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PubMed1996

[Tonsillectomy in a boy liver transplant].

As of 1995, organ transplantation from cadaver donors is under debate in the Japanese Diet. Depending on what the Diet decides, more organ transplantations may be performed. Since cases of orthotopic liver transplantation (OLT) may increase, the need to perform surgical operations in post-OLT patients may arise. The purpose of this report is to enlighten Japanese otorhinolaryngologists on the post-transplant state. An 8-year-old boy who underwent OLT in Australia 7 years previously underwent successful tonsillectomy, adenoidectomy and insertion of ventilation tubes into both ears under general anesthesia (GA) to treat habitual angina, hypertrophy of the nasopharyngeal and palatine tonsils, and secretory otitis media. The optimal circumstances for operation require adequate but not excessive immunosuppression and a well-functioning graft. Vascular complications (VCs) such as hepatic artery thrombosis become rare after a few years post-OLT. However, once VCs occur the mortality rate of OLT patients is high, and excessive perioperative changes in circulation must be avoided. Immunosuppressive agents should be continued throughout the perioperative period and perioperative antibiotic prophylaxis should be employed, just as in non-transplant patients. Tonsillectomy is an effective means of prophylaxis for upper respiratory infection in habitual angina patients. Infection of an OLT patient may become critical because immunosuppressive agents to prevent rejection lower immune barriers and increase the risk of infection, and dose reduction may increase the risk of rejection. Tonsillectomy may also prevent a possible lympho-proliferative disorder (LPD). Tonsillar hypertrophy in OLT patients may be due to life-threatening LPD. Thus, tonsillectomy serves both as a prophylactic and curative measure against possible complications OLT may cause later, and therefore may improve the outcome of OLT.

Anesthesia, General↗
PubMed1999

Impact of clinical practice guidelines on clinicians' behaviour: tonsillectomy in children.

OBJECTIVE: This study was conducted to assess the extent to which developing and implementing clinical practice guidelines for listing children for tonsillectomy (with or without adenoidectomy) influenced the behaviour of participating ENT surgeons. METHOD: A before and after study in which the intervention (the development and dissemination of local practice guidelines) was introduced sequentially into different hospitals and surgical practice. The study was conducted in four ear, nose, and throat surgical services in the North of England, with 16 consultant ENT surgeons and their junior staff on 1190 children aged 0 to 14 years who were judged, prior to consultation with an ENT surgeon, to have been referred for throat-related problems for which tonsillectomy was one possible treatment option were included in the study. Decision reached by surgeons and proportion of decisions that complied with new guidelines. RESULTS: Of the clinical decisions to list children for tonsillectomy taken before introduction of locally agreed guidelines, 73% (486/660) conformed to the criteria in the subsequent guidelines, 15% (97/660) did not, and in 12% (77/660), it was impossible to judge. After the intervention, the corresponding figures were 73% (386/530), 14% (73/53), and 13% (71/530), respectively. When decisions were taken to break the guidelines, this was more often to list for tonsillectomy when it was not indicated--83% (141/170)--than to withhold tonsillectomy when it was indicated--17% (29/170). The aspects of guidelines that were breached in decisions to carry out tonsillectomy were: the age of the child was younger than the guidelines recommended--54% (75/141); there had been fever attacks of tonsillitis than the guidelines recommended--22% (32/141); and there were "significant" symptoms not included in the guidelines--20% (29/141). CONCLUSIONS: In spite of strong evidence to the contrary, local guidelines were formulated at a level that the majority of surgeons already attained. Guideline development and implementation, therefore, had very little impact on clinical practice. The process of local formulation of guidelines was not sufficient to achieve change toward evidence-based practice; clinical preference proved to be quite intractable. There is a need to enhance the ability of clinicians in the assessment and interpretation of research evidence. Previous work has emphasized the need to explore factors that influence clinical behaviour toward evidence-based practice. Our study suggests the need for more research into why clinicians continue to follow clinical preference even when invited to base agreed local clinical policies on evidence.

Adolescent↗
PubMedDate not supplied

[Effectiveness of tonsillectomy, evaluated by acoustic rhinometry].

