Is the number of tonsillectomies and tonsillotomies a relevant issue?

BACKGROUND: A second-opinion procedure was introduced for (adeno)tonsillectomy and tonsillotomy in 2018 by the Federal Joint Committee, due to the assumed high prevalence of both procedures. This study was conducted to quantify and analyze both types of tonsil surgery in Germany. METHODS: Data from the Federal Office of Statistics on the number of procedures and population size were used to calculate annual intervention rates between 2005 and 2017. Percentual changes in intervention rates compared to the previous year were calculated for Germany, for the total number of ENT specialists, for the ENT specialists of the federal states, and for four age groups (≤10; ≤20; ≤40; >40 years). RESULTS: Regression analysis revealed a significant decrease in (adeno)tonsillectomy and a significant increase in tonsillotomy in each investigated year (p < 0.001; exception: 2006 for adenotonsillectomy). Surgical rates of tonsillectomy and tonsillotomy decreased significantly with age (p < 0.001). There was no clear relationship between the density of ENT specialists in the different federal states and the number of surgical procedures. CONCLUSION: There was no clear association between the surgical prevalence and the density of ENT specialists. The significant decrease in rates of (adeno)tonsillectomy began in 2005 and the tonsillotomy rates have been increasing since 2007, albeit without a compensatory effect. Both procedures are on the list of the 50 most frequently performed operations. The decreasing total number of both surgical procedures questions the value of a second-opinion procedure as suggested by the Federal Joint Committee. Tonsil surgery is significantly associated with young age (<10 years) and discussions on surgery rates must consider the age structure of the investigated population, since this is the most important influencing factor in tonsil surgery.

[Is the number of tonsillectomies and tonsillotomies a relevant issue? German version]. / Sind Tonsillektomie und Tonsillotomie "mengenanfällige" Eingriffe?

BACKGROUND: A second-opinion procedure was introduced for (adeno)tonsillectomy and tonsillotomy in 2018 by the Federal Joint Committee, due to the assumed high prevalence of both procedures. This study was conducted to quantify and analyze both types of tonsil surgery in Germany. METHODS: Data from the Federal Office of Statistics on the number of procedures and population size were used to calculate annual intervention rates between 2005 and 2017. Percentual changes in intervention rates compared to the previous year were calculated for Germany, for the total number of ENT specialists, for the ENT specialists of the federal states, and for four age groups (≤10; ≤20; ≤40; >40 years). RESULTS: Regression analysis revealed a significant decrease in (adeno)tonsillectomy and a significant increase in tonsillotomy in each investigated year (p < 0.001; exception: 2006 for adenotonsillectomy). Surgical rates of tonsillectomy and tonsillotomy decreased significantly with age (p < 0.001). There was no clear relationship between the density of ENT specialists in the different federal states and the number of surgical procedures. CONCLUSION: There was no clear association between the surgical prevalence and the density of ENT specialists. The significant decrease in rates of (adeno)tonsillectomy began in 2005 and the tonsillotomy rates have been increasing since 2007, albeit without a compensatory effect. Both procedures are on the list of the 50 most frequently performed operations. The decreasing total number of both surgical procedures questions the value of a second-opinion procedure as suggested by the Federal Joint Committee. Tonsil surgery is significantly associated with young age (<10 years) and discussions on surgery rates must consider the age structure of the investigated population, since this is the most important influencing factor in tonsil surgery.

[Tonsil surgery in the federal states of Germany: similarities and differences. German version]. / Tonsillenchirurgie in den Bundesländern: Unterschiede und Gemeinsamkeiten.

