Environmental Impact of Adult Tonsillectomy: Life Cycle Assessment and Cost Comparison of Techniques.

OBJECTIVES: To quantify and compare the cost and environmental impact of different techniques for adult tonsillectomy surgery, and to identify target areas for impact reduction. METHODS: Fifteen consecutive adult tonsillectomy surgeries were prospectively randomized to one of three tonsillectomy techniques: cold, monopolar electrocautery, or low-temperature radiofrequency ablation (Coblation). Life cycle assessment was used to comprehensively evaluate the environmental impact of study surgeries. Outcomes assessed included multiple measures of environmental impact, including greenhouse gas (GHG) emissions, and cost. Environmental impact measures were analyzed to identify highest-yield areas for improvement, and outcomes were compared between surgical techniques using statistical analysis. RESULTS: GHG emissions for cold, monopolar electrocautery, and Coblation techniques were 157.6, 184.5, and 204.7 kilograms of carbon dioxide equivalents (kgCO2 -eq) per surgery, respectively, with costs totaling $472.51, $619.10, and $715.53 per surgery, respectively. Regardless of surgery technique, anesthesia medications and disposable equipment contributed most to environmental harm. Cold technique demonstrated reduced environmental impact related to disposable surgical equipment in the categories of greenhouse gas emissions, acidification of soil and water, eutrophication of air, ozone depletion, release of carcinogenic, and non-carcinogenic toxic substances, and respiratory pollutant production (p < 0.05 for all comparisons with other techniques). CONCLUSION: Within the boundaries of operating room processes, cold technique minimizes cost and environmental impact of adult tonsillectomy surgery, with statistical significance noted in the impact of disposable surgical equipment. Areas of highest potential for improvement identified include reducing use of disposable equipment and collaboration with the Anesthesiology care team to streamline medication use. LEVEL OF EVIDENCE: 2, randomized trial Laryngoscope, 134:622-628, 2024.

Variation in paediatric tonsillectomy rates between Scottish health board areas, 2001-2018: is socio-economic deprivation to blame?

BACKGROUND: Tonsillectomy is one of the commonest operations in children. Routinely collected national data were used to assess variations in the paediatric tonsillectomy rate across Scotland, and to determine if socio-economic deprivation is the cause. METHOD: The Scottish Morbidity Records were reviewed for all children (0-16 years) undergoing tonsillectomy from 2001 to 2018. RESULTS: The mean annual tonsillectomy rate was 2.64 per 1000 children. Rates in each health board area varied from 1.24 to 3.9 per 1000. Half of this variation resulted from transfers between regions. There was a 1.75-fold difference between tonsillectomy rates in the most and least deprived population quintiles, but this did not account for the geographical variation. CONCLUSION: Half the variance in paediatric tonsillectomy rates is associated with children being transferred between regions for treatment. After accounting for this, there is a 1.5-fold difference in rate between health board areas, which is not related to socio-economic deprivation and is currently unexplained.

Assessing outcomes after partial and total tonsillectomy for sleep-disordered breathing in children using Clinical Assessment Score-15.

INTRODUCTION: The Clinical Assessment Score-15 (CAS-15) is an office-based tool for assessing the risk of sleep disordered breathing (SDB), a relatively common condition in the pediatric population. Change in CAS-15 following total tonsillectomy (TT) has been shown to have a large effect size, but it is unclear how it varies following partial intracapsular tonsillectomy (PIT). Thus, the objective of the present study is to evaluate the utility of the CAS-15 score in assessing the effectiveness of PIT and how this compares to change after TT. MATERIAL METHODS: Children ages 2-18 undergoing PIT (N = 16) or TT (N = 8) with or without adenoidectomy for SDB completed the CAS-15 before surgery and at their post-operative follow-up visit. Changes in CAS-15 score were assessed by paired t-test. The mean difference in CAS-15 change between PIT and TT was evaluated by unpaired t-test for unequal variances. Differences in participant characteristics were determined via unpaired t-test for unequal variances. RESULTS: Participants undergoing PIT did not differ significantly than those undergoing TT with regard to age, sex, BMI percentile, pre-op CAS-15 score or tonsil size, or admission rates following surgery (p > 0.05). The median follow-up after surgery was 5.2 (PIT) and 4.4 (TT) weeks. CAS-15 score improved significantly following PIT (42.8 ± 12.3 vs. 9.4 ± 5.6, p < 0.0001) and TT (45.5 ± 13.3 vs. 7.9 ± 5.8, p < 0.0002). The decrease in CAS-15 for PIT did not differ from TT (33.3 ± 11.8 vs. 37.6 ± 15.0, p > 0.49). DISCUSSION: CAS-15 decreases drastically following PIT and TT, indicating significant improvement of SDB symptoms. Because the change in CAS-15 after PIT was similar to TT, PIT may be preferred due to the decreased morbidity of the procedure. Given the cost, time required, inconvenience, and other limitations of overnight polysomnography (PSG), which is the gold standard method of diagnosing SDB, CAS-15 may be a suitable replacement or adjunct for the assessment of SDB following PIT in addition to TT.