Hypertrophy adenoid commonest cause of nasal obstruction in paediatrics. The morbility can be try alteration in the respiratory physiology, as well as in the face development and function of the middle ear. We used the acoustic rhinometry to evaluate the surgical results of the adenoidectomy in children with hypertrophy adenoid, compiling the data on their clinic, and correlating them as well with the rhinometric results. The acoustic rhinometry is a relatively new method of exploration of the nasal cavity. We obtain space measures that are going to allow to us to prove it. These measures are the cross-sectional areas and volumes registered in the nasal cavity when this cavity is divided longitudinally in two zones, the previous one until 32 mm measured from the narina, and the later one to 64 mm from the same point. For this study we have taken 45 patients with hypertrophied adenoids. We have made measurements pre and post surgery. Our results show a clear gain in areas as in volumes after surgery and also show the utility of the acoustic rhinometry like method of exploration at the time of quantifying the morphometric alterations of the nasal cavity.

Acoustics↗
PubMed2000

Otolaryngologists' perceptions of the indications for tympanostomy tube insertion in children.

BACKGROUND: Bilateral myringotomy with insertion of tympanostomy tubes is the most common operation that children in Canada undergo. Area variations in surgical rates for this procedure have raised questions about indications used to decide about surgery. The objective of this study was to describe the factors that influence otolaryngologists to recommend tympanostomy tube insertion in children with otitis media and their level of agreement about indications for surgery. METHODS: A survey was sent to all 227 otolaryngologists in Ontario in the fall of 1996. The influence of 17 clinical and social factors on recommendations to insert tympanostomy tubes were assessed. Case vignettes were used to determine the effect of multiple factors in decisions about the need for surgical management. RESULTS: Surveys were returned by 138 (68.3%) of the 202 eligible otolaryngologists. There was agreement (more than 90% of respondents) about 6 indications for surgery: persistent effusion, a lack of improvement after 3 months of antibiotic therapy, a history of persistent effusion for 3 or more months per episode of otitis media, more than 7 episodes of otitis media in 6 months, a bilateral conductive hearing loss of 20 dB or more and a persistently abnormal tympanic membrane. Some respondents were more likely to recommend tube insertion if there were parental concerns about hearing problems or the frequency or severity of episodes of otitis media. Otolaryngologists agreed about the role of tympanostomy tubes in 1 of 4 case vignettes but disagreed about whether adenoidectomy should also be performed in that instance. Most viewed tympanostomy tube insertion as beneficial, with few adverse effects. INTERPRETATION: There is a lack of consensus among practising otolaryngologists in Ontario as to which children with recurrent otitis media or persistent effusion should undergo bilateral myringotomy with tympanostomy tube insertion. These findings suggest the need to revisit clinical guidelines for this procedure.

Attitude of Health Personnel↗
PubMed2000

The effect of ventilation tubes on language development in infants with otitis media with effusion: A randomized trial.

OBJECTIVE: To study the effectiveness of ventilation tubes on the language development in infants with persistent otitis media with effusion (OME). All existing studies addressed children 3 years of age or older. Currently, OME is detected and treated with ventilation tubes at a younger age. Because of the critical relationship between age, hearing, and language development, we conducted a study of the effects of ventilation tubes on language development in infants 1 to 2 years old with persistent OME. DESIGN: A multicenter, randomized, controlled trial (embedded in a cohort) with 2 treatment arms: 1) treatment with ventilation tubes (VT group; n = 93); or 2) with a period of watchful waiting (WW group; n = 94). Hearing loss and expressive and comprehensive language were assessed every 6 months, while tympanometry and otoscopy were performed every 3 months. Other factors with potential influence on language development were also included: adenoidectomy, hospital, attending day care, sex, age at randomization, educational level of the mother, upper respiratory infections, and the native country of the parents and older siblings. The trial was designed to allow for the detection of a mean difference in language development of 3 months or more between children allocated to the VT and WW groups. RESULTS: No relevant differences were found in expressive or comprehensive language between the 2 groups after adjustment for educational level of the mother, IQ of the child, and differences at baseline. A principal component analysis showed that in the VT group, the children with frequent complaints improved 1.6 months more in comprehensive language than those with no or some complaints. The children with favorable language stimulation, however, did not improve more than the children with less favorable stimulation. No differences were found for expressive language among the various clusters. The probability to improve >3 months in comprehensive language was.48 (95% confidence interval [CI]:.29-.68) for children with highly educated mothers versus.09 (95% CI:.02-.30) for children whose mothers had a low educational level. In the WW group, these changes were.30 (95% CI:.14-.53) and.14 (95% CI:.04-.35), respectively. The probability to improve >4 months in expressive language was.52 (95% CI:.32-.71) for children with highly educated mothers versus.06 (95% CI:.01-.31) for children whose mothers had a low educational level. In the WW group these changes were.42 (95% CI:.23-.64) and.11 (95% CI:.03-.35), respectively. In addition, there were delays in expressive language in both groups compared with their age expected values. The comprehensive language of the children who were effusion-free during the follow-up (n = 54) improved 1.5 months (95% CI: -.2-3.2) more than that of the children who had persistent effusion during the entire follow-up (n = 28). No differences were found for expressive language development. Disregarding the intervention contrast, improvements in hearing seemed to be related to improvements in language development, especially in verbal comprehension. DISCUSSION: In this study, we used the Reynell, Schlichting, and Lexi tests to study the relation between early persistent OME and language development. These tests are directly related to normal language, widely accepted, and validated. It cannot be ruled out that more specific measures such as auditory perception tests would have produced more differences between groups, but the focus was on general language development. A total of 10 children in the WW group received treatment with ventilation tubes during follow-up. A further 11 children dropped out during the trial. A sensitivity analysis with the 10 children who received ventilation tubes did not change the results, and baseline differences were not found between the 11 children who dropped out and those who completed the trial. CONCLUSIONS: In the total group of infants with persistent OME, ventilation tubes did not h