BACKGROUND: Tonsillectomy remains a common procedure in Germany. However, demographic changes, the advent of tonsillotomy, and current guidelines may have an impact on the overall incidence. OBJECTIVE: To longitudinally evaluate the number of tonsillectomies, with (ATE) or without adenoidectomy (TE), and tonsillotomies (TT) performed annually in Germany. MATERIALS AND METHODS: Based on comprehensive data from the Federal Office for Statistics, the number of patients undergoing the above-stated surgical procedures on an inpatient basis was retrospectively assessed in terms of year and federal state, without restriction by age or gender. Annual rates of ATE, TE, and TT were calculated based on population statistics. Regression analysis was performed to compare different federal states, years, and age groups. The variables were compared using the Pearson correlation coefficient. RESULTS: Between 2005 and 2017, 1,313,449 tonsil surgeries were registered. There was a considerable decrease in the overall incidence rate (per 100,000) of TE (92 to 43), which was even more pronounced for ATE (51 to 15). In contrast, an increased TT rate (6 to 22) was observed. Correlation analysis revealed a strong positive correlation (r = 0.986). CONCLUSION: The change of trends in tonsil surgery started long before relevant national guidelines were published. The national trend was associated with considerably less surgical activity overall, a significant decrease in ATE/TE, and a significant increase in TT. Regional differences to the national trend were identified and found to be significant in at least in 7 of 16 federal states.

[Hospitalization of children after ENT surgery in Germany]. / Hospitalisierung von Kindern nach HNO-Eingriffen in Deutschland.

BACKGROUND: Morbidity following tonsil surgery is widely determined by pain, odynophagia, and bleeding. Detailed information about postoperative care in pediatric patients in Germany in the context of otolaryngologic interventions is currently lacking. MATERIALS AND METHODS: A questionnaire including eight questions to clarify trends and traditions in hospitalization strategies for pediatric patients was sent via email on January 14, 2019, to all heads of ENT departments who were also members of the German Society of Otorhinolaryngology, Head and Neck Surgery (DGHNO). The electronic survey was designed by the Pediatric Working Group of the DGHNO. RESULTS: The response rate was 72.9% (120/166), one response was excluded because it was not provided via the online tool. Children are currently transferred to pediatric clinics after surgery in 64 of 120 otorhinolaryngology departments, a tradition in existence for at least 5 years in 48 of the 64 departments. In the remaining 56 institutions, children remained in the otorhinolaryngology department despite 30 having specialized pediatric clinics or clinics for pediatric surgery. This strategy is expected to be discontinued in 5 of the 56 hospitals in due course. A separate pediatric ENT clinic within the same institution is uncommon (27/120). The average travel time of on-call physicians in cases of postoperative bleeding is 3.4 min; transportation of the child to the emergency operation room takes 5.4 min on average. The nursing staff is predominantly responsible for transportation of pediatric emergency patients (109/120). The wards and operation rooms are commonly located in the same building, but on different floors (83/120). CONCLUSION: There is currently no uniform hospitalization strategy for postoperative care of children who undergo typical otorhinolaryngologic interventions in Germany.

Tonsil surgery in the federal states of Germany: similarities and differences.

BACKGROUND: Tonsillectomy remains a common procedure in Germany. However, demographic changes, the advent of tonsillotomy, and current guidelines may have an impact on the overall incidence. OBJECTIVE: To longitudinally evaluate the number of tonsillectomies, with (ATE) or without adenoidectomy (TE), and tonsillotomies (TT) performed annually in Germany. MATERIALS AND METHODS: Based on comprehensive data from the Federal Office for Statistics, the number of patients undergoing the above-stated surgical procedures on an inpatient basis was retrospectively assessed in terms of year and federal state, without restriction by age or gender. Annual rates of ATE, TE, and TT were calculated based on population statistics. Regression analysis was performed to compare different federal states, years, and age groups. The variables were compared using the Pearson correlation coefficient. RESULTS: Between 2005 and 2017, 1,313,449 tonsil surgeries were registered. There was a considerable decrease in the overall incidence rate (per 100,000) of TE (92 to 43), which was even more pronounced for ATE (51 to 15). In contrast, an increased TT rate (6 to 22) was observed. Correlation analysis revealed a strong positive correlation (r = 0.986). CONCLUSION: The change of trends in tonsil surgery started long before relevant national guidelines were published. The national trend was associated with considerably less surgical activity overall, a significant decrease in ATE/TE, and a significant increase in TT. Regional differences to the national trend were identified and found to be significant in at least in 7 of 16 federal states.

[Tonsil surgery: impact of the mouth gag on pharyngeal diameter]. / Tonsillenchirurgie: Einfluss des Tonsillenspatels auf den Pharynxdurchmesser.

