The impact of new evidence on regional variation in paediatric tonsillectomy and adenoidectomy: a historical review.

BACKGROUND: Tonsillectomy and adenoidectomy have been among the most commonly performed procedures in children for approximately 100 years. These procedures were the first for which unwarranted regional variation was discovered, in 1938. Indications for these procedures have become stricter over time, which might have reduced regional practice variation. METHODS: This paper presents a historical review on practice variation in paediatric tonsillectomy and adenoidectomy rates. Data on publication year, region, level of variation, methodology and outcomes were collected. RESULTS: Twenty-one articles on practice variation in paediatric tonsil surgery were included, with data from 12 different countries. Significant variation was found throughout the years, although a greater than 10-fold variation was observed only in the earliest publications. CONCLUSION: No evidence has yet been found that better indications for tonsillectomy and adenoidectomy have reduced practice variation. International efforts are needed to reconsider why we are still unable to tackle this variation.

The shifting relationship between weight and pediatric obstructive sleep apnea: A historical review.

OBJECTIVES: For more than a century, pediatric obstructive sleep apnea (OSA) was associated with failure to thrive. However, that association has faded over the last few decades. A 21st century child with OSA is much more likely to be overweight than underweight. This raises the question: Has pediatric OSA changed over time, or has the rise of childhood obesity in the United States created a new, separate disease? This literature review explores the historical shift in the relationship between weight and OSA, and the associated changes in treatment. RESULTS: We demonstrate a clear transition in the prevalence of failure to thrive and obesity in the OSA literature in the mid-2000s. What is less clear is whether these two clinical phenotypes should be considered two distinct diseases, or whether subtle differences in one set of pathophysiologic pathways-adenotonsillar hypertrophy, altered inflammation, and increased energy expenditure-can lead to divergent metabolic outcomes. More research is needed to fully elucidate the pathophysiology of OSA in children with obesity. CONCLUSIONS: We may need new and different treatments for obesity-associated OSA as adenotonsillectomy-which is effective at reversing failure to thrive in OSA-is not as effective at treating OSA in children with obesity. One option is drug-induced sleep endoscopy, which could personalize and improve surgical treatment of OSA. There is some evidence that therapies used for OSA in adults (e.g., weight loss and positive airway pressure) are also helpful for overweight/obese children with OSA. Laryngoscope, 129:2414-2419, 2019.

The adenoid: Its history and a cautionary tale.

The existence of the adenoid first appears to have been noted by Conrad Victor Schneider in 1661. James Yearsley reported in 1842 one case in which he improved hearing by removal of a mucus membrane from behind the uvula, which indicates some appreciation of a relationship of the nasopharynx to ear disease. Hans Wilhelm Meyer, in 1868, was the first to demonstrate the relationship of the adenoid to ear disease and to develop an effective, although somewhat difficult, surgical operation to remove the adenoid. Removal of the adenoid became rapidly accepted worldwide as a treatment for many morbidities, including otitis, speech problems, cognitive problems, and sleep apnea. Until the 1920s, adenoidectomy often was performed as a staged procedure and without general anesthesia. Early tools and techniques included use of the bare fingernail, a finger ring knife, a curette, and electrical desiccation. From the mid-1930s to the early 1960s, radiation therapy of the adenoid was in extensive use, both for children and in caring for army aviators and navy submarine crews during WWII. The effectiveness of surgical adenoidectomy for hearing loss led to a belief that radiation, which had been found to ablate lymphoid tissue, would be equally effective, and led to the wide-spread use of radiation. Ultimately, 500 thousand to 2.5 million children and adults were estimated to have been treated with radiation, and follow-up studies found increased risk for cancer. Furthermore, a follow-up study by Stacey R. Guild (1890-1966), published in 1950, on a very large sample of children who previously were reported to have had their hearing loss diminished through radiation, found that irradiation had produced no effect on high-tone loss. Thus, irradiation was both useless and harmful. Acceptance of authority, which can lurk within medical culture, led to the development of a tragically misguided management of adenoid disease. Laryngoscope, 127:S13-S28, 2017.

Unwarranted variation in pediatric medical care.

This article provides a survey on the concepts, methods, and applications of the study of unwarranted variation in health care with particular attention to children's medical services.

The rise and decline of tonsillectomy in twentieth-century America.