Child Language↗
PubMed2000

Aberrant cervical carotid artery.

Aberrant cervical carotid artery is an uncommon anomaly. Because this anomaly can lie in close proximity to the midline of the posterior part of the pharynx, it poses a significant risk during both major pharyngeal tumor resection and less extensive procedures such as tonsillectomy, adenoidectomy and palatopharyngoplasty. Five cases of aberrant cervical carotid artery were encountered and diagnosed using computerized tomography. In all five cases, the anomalous finding did not correlate with the presenting symptoms. Computerized tomographic images of these cases are provided. A review of the literature and the embryology of the aberrant carotid artery are presented. Awareness of the anomaly by radiologists and surgeons is essential to avoid accidental injury to the vessel during surgery.

Adult↗
PubMedDate not supplied

[Major outpatient surgery in the ear, nose and throat clinic].

In recent years, outpatient surgery in otolaryngology has advanced because it benefits both patients and health-care systems. We analyzed the surgical procedures that can be performed in outpatient surgery programs, evaluating patient selection, release criteria, and potential complications. A one-year retrospective study was made of 456 patients, of which 369 (80.92%) were discharged from the hospital on the same day as surgery. The operations with the best performance in outpatient surgery were adenoidectomy, tonsillectomy, laryngeal microsurgery, and septoplasty. Most surgical procedures in otolaryngology can be performed without hospitalization. Outpatient surgery is easier for patients and increases their sense of safety. It also has an excellent cost-benefit relation for health-care systems.

Ambulatory Surgical Procedures↗
PubMed2000

The incidence of potential conjunctival contamination in tonsillectomy.

A prospective study of 100 consecutive tonsillectomies was performed to assess the incidence of potential blood contamination of the surgeons' conjunctivae. Operating masks with plastic visors were used during these operations and examined by microscopy to detect blood contamination. 46% of visors were contaminated by blood. There was no significant difference with respect to how the operation was performed, or with the addition of adenoidectomy, but there was a significant difference between the rate of contamination between some surgeons. No surgeon performing more than three operations, however, escaped contamination. We recommend that eye protection be worn routinely in tonsillectomy.

Adult↗
PubMed2000

[Rhinitis, sore throate and otalgia... Benign common cold or dangerous infection?].

One of mankind's most common illnesses is rhinitis, which almost regularly leads to involvement of the paranasal sinuses. Acute sinusitis is a consequence of a viral infection which, by damaging the mucosa, opens the door to bacterial superinfection. The aim of treatment is to cure the acute inflammation, re-establish normal drainage and ventilation, and prevent the development of "rhinosinugenic" complications. Acute otitis media is also preceded by viral damage to the mucosa. In children, acute otitis media is favored by the short, straight Eustachian tube, and often by adenoids. The therapeutic aim of antibiotic treatment and decongestive nose drops is to re-establish the draining function of the tube. Children who suffer from otitis media several times a year, need adenoidectomy. Acute tonsillitis, or quinsy, should be distinguished in particular from infectious mononucleosis. It is imperative to recognize a peritonsillar abscess, which requires more aggressive treatment.

Adult↗
PubMed1975

Comparison of provincial surgical rates in 1968.