BACKGROUND: Photo documentation of hypertrophic tonsils is requested by some insurance companies to justify reimbursement of tonsillotomy. In 2017, a standardized photo documentation was introduced in tonsillotomy patients to verify the indication and effectiveness of the procedure. OBJECTIVE: Using the archived photo documentation, this study aimed to evaluate the impact of two different positions of the mouth gag on the oropharyngeal airway. MATERIALS AND METHODS: Pictures were taken through the operating microscope after insertion of the mouth gag but without suspension (D1), after suspension before tonsillotomy (D2), and after resection of tonsillar tissue with the mouth gag under tension (D3). For each picture, a 10-mm scale from a single-use paper ruler was placed on the uvula. For this retrospective study, the patient's images were inserted into PowerPoint slides. Distances were measured with the use of an inserted rectangular grid. RESULTS: The files of 149 patients undergoing tonsillotomy in a 6-month period were eligible for evaluation. Gender was balanced. The youngest patient was 16 months, the oldest patient 48 years old (mean: 6.95 years; median: 5 years). In all patients, tension of the mouth gag had significantly widened the oropharyngeal diameter (p < 0.001), making the tonsils appear smaller. CONCLUSION: Suspension of the mouth gag results in a significant relative "downsizing" of the tonsils due to expansion of the oropharynx. Intraoperative photo documentation should also be performed without suspension of the mouth gag. Further studies may clarify whether stretching of the oropharynx has an impact on the distance between the tonsils and surrounding greater arteries.

Extranasopharyngeal angiofibroma revisited.

BACKGROUND: Angiofibromas in the head and neck region usually arise in the nasopharynx, but may also occur elsewhere. This study aims at evaluating the incidence and clinical features of extranasopharyngeal angiofibroma (ENA). MATERIAL AND METHODS: Systematic review of the literature (Medline® and Google™ ) up to 31 December 2015. RESULTS: 174 cases of ENA were retrieved from a total of 170 publications. In contrast to former publications and previous understanding, the nasal septum was by far the most common site of the disease. Four patients had a congenital lesion, the oldest patient was 87 years old (mean: 28.7 years; median: 23 years). Male gender was predominantly affected, but the sex ratio was more balanced (2.13:1) than in previous reports in the literature until 12/2015. The majority of patients presented with nasal obstruction, either in combination with epistaxis (25.8%) or other symptoms (12.6%). Symptoms had developed within 13.1 months on average (median: 4 months). Brisk bleeding resulted in 11 of 43 biopsy procedures. Surgical resection as first-line therapy was performed in 170 patients. A tumour regrowth within 12 months was registered in four patients. CONCLUSION: The increasing awareness of ENA and the willingness to publish case reports-not only in Medline-listed journals-resulted in a significant increase of published case reports lately. Although extremely rare, ENAs have to be taken into account in the differential diagnosis of unclear masses, particularly in adult patients presenting with a rapidly developing nasal obstruction resulting from a nasal septum tumour. Female gender or normal vascularity does not exclude the diagnosis. Transnasal resection is sufficient in most cases, and recurrences are rare. Pathologists as well as clinicians should consider ENA in their differential diagnosis of any mass of the upper airway.

[An update on tonsillotomy studies]. / Aktuelle Studienlage zur Tonsillotomie.