Assessment of Parental Choice Predisposition for Tonsillectomy in Children.

Importance: The decision to proceed with tonsillectomy to treat pediatric obstructive sleep-disordered breathing (OSDB) often falls on individual families. Despite emphasis on shared decision-making between parents and surgeons about tonsillectomy for OSDB, the extent to which parents have already decided about surgery prior to the child's consultation is not known. Objective: To identify predictors of parent choice predisposition for surgical treatment of OSDB with tonsillectomy and describe its association with parent-clinician communication. Design, Setting, and Participants: Observational cohort study conducted at 3 outpatient clinical sites (urban-based outpatient center, suburban off-site outpatient center, and community-based medical center) associated with a large academic center. A total of 149 parents of children undergoing their initial otolaryngology consultation for OSDB were identified through clinic scheduling records and deemed eligible for participation in this study. Of the 149 parents, a volunteer sample of 64 parents (42.9%) agreed to participate and have their consultation audiorecorded. Of these 64 participants, 12 parents were excluded because their child had previously been evaluated for OSDB by a specialist. Main Outcomes and Measures: The primary outcomes and measures were treatment choice predisposition scale (a measure of the strength of a patient's treatment decision prior to entering a medical consultation), parent communication behaviors coded in consultation audiorecordings (substantive questions asked, introduced medical jargon, expression of treatment preference, and scores on the OSDB and Adenotonsillectomy Knowledge Scale for parents). Results: A total of 52 parent participants were included in the final analysis. Most parent participants were female (n = 48; 92%); 50% (n = 26) of parents were non-Hispanic White, 37% (n = 19) were Black, 10% (n = 5) were Hispanic/Latino, and 4% (n = 2) self-reported race/ethnicity as "Other." Mean (range) choice predisposition was 6.84 (2-10), with 22 parents (42%) more predisposed to choose tonsillectomy. Parents more predisposed to choose tonsillectomy used more medical jargon during the consultation (odds ratio [OR], 3.95; 95% CI, 1.16-15.15) and were less likely to ask questions (OR, 0.22; 95% CI, 0.05-0.87). Parental predictors of greater predisposition toward choosing surgery were White race (OR, 7.31; 95% CI, 1.77-39.33) and prior evaluation by a pediatrician for OSDB (OR, 6.10; 95% CI, 1.44-33.34). Conclusions and Relevance: In this cohort study of parents of children with OSDB, many parents were predisposed to choose treatment with tonsillectomy prior to initial surgical consultation, which may lessen engagement and influence 2-way communication. In this cohort, greater predisposition for tonsillectomy was observed in non-Hispanic White parents and parents of patients who had been previously evaluated by a pediatrician for OSDB. Understanding parent choice predisposition for surgery may promote improved communication and parental engagement during surgical consultations. It may also help direct education about sleep and tonsillectomy to nonsurgical forums.

Cold Technique in Adult Tonsillectomy Reduces Waste and Cost.

OBJECTIVES: To quantify differences in waste and cost of disposable equipment between different tonsillectomy techniques. METHODS: Prospective study of waste attributable to disposable waste produced by tonsillectomy surgery. Disposable equipment required for tonsillectomy using cold, monopolar electrocautery (ME), and coblation techniques was measured; and differences in mass, volume, and cost of equipment between the 3 techniques were quantified. RESULTS: Cold technique was found to produce the least waste and have the lowest cost attributable to disposable surgical equipment. Projected single-case savings in mass and volume of waste resulting from using cold technique compared to ME were 1.272 kg and 1.013 L, respectively, and 1.043 kg and 1.723 L compared to coblation. Projected single-case savings in cost of disposable equipment for cold technique compared to ME were US$9.35 and US$185.05 compared to coblation. DISCUSSION: Using cold technique for adult tonsillectomy reduces waste and cost of disposable equipment compared to ME and coblation. Implications for Practice: Surgeons desiring to reduce cost and waste associated with tonsillectomy surgery may consider transitioning to cold technique.

Radical Tonsillectomy and Superior Pharyngeal Constrictor Anatomy: A Cadaveric and Oncologic Specimen Assessment.