Studies have been made of age- and sex-adjusted 1968 provincial rates for individual surgical procedures. For elective and discretionary operations, such as tonsillectomy and adenoidectomy, hysterectomy, vein stripping and lens extraction, provincial rates varied by approximately 100 percent. Newfoundland, with few surgeons and hospital beds, had the lowest discretionary rates, and Alberta, which ranked hgih both for surgeons and hospital beds, the highest. Interprovincial differences were of smaller magnitude for non-discretionary surgery (radical mastectomy, cesarean section, colectomy., lobectomy, etc.). Ther were statistically significant correlations between numbers of surgeons and elective and discretionary surgical rates and between numbers of hospital beds and bed use in the provinces. The effect of disease prevalence on discretionary surgical rates was minimized because the rates were age- and sex-adjusted. Provincial organization of, and payment for, medical services has been similar. Hence, the ratio of surgical personnel to population in each province is postulated as a major determinant of the differing interprovincial rates.

Age Factors↗
PubMed2001

[Major ambulatory surgery in otorhinolaryngology].

In the last years we have witnessed a great increase of major ambulatory surgery procedures in our specialty. Some of them are very common as adenoidectomies, tonsillectomies and also the insertion of transtympanic tubes. Nevertheless there is no agreement about which of the procedures should be realized through AMS. The aim of this work is to do a review on the most important features involved in AMS entlightening what kind of operations can be included i such programmes.

Ambulatory Surgical Procedures↗
PubMed2001

[Functional consequences of cleft palate and its management].

On the basis of the experience with 5200 various types of orofacial cleft operations performed during 42 years (1959-2000) and of the 60-70 cases with velopharyngeal insufficiency without cleft examined yearly author stresses that the surgical closure of the cleft is not enough in the care: the functional consequences (respiratory, sucking, swallowing, speech, hearing and maxillofacial developmental disorders) should also be managed. The first symptom of Robin sequent (cleft palate associated with dysgnathia) is respiratory disorder improving mostly spontaneously but worsening sometimes after palatoplasty. Polysomnography has been performed by the author routinely before all primary palatoplasties for establishing the possible surgical risks and for choice of the optimal time for surgery. On the basis of the results in 61 infants, the surgery was contraindicated and postponed in 6 cases. The various orofacial clefts may cause swallowing problems in different phase of swallowing and different types of dysphagia: the cleft lip cause sucking problems in the preparatory phase, the cleft palate in the oral transitory phase and the velopharyngeal insufficiency in the pharyngeal phase, but the sensomotor function is more decisive in the swallowing process than the cleft itself. Use of an obturator is not necessary, long-term catheter feeding is inappropriate, early closure of the soft palate (in the age of 8-10 months) is recommended. The liquid or food reflux through the nose can be established by cinefluoroscopy with contrast material and with nasoendoscopy following the way of coloured boluses. Retarded speech development, hyperrhinophony, nasal escape, facial grimacing, articulation disorders and dysphonia are the most frequent voice and speech disorders; speech therapy is in 70%, velopharyngoplasty in 20% of the cases indicated. Anatomical result was good in 98% of 1107 flap surgeries operated on by the author, hyperrhinophony ceased in 90%. The results are assessed by a 5-grade perceptual scale. Among the instrumental procedures videofluoroscopy, videoendoscopy, and nasometry seems to be the most informative. The cause of the frequent hearing disorders is mostly the eustachian tube dysfunction. Author found pathological tympanograms in 64% of their cases. The hearing slightly improves after staphylorraphy and often after flap surgery. Adenoidectomy and grommet insertion are alternative procedures in the therapy. The surgeries have an effect on the maxillofacial growth but this is not significant. Multidisciplinary co-operation in the management of cleft patients is indispensable.

Adolescent↗
PubMed2001

[Cytological assessment of the nasal mucosa in children with adenoidal hypertrophy. Part I].

Investigation was performed on 68 children (24 girls and 44 boys) aged of 3-14, who was qualified by paediatricians for cytological evaluation of the nasal mucosa. They had undergone treatment for chronic upper respiratory tract infection and had clinical symptoms of the adenoidal hypertrophy. The adenoidal hypertrophy in children was confirmed by x-ray of nasopharynx. Seven children had previously undergone adenoidectomy and 3 had recurrent otitis. In the investigated group of children the majority of cytograms contained high level of neutrophils (> 50% of the total number of cells). Only 2 children showed normal cytogram. Discovery of substantial eosinophilia of the nasal mucosa (11.76% of investigated children) indicates that allergy diagnosis should be performed in children with adenoidal hypertrophy.