BACKGROUND: Tonsillotomy procedures (TT) are being increasingly performed owing to the low postoperative morbidity compared with extracapsular tonsillectomy (TE). Patients may experience regrowth of tonsillar tissue or tonsillitis in the tonsillar remnants eventually resulting in a secondary tonsillectomy. OBJECTIVES: A review of the literature was undertaken to evaluate the current indications and contraindications, surgical instruments, risks of surgery, and the need for further research related to TT. MATERIAL AND METHODS: A search of the PubMed database was performed with the following terms: "tonsillotomy," "partial tonsillectomy," "subtotal tonsillectomy," "intracapsular tonsillectomy," "RFITT," and "tonsil ablation." Filters included language (English; German) and publication date (1960-2016). Articles were excluded if they were not related to tonsil surgery, did not provide clinical data, dealt with uncommon surgical techniques, or presented only data from polysomnographic studies. RESULTS: In all, 104 papers encompassing 97 studies and seven national surveys were eligible for analysis. In total, 13,270 patients had undergone TT and were compared with 11,485 patients after TE. Partial resection of the tonsils was most commonly accomplished with a microdebrider (51.5 %), and less frequently with coblation (20.5 %), radiofrequency (9.1 %), CO2 laser (6.6 %), or other surgical instruments. The age in the study groups ranged between 6 months and 78 years (median: 6.0 years). The prevailing indication for surgery was upper airway obstruction resulting from tonsillar hyperplasia with (n = 20) or without (n = 60) a history of tonsillits. In seven studies, TT was explicitly performed to resolve tonsillitis, while three authors did not specify the indication for surgery. The hemorrhage rate after TT was 0.2 % on average. CONCLUSION: TT is predominantly indicated for tonsillar hyperplasia, with or without tonsillitis. Restrictions related to age or surgical instruments are not reported in the literature data. Data concerning operation time, intraoperative bleeding, and outcome favor TT over TE. The median values for regrowth (3.0 %), postoperative tonsillitis (2.85 %), and secondary TE (1.37 %) emphasize the high success rate of TT. Further research utilizing a uniform terminology is mandatory to clarify the benefit of TT over TE in the long term and to resolve sleep-related breathing disorders resulting from tonsillar hyperplasia or tonsillitis.

[Evidence-based Indications for Tonsillectomy]. / Evidenz basierte Indikationen der Tonsillektomie.

BACKGROUND: One of the most significant clinical trials, demonstrating the efficacy of tonsillectomy (TE) for recurrent throat infection in severely affected children, was published in 1984. This systematic review was undertaken to compile various indications for TE as suggested in the literature after 1984 and to stratify the papers according to the current concept of Evidence-based Medicine. MATERIAL AND METHODS: A systematic Medline research was performed using the key word "tonsillectomy" in combination with different filters such as "systematic reviews", "meta-analysis", "English", "German" and "from 1984/01/01 to 2015/05/31". Further research was performed in the Cochrane Database of Systematic Reviews, National Guideline Clearinghouse, Guidelines International Network and BMJ Clinical Evidence using the same key word. Finally, data from the "Trip Database" were researched for "tonsillectomy" and "indication" and "from: 1984 to: 2015" in combination with either "systematic review" or "meta-analysis" or "metaanalysis. RESULTS: A total of 237 papers were retrieved but only 57 matched our inclusion criteria covering the following topics: peritonsillar abscess (3), guidelines (5), otitis media with effusion (5), psoriasis (3), PFAPA-Syndrome (6), evidence-based indications (5), renal diseases (7), sleep-related breathing disorders (11), and tonsillitis/pharyngitis (12), respectively. CONCLUSIONS: 1) The literature suggests, that TE is not indicated to treat otitis media with effusion. 2) It has been shown, that the PFAPA-syndrome is self-limiting and responds well to steroid administration, at least in a considerable amount of children. The indication for TE therefore appears to be imbalanced but further research is required to clarify the value of surgery. 3) Abscesstonsillectomy as a routine is not justified and indicated only for cases not responding to other measures of treatment, evident complications, or with a significant history of tonsillitis. In particular, interval-tonsillectomy is not justified as a routine. 4) TE, with or without adenoidectomy, is efficacious to resolve sleep-related breathing disorders resulting from (adeno)tonsillar hypertrophy in children. However, the benefit is reduced by co-morbidities, such as obesity, and further research required to identify prognostic factors for this subgroup of patients. Further research is indicated to clarify selection criteria not only for this subpopulation that may benefit from less invasive procedures such as tonsillotomy in the long-term. 5) Further trials are also indicated to evaluate the efficacy of TE on the clinical course in children with psoriasis guttata as well as on psoriasis vulgaris in adults, not responding to first-line therapy. 6) Conflicting results were reported concerning the role of TE in the concert to treat Ig-A nephropathy, mandating further clinical research. 7) Most importantly, randomized-controlled clinical trials with an adequate long-term follow-up are desirable to clarify the benefit of TE in patients with recurrent episodes of tonsillitis, with or without pharyngitis. Factors like age, spontaneous healing rate and postoperative quality of life have to be included when comparing TE with antibiotic therapy.

