomy tubes and adenoidectomy are important. Sinus surgery is less important and cleft palate surgery needs to be mentioned for completeness sake. There is no evidence supporting the value of tonsillectomy in the treatment of OME. Tympanostomy tubes are possibly best regarded as artificial eustachian tubes, which remain in position for a variable amount of time. It is therefore apparent that resolution of OME from tympanostomy tube placement largely depends on whether underlying aetiological factors have either resolved or been corrected when the tympanostomy tube was in position.

Adenoidectomy↗
PubMed1997

The effects of an outpatient practice guideline at a teaching hospital: a prospective pilot study.

Practice guidelines (PGs) are becoming increasingly important in modern medicine. To study the effects of a PG, we performed a pilot study at a large, urban, public teaching hospital according to a prospective, observational research design with both concurrent and historic controls. Specifically, we studied the effects of a multidisciplinary PG for pediatric outpatient tonsillectomy and adenoidectomy on the process of health-care delivery. Variables in the health-care process included patient compliance with clinic and surgery appointments, surgery time, operating room turnover, time in recovery room, unplanned admission rate, patient compliance with postoperative follow-up, provider compliance with guidelines, and hospital charges. Patients in the PG were found to have fewer preoperative laboratory tests, decreased duplication of services, and shorter operating room turnover times. Provider compliance with the PG varied by service and was intermittent at first but improved gradually. There was a trend toward improved compliance with postoperative follow-up in patients in the PG. Provider opinions concerning the guideline were positive. This pilot study demonstrates several advantages and disadvantages of the use of PGs in the outpatient setting and in a teaching hospital.

Adenoidectomy↗
PubMed1998

Microscopic examination of routine tonsillectomy specimens: is it necessary?

Controversy continues to exist regarding the routine histologic examining of tonsillectomy specimens. Proponents suggest that among other reasons, missing an important diagnosis such as occult malignancy or granulomatous disease and possible medicolegal consequences argue in favor of routine histologic examination. Others state that we should consider the very low yield of significant histologic findings in routine tonsillectomy specimens and its added cost. We performed a retrospective evaluation of all cases of patients who underwent tonsillectomy with or without adenoidectomy between January 1992 and July 1996. Two hundred eighty-eight charts were evaluable. Group 1 consisted of all tonsillectomy specimens that were subjected to gross examination only. Group 2 consisted of all tonsillectomy specimens that were subjected to gross examination as well as microscopic examination. In group 1, no abnormal gross findings were noted. Group 2 consisted of specimens from an older population with a mean age of 21.6 years. There were 43 patients older than 20 years old in group 2, and in all cases except four the preoperative clinical impression correlated with the microscopic findings. Occult malignancy was found in only one of these four patients. No cases of granulomatous disease were discovered. Overall, no patients except one had any change in postoperative treatment on the basis of the results of microscopic examination. We believe that routine microscopic examination of tonsillectomy specimens results in unnecessary cost and consumption of resources and time. Microscopic examination should be done in only selected cases such as in patients with grossly asymmetric tonsils or in patients with a history of malignancy.

Adenoidectomy↗
PubMed1999

Postoperative hemorrhage after tonsillectomy: use of ketorolac tromethamine.

Recent reports have associated an increased incidence of bleeding after tonsillectomy with the perioperative use of ketorolac tromethamine. To review this association, we examined the hospital and office records of 310 pediatric patients who underwent tonsillectomy with or without adenoidectomy at our institution during a 2-year period. Of these patients, 213 received ketorolac administered as a single dose at the conclusion of the procedure. The remaining 97 patients did not receive ketorolac. The frequency of postoperative hemorrhage was not found to differ significantly between these 2 groups (2.3% vs. 3.1% respectively, P = 0.71). Furthermore, the average time to discharge after surgery was significantly shorter in those patients who received ketorolac than in those who did not (8.5 hours vs. 12.5 hours, respectively, P < 0.0001). The frequency of overnight hospital stays was also significantly lower in those patients who received ketorolac (16.0% vs. 31.6%, respectively, P < 0.01). Concern over the potential for increased hemorrhage after tonsillectomy has led several authors to caution against the use of ketorolac in this setting. In our study, however, the use of ketorolac was not found to increase the incidence of posttonsillectomy hemorrhage and furthermore was associated with a significant decrease in the length of hospital stay as well as a decreased likelihood of overnight hospital stay after surgery.

Adenoidectomy↗