Adenoids↗
PubMed1997

Prevention of acute otitis media.

Breast-feeding, using family or small-group day care for infants and toddlers and avoiding exposure to household tobacco smoke are the main preventive measures against acute otitis media (AOM). It is also useful to immunize children who have recurrent otitis media with the influenza and the pneumococcal vaccines. Antibiotic prophylaxis is the most effective method to reduce the frequency of new episodes of otitis in children with recurrent AOM, but it should be used with caution. Tympanostomy tube placement and/or adenoidectomy can be considered as options in some situations. Now, probably, the best initial steps to take to prevent new episodes of otitis in children with recurrent AOM are antimicrobial treatment of each individual AOM episode and, in certain cases, antibiotic prophylaxis for short periods when an upper respiratory tract infection is present.

Journal Article↗
PubMed2002

[Effect of middle ear impedance on hearing threshold level in children with adenoid hypertrophy].

The adenoid hypertrophy in children may lift the hearing threshold level especially for low frequency and also influence on the middle-ear impedance. The authors tested eighteen children with adenoid hypertrophy and ten healthy children. The tone audiometry for 250 Hz-8 kHz and impedance audiometry was made. For eight children with adenoid hypertrophy tests were made before and after adenoidectomy (surgical removal of the adenoids). The authors found the relation between the curve of the hearing threshold level and the middle-ear impedance. It was found correlation between the middle-ear impedance and the value of hearing threshold level for 250 Hz, 1000 Hz, 2000 Hz and average of value for 250, 500 and 1000 Hz. There was no correlation between the middle-ear impedance and the value of hearing threshold level for 500 Hz and average of value for 500, 1000 and 2000 Hz.

Acoustic Impedance Tests↗
PubMed2002

[Lymphoproliferative disorders of Waldeyer's ring].

OBJECTIVE: To investigate the incidence and characteristics of lymphoproliferative disorders of Waldeyer's ring in our pediatric patients. MATERIAL AND METHODS: We retrospectively reviewed 20 children under 14 years of age who underwent surgery in our department for adenoidectomy and/or tonsillectomy between 1 January 1996 and 30 November 2000. In non-immunocompromised children, surgical indication was the recent development of progressive unilateral tonsillar hyperplasia, and in immunocompromised patients indication was mainly the enlargement of adenoids and/or tonsils, although eradication of local Ebstein-Barr virus infection and recurrent acute tonsillitis were also indications. RESULTS: The mean age was 4.6+/-2.3 years (range: 16.9 months-13.9 years). Sixteen patients (80.0 %) were male. In the nine patients with unilateral hyperplasia, histopathological diagnosis was diffuse lymphoid hyperplasia. Of the 11 immunocompromised patients, 5 (45.5 %) had some type of lymphoproliferative disorder. DISCUSSION AND CONCLUSIONS: Lymphoproliferative disorders of Waldeyer's ring are relatively frequent in immunocompromised children who have undergone surgery of the adenoids and/or tonsils. Although no cases of unilateral hyperplasia of the tonsils were diagnosed in our series, tonsillectomy is indicated in patients with this diagnosis, independent of their immunological status.

Adolescent↗
PubMed2003

Cephalometric norms for the upper airway in a healthy Hong Kong Chinese population.

OBJECTIVE: To obtain normative data for cephalometric measurements of the upper airway in the local Chinese population. DESIGN: Observational study. SETTING: University department and teaching hospital out-patient clinic. SUBJECTS AND METHODS: Subjects included 74 healthy patients, 29 males (age range, 18-35 years) and 45 females (age range, 16-42 years), with normal skeletal facial profile, no history of snoring, sleep apnoea, upper airway disease, tonsillectomy or adenoidectomy, obesity, or pathology in the pharynx. Twenty cephalometric airway measurements, including size of the tongue, soft palate, nasopharynx, oropharynx, hypopharynx, and relative position of the hyoid bone and valleculae were obtained. Landmarks on cephalometric radiographs were digitised and measurements were made using a specially designed computer programme. Error analysis of measurements was performed and comparison of measurements according to sex was made. RESULTS: Significant sex dimorphism was seen for the majority of measurements, with the exception of minimal depth of the airway, oropharyngeal depth of the airway, and the soft palate angle with the hard palate. CONCLUSION: A minimum sagittal dimension of the upper airway was evident despite differences in measurements between sexes. Findings from this study should be a useful reference for the assessment of sleep apnoea in the local population.

Adolescent↗