[Tonsil Surgery in Germany: Rates, Numbers and Trends]. / Tonsillektomie: offizielle Zahlen und Trends in Deutschland.

BACKGROUND: Tonsillectomy rates vary considerably among different states, regions and times. This study was undertaken to identify the prevalence of "chronic" tonsillitis, peritonsillar abscess, hyperplasia of the tonsils with and without adenoids in absolute and relative numbers in an 80m people nation. Moreover, the number and rates of different surgical procedures to resolve either "chronic" tonsillitis, peritonsillar abscess or upper airway obstruction due to (adeno)tonsillar hyperplasia over several years was evaluated in this study (tonsillectomy, adenotonsillectomy, tonsillotomy , abscess tonsillectomy, transoral incision and drainage). Finally, the post-tonsillectomy hemorrhage rate was determined and analyzed in relation to age and gender.. MATERIAL AND METHODS: Calculations were based on data as published by the Federal Institute of Statistics or on request, if needed. The latest data were provided for 2013.. RESULTS: The total number of the aforementioned diseases (stratified by ICD-10) decreased from 142.574 (in 2000) to 87.624 in 2013 (38.5 %). Tonsillectomy, with or without adenoidectomy, was performed in a total of 833.896 patients between 2006 and 2013 in Germany. The yearly number decreased continually from 120.993 in 2006 to 84.332 procedures in 2013 (30.3 %). The most significant decrease was registered in patients younger than 20 years of age for this time period: 70.92 per 10.000 in 2010 to 58.68 per 10.000 in 2013. If all age groups were included, the rate decreased from 13.34 per 10.000 to 10.90 per 10.000. In contrast, an increasing number of tonsillotomies was performed between 2007 (4.659 procedures) and 2013 (11.493). The cumulated number of procedures was 59.049. A constant number of 15.000 cases with peritonsillar abscess were diagnosed per year in Germany (19 patients per 100.000). The prevalence increased significantly at an age of 15 years and there was a preponderance of female patients below that age. Compared to transoral incision and drainage, a 2.8-fold greater number of abscess tonsillectomies were performed annually. Post-tonsillectomy hemorrhage was experienced by 5.98% of all patients after 245.721 procedures in 2010 and 2013 (all indications, except tonsillotomy). Bleeding complications had occurred less frequently in female patients (5.06 % vs. 7.02 %). Finally, a considerable increase of post-tonsillectomy hemorrhage in patients older than 10 years of age was registered in male patients only. CONCLUSIONS: chronic tonsillitis was less frequently diagnosed and surgically treated in terms of tonsillectomy (with or without adenoidectomy), particularly in female patients. In contrast, the number of tonsillotomies increased continullay, particularly in male patients. Peritonsillar abscess was diagnosed and surgically treated in a constant number of patients in the yearly comparison. Most of these patients were scheduled for abscess tonsillectomy, and only a 2.8-fold smaller number for transoral incision and drainage. Independent from the indication for surgery, post-tonsillectomy hemorrhage was clearly associated with male gender and age (>10 years). The study reveals a dramatic change mandating further surveillance by insurance companies and authorities in the national health system of an 80m people nation..

Tonsillotomy: facts and fiction.