This article explores the rise and decline of tonsillectomy/adenoidectomy (T&A) in twentieth-century America. Between 1915 and the 1960s, T&A was the most frequently performed surgical procedure in the United States. Its rise was dependent on novel medical concepts, paradigms, and institutions that were in the process of reshaping the structure and practice of medicine. The driving force was the focal theory of infection, which assumed that circumscribed and confined infections could lead to systemic disease in any part of the body. The tonsils in particular were singled out as "portals of infection," and therefore their removal became a legitimate therapy. Nevertheless, what kinds of evidence could prove that tonsils were portals of infection? How could the effectiveness of tonsillectomy be determined? An inherent difficulty was the absence of any consensus on the criteria that would be employed to judge its efficacy. Yet tonsillectomy persisted despite ambiguous supportive evidence. Although criticisms of the procedure were common by the 1930s, its decline did not begin until well after 1945 and involved debates over the nature of evidence, the significance of clinical experience in the validation of a particular therapy, and the role of competing medical specialties.

[The hypertrophy of pharyngeal tonsill in the estimation of XIX-century physicians]. / Przerost migdalka gardlowego w ocenie XIX-wiecznych lekarzy.

The role of such physicians as Rudolph A. Kolliker, Johann N. Czermak, Ludwig Tuerck, Friedrich E. Voltlini, Benjamin B. Loewenberg, Hubert v. Luschka in the building of the science on hypertrophy of pharyngeal tonsil are pointed out first of all. The specific significance of achievements of Wilhelm Meyer (1824-1895) of Copenhagen based on scrupulous examinations is described. In the Polish territories the innovatory were works of Teodor Heryng, Klemens Koehler, Wladyslaw Wróblewski, Jan Sedziak, Teofil Zalewski. The epidemiology, etiology, pathogenesis, anatomo-patological examinations, the role of pharyngeal tonsil on immunity system are presented widely. The influence of hypertrophy of pharyngeal tonsil on general evolution of child, on his intellectual sphere, on speech disorders, on upper respiratory tract disorders, on auditory disorders, on the origination of deaf-mutism, on the origination of reflexogenous neuroses are described in more detail. An important role of anterior rhinoscopy, posterior rhinoscopy, and digital examination in the diagnosis of this illnes are also presented with full particulars.

[The historical review of the adenotomy]. / Adenotomia w ujeciu historycznym.

The opinions of famous foreign and also such Polish physicians as Jan Sedziak, Wladyslaw Wr6blewski, Zdzislaw Dmochowski on problem of removal of hypertrophic pharyngeal tonsil are presented first of all. An unsuccessful trials of conservative treatment are pointed out. Adenotomy was preformed in general anaesthesia, especially by chloroform, in "half-anaesthization", in local anaesthesia. The problems of anaesthesia are presented widely. The various method of removal of hypertrophic pharyngeal tonsils by forceps, by curettes, by loops, by nail are depicted with full particulars. The Loewenberg's forceps in various modifications, the Gottstein's curette and later the Beckmann's and La Force's adenotoms were best. The problem of rinsing of nose after the operation and influence of this rinsing on complications in auditory organ, the problem of postoperative relapses are discussed. The postoperative complications after adenotomy, bleeding and haemmorhage early and late, running of bits of tonsil into larynx, the inflammations of upper respiratory tract are also presented. The Jan Miodonski's and Jan Danielewicz's modern opinions at a performance of problem of adenotomy are depicted finally.

History and current practice of tonsillectomy.

OBJECTIVE: To review important developments in the history of adenotonsillectomy and describe current methods and results for the operation. STUDY DESIGN: Review. METHODS: Tonsillectomy practices since antiquity were reviewed, with emphasis on introductions of new surgical tools and procedures, anesthesia methods, and patient care practices. Past and current indications for and complications associated with tonsillectomy were also reviewed. RESULTS: Devices used for adenotonsillectomy have included snares, forceps, guillotines, various kinds of scalpels, lasers, ultrasonic scalpels, powered microdebriders, and bipolar scissors. General anesthesia, the Crowe-Davis mouth gag, and methods for controlling bleeding have contributed greatly to success with the operation. Past and current indications for adenotonsillectomy are similar, although the relative importance of some indications has changed. The complication rate has declined, but the problems that do occur remain the same. Currently, cost-effectiveness is a principal concern. CONCLUSION: The instruments and procedures used for adenotonsillectomy have evolved to render it a precise operation. Today, the procedure is a safe, effective method for treating breathing obstruction, throat infections, and recurrent childhood ear disease.