In contrast to total or extracapsular tonsillectomy (TE), subtotal/intracapsular/partial tonsillectomy (SIPT) or tonsillotomy (TT) is associated with significant less postoperative morbidity. It has been stated that patients older than 8 years of age or with a history of tonsillitis should be excluded from SIPT/TT. Some health insurance companies mandate utilization of particular surgical instruments. Finally, it has been stated that the remaining tonsillar tissue may become a subject of recurrent tonsillitis or tonsillar regrowth, in both cases requiring revision surgery in terms of TE. This literature review was undertaken to clarify what has been validated in the literature concerning indications, surgical techniques, complications and outcome of SIPT/TT as reported since 1960. A Medline review was undertaken and all papers included that were published in English or German language until September 30, 2013. Exclusion criteria were: publication date 1960 and earlier, other languages, no relation to tonsil surgery, papers not available to the authors, uncommon surgical techniques, national surveys or studies without patients. The quality of the papers was classified according to "The Oxford 2011 Levels of Evidence". The surgical techniques were classified according to Windfuhr and Werner and extended to interstitial tonsil therapy. Other issues were: study period, hemorrhage, dehydration, intake of analgesics, return to normal diet, surgical instruments, operation time, number of surgeons involved, number of patients, age, indications, follow-up, rate of tonsillar regrowth, tonsillitis and secondary TE. A total of 379 different publications were retrieved, but only 86 studies found eligible for further analysis. There were 10,499 patients in the study groups and 10,448 patients in the control groups. Utilization of the microdebrider largely prevailed, followed by Coblation, CO2-LASER, surgical scissor, Radiofrequency, Interstitial ThermoTherapy with various instruments, Diode-LASER, and other instruments. Instruments were not specified for 1,815 patients. Data for operation time, intraoperative bleeding, return to normal diet, analgesic intake were in favor for SIPT/TT and ablation procedures. Regrowth and tonsillitis occurred in rates of <6 % on average. Secondary surgery became necessary in only every third patient of this subgroup. Studies of variable quality impede comparison of all aspects in the papers. At least every second study did not address issues like operation time, intraoperative bleeding, return to normal diet, analgesic intake, rates of tonsillar regrowth, postsurgical tonsillitis and secondary TE. There are insufficient data to show that a single surgical instrument is superior. A history of tonsillitis and an age >8 years are definitely not commonly accepted as contraindication for SIPT, TT or ablation procedures. There is a strong evidence that pain is less after SIPT, TT and tonsil ablation resulting in an earlier return to normal diet and activity. Large, well-designed randomized controlled trials with an adequate follow-up are necessary to determine whether the procedure is capable to replace TE to resolve upper airway obstruction resulting from tonsillar hypertrophy as well as recurrent episodes of tonsillitis in children and adults.

[Faults and failure of tonsil surgery and other standard procedures in otorhinolaryngology]. / Fehler und Gefahren: tonsillektomie und andere Standard-Eingriffe.

Septoplasty, tonsillectomy (with and without adenoidectomy) and cervical lymph node excision are amongst the most common 50 inpatient operations in Germany. Intracapsular tonsillectomies (i.e., tonsillotomies) are increasingly performed. The aim of this study was to evaluate alleged medical malpractice, technical traps and pitfalls associated with tonsillectomy (TE), adenoidectomy (AE), tonsillotomy (TT), septoplasty (SP) and cervical lymph node excision (LN).A questionnaire was sent to the Regional Medical Conciliation Boards, Medical Services of the Health Insurance Companies (MDK) and Regional Institutes of Forensic Medicine in Germany to collect anonymized cases of complications or medico legal implications following TE, TT, AE, LN and SP. The results were discussed in the light of the contemporary medical literature and published verdicts in Germany.The response rate of our survey was 55.9%. The Institutes of Forensic Medicine contributed 9 cases, 49 cases were submitted by the Regional Conciliation Boards and none by MDK. All forensic cases were associated with exsanguinations following tonsillectomy including 2 children (5 and 8 years of age) and 7 adults (aged 20-69 years). The fatal post-tonsillectomy hemorrhage (PTH) had occurred 8.7 days on average; 4 patients experienced the bleeding episode at home (day 5, 8, 9 and 17, respectively). Repeated episodes of bleeding requiring surgical intervention had occurred in 6 patients. 3 Conciliation Boards submitted expert opinions concerning cases TT (1), AE (4), LN (3), SP (16) and TE (25). Cases with lethal outcome were not registered. Only 3 of the 49 cases were assessed as surgical malpractice (6.1%) including lesion of the spinal accessory nerve, wrong indication for TE and dental lesion after insertion of the mouth gag. The review of the medico legal literature yielded 71 published verdicts after AE and TE (29), LN (28) and SP (14) of which 37 resulted in compensation of malpractice after LN (16; 57%), TE (11; 41%), SP (8; 57%) and AE (2; 100%). There were 16 cases of PTH amongst 27 trials after TE resulting either in death (5) or apallic syndrome (5). Bleeding complications had occurred on the day of surgery in only 2 patients. 16 trials were based on malpractice claims following SP encompassing lack of informed consent (6), anosmia (4), septal perforation (2), frontobasal injury (2) and dry nose (2). Trials based on LN were associated exclusively with a lesion of the spinal accessory nerve (28), including lack of informed consent in 19 cases. 49 cases (69%) were decided for the defendant, 22 (31%) were decided for the plaintiff with monetary compensation in 7 of 29 AE/TE-trials, 9 of 28 LN-trials and 6 of 14 SP-trials. Lack of informed consent was not registered for AE/TE but LN (11) and SP (2).Complicated cases following TE, TT, ATE, SP and LN are not systematically collected in Germany. It can be assumed, that not every complicated case is published in the medical literature or law journals and therefore not obtainable for scientific research. Alleged medical malpracice is proven for less than 6% before trial stage. Approximately half of all cases result in a plaintiff verdict or settlement at court. Proper documentation of a thorough counselling, examination, indication, informed consent and follow-up assists the surgeon in litigation. An adequate complication management of PTH is essential, including instructions for the patients/parents, instructions for the medical staff, readily available surgical instruments and appropriate airway management in an interdisciplinary approach. Electrosurgical tonsillectomy techniques were repeatedly labeled as a risk factor for bleeding complications following TE. Institutions should analyse the individual PTH rate on a yearly basis. Contradictory expert opinions and verdicts of the courts concerning spinal accesory nerve lesions following LN are due to a lack of a surgical standard.

Post-tonsillectomy pseudoaneurysm: an underestimated entity?

OBJECTIVE: To identify patients undergoing arteriography to verify vascular complications of tonsillectomy, with an emphasis on pseudoaneurysm. PATIENTS AND METHODS: We undertook a retrospective analysis of the case records of 8837 patients who had undergone tonsillectomy between 1988 and 2004 at our institution, together with a review of expert reports written for professional boards and civil courts as well as personal experiences or communication. We also conducted a literature review using the PubMed database. RESULTS: We identified seven cases with vascular abnormalities. In addition, we identified three cases of pseudoaneurysm formation, involving two children and one adult patient, with bleeding 21, 36 and 58 days after tonsillectomy. Successful management included embolisation (two patients) and revision surgery (one patient). CONCLUSION: Post-tonsillectomy pseudoaneurysm formation is extremely rare and unrestricted by age. Correct diagnosis depends largely on a high index of clinical suspicion. Delayed and repeated episodes of gushing haemorrhage with spontaneous cessation appear to be a significant clinical marker. Immediate arteriography, with simultaneous embolisation, is highly recommended. The lingual artery is the most commonly involved vessel.

Electrosurgery as a risk factor for secondary post-tonsillectomy hemorrhage.

The literature suggests that tonsillectomy techniques are not standardized throughout the world although certain techniques were identified as risk factors for post-tonsillectomy hemorrhage (PTH). This survey was undertaken to evaluate whether surgical techniques are uniformly performed in a nation of 82 million people and if they are related to the incidence of PTH or lethal outcome. A questionnaire was sent personally to the chairmen of 156 departments of otorhinolaryngology, including 37 University Hospitals to assess the surgical training techniques of tonsil dissection and hemostasis, incidence of primary (<24 h) and secondary (>24 h) PTH, number of tonsillectomies performed in 2006 and the number of cases with lethal outcome. The responses were made anonymous for further analysis. The response rate was 88.5% (138/156). A total of 54,572 procedures were performed (mean 395.4, median 361.5, SD 199.5, range 100-975 annually per clinic). Cold dissection was the teaching method of choice (117). Hemostasis was either achieved by suture ligation or bipolar cautery in 91 departments. Secondary bleeding clearly prevailed in the responses (97). One patient experienced a fatal bleeding after tonsillectomy indicated for tumour removal. Two other cases with lethal outcome had undergone surgery elsewhere including one patient who had undergone tonsillotomy. Lethal outcome occurred with an estimated incidence of 1/75,000. The term "conventional tonsillectomy" is loosely defined and includes various surgical techniques for tonsil dissection and methods to achieve hemostasis. The incidence of secondary PTH is related to electrosurgery with statistical significance. Lethal outcome may occur, if ever, rarely but even after intracapsular tonsillectomy.