[The nasopharynx and pharyngeal tonsil in the history of otology and rhinology. Pictures from the history of otorhinolaryngology, presented by instruments from the collection of the Ingolstadt Medical History Museum]. / Der Nasenrachenraum und die Rachenmandel in der Geschichte der Otologie und Rhinologie. Bilder aus der Geschichte der Hals-Nasen-Ohren-Heilkunde, dargestellt an Instrumenten aus der Sammlung im Deutschen Medizinhistorischen Museum in Ingolstadt.

Anatomy, nomenclature, first clinical observations: In ancient Greece and Rome and in the Middle Ages the posterior opening of the nasal passage was known (Greek "choane" = funnel) as an atomical structure, and it was also known that chronic nasal catarrh is common in children, but it was not realized that this was associated with special pathological alterations. The anatomist H. von Luschka in Tübingen, Germany, was the first to describe the nasopharynx in detail, and he coined the term "pharyngeal tonsil." The otologists of the 19th century like Kramer and Toynbee had placed the Eustachian tube in the center of their investigations and carried out numerous dissections with demonstration of the tubal orifice. They also knew that middle ear infections usually originated in the nasopharynx, but they did not realize that the hypertrophic pharyngeal tonsil was the cause. Posterior rhinoscopy and the diagnosis of the hypertrophy of the pharyngeal tonsil: Czermak in Budapest in 1860 had invented posterior rhinoscopy, and he was the first to diagnose hypertrophic alterations around the tubal orifice and the first to realize that they were the cause of tubal malfunction. Wilhelm Meyer in Kopenhagen in 1868 and 1873-1874 described hypertrophy of the pharyngeal tonsil ("adenoid vegetations") in detail and associated this finding with a syndrome characterized by mouth-breathing, snoring, a typical facial expression, deafness, recurring middle-ear affections, and characteristic alterations of speech. He based his conclusions on 5 years' experience with 175 observations in his office and on examination of 2700 children in Denmark and England. Surgical therapy of adenoid vegetations: Voltolini in Breslau in 1865 had observed a few cases of hypertrophy of the pharyngeal tonsil, and he was the first to treat them by galvanic cauterization. Meyer developed various instruments for reducing the pharyngeal tonsil. They were introduced through the nose while the application of the instrument was assisted digitally via the mouth and pharynx. The operation of the pharyngeal tonsil was adopted very eagerly by a great number of nasal surgeons. Among the numerous special instruments that subsequently were invented the most promising was the ring knife invented by Gottstein in 1886. Anesthesia and positioning: The pioneers of this intervention, Voltolini, Meyer, Semon and others, all operated without any anesthesia, but they usually would need up to 12 sessions (Semon) until the pharyngeal tonsil had been sufficiently reduced. Beckmann in Berlin, who had invented a modification of Gottstein's ring knife, reported in 1897 on more than 5000 cases in which he had removed the adenoids in just one session, in each case without anesthesia. Besides these surgeons, others used cocaine for local anesthesia or chlorethyl or bromethyl for general anesthesia. The German surgeon Edmund Rose (Berlin and Zürich) in 1874 introduced the position with the head suspended for larger interventions like resection ot the maxilla. Rudloff in Wiesbaden, Germany, in 1900 adopted this position for adenoidectomy, but this was generally accepted only after the mouth gags developed by Davis-Boyle and Negus had been introduced. The diagnostic and surgical interventions in the nasopharynx were a powerful link in the process of fusion between otology and rhinolaryngology around the turn of the century. This historical development is described in great detail with many figures and quotations from the literature.

The development of adenoidectomy from Wilhelm Meyer of Copenhagen (1868) to the present time

It is presented a historical study on the origin of adenoidectomy and its evolution from this time untill the present time

The history of tonsil and adenoid surgery.

At present, there remains the controversial issue as to who should or should not have his tonsils removed. But whether or not a particular patient needs them removed, the historical development of tonsillectomy has rendered tonsillectomy a very precise operation. It is by no means a minor procedure and requires great skill and concentration to meet the altering circumstances that may occur during this procedure.