INTRODUCTION: The rise in primary surgical management of oropharyngeal squamous cell carcinoma has led to varying interpretations of the histopathologic evaluation following a radical tonsillectomy. The oncologic margin may be significantly influenced by the morphologic relations and anatomic dimensions of the palatine tonsil and superior pharyngeal constrictor (SPC) muscle. OBJECTIVE: The aim of this study was to characterize the gross and histologic anatomic features of the palatine tonsil and SPC muscle following an en bloc radical tonsillectomy. METHODS: Radical tonsillectomy specimens were collected from cadaveric and oncologic subjects. Specimens were processed using standard histopathologic techniques and were analyzed by a board-certified head and neck pathologist. The thickness of the SPC muscle and relationship to the tonsillar carcinoma were assessed. RESULTS: Six cadaveric and 10 oncologic specimens were analyzed. The mean minimum SPC width for all cadaveric specimens was 1.02 ± 0.50 mm. The mean minimum width for oncologic specimens was 0.76 ± 0.46 mm. The mean distance from tonsil carcinoma to the lateral specimen margin was 1.79 ± 1.39 mm. CONCLUSION: Due to the limited width of the SPC muscle, a margin in excess of 2 mm may not be attainable in a transoral radical tonsillectomy. Margin status may be ideally determined by the integrity of the SPC muscle in future oncologic studies, rather than an adequate distance measurement.

What is the cost benefit ratio of sending adeno-tonsillar tissues for histology: does adenoid/tonsillar tissue in children undergo malignant transformation?

Due to the enormous amount spent on histology of adenoid and tonsillar samples from children with adeno-tonsillectomy with no confirmed result of malignancy, it has become expedient to reconsider sending such tissues for histologyThe objective of this study was to determine the necessity of sending tissues of adenoid and tonsils for histology by means of ascertaining the prevalence of malignancy among children with adeno-tonsillectomy. This was a retrospective study done in three private hospitals that provide care for children in Enugu. Data was obtained from the medical records of 72 patients who had undergone tonsillectomy and/or adenoidectomy from September 2011 to May 2018. All the surgical cases done had their samples sent immediately for histology. A total of 72 adeno-tonsillar tissues were taken for histology of which all showed lymphoid hyperplasia with none showing any form of malignancy. Age group ranged from 6 months-18 years with 57 males and 15 females. Histology of the adeno-tonsillar tissue specimen was done among all the children with each costing 9000 Naira (26 US dollars). There were 3 tonsillectomies, 1 adenectomy and 68 adeno-tonsillectomies done. Indications for surgery were mainly upper airway obstruction for 69 cases and recurrent tonsillectomy for 3 cases. Histology revealed lymphoid hyperplasia for all cases. None of the patients in our study had histologic evidence of malignancy. Routine histopathologic examination in adeno-tonsillectomy specimens among children may be dispensable as it showed a negative cost-benefit ratio.

Morbidity after tonsillectomy in children with autism spectrum disorders.

OBJECTIVES: As the incidence of autism spectrum disorder (ASD) increases, otolaryngologists are more likely to encounter patients from this population during tonsillectomy. The purpose of this study was to examine whether outcomes differ between pediatric patients with and without ASD in a national cohort of children undergoing tonsillectomy. Understanding these differences may be used to inform future approaches to improve clinical outcomes and healthcare costs. METHODS: Data for this study were obtained from the Kids Inpatient Database (KID) of the Healthcare Cost Utilization Project. We studied pediatric patients who underwent tonsillectomy during 2003, 2006, 2009, and 2012. Tonsillectomy was identified using ICD-9-CM diagnosis codes 28.2 (tonsillectomy without adenoidectomy) and 28.3 (tonsillectomy with adenoidectomy). ASD was identified using ICD-9-CM diagnosis code 299 (autism). Outcomes including complications, length of hospital stay, and total hospitalization costs. Analyses were performed using multivariable models. Propensity score matching was used to control for covariate imbalance between patients with and without ASD. RESULTS: In our sample of 27,040 patients, 322 (1.2%) had a diagnosis of ASD. After controlling for potential confounders, multivariable modeling suggested patients with ASD had a shorter LOS of 0.50 days (p < 0.0001), were less likely to experience complications (odds ratio 0.57, p = 0.001), and had lower associated costs of $1308 less (p < 0.0001). Propensity score matching confirmed the findings of the multivariable modeling. CONCLUSION: Although ASD alone does not appear to confer additional costs or morbidity, differences between children with and without ASD suggest the need for providers to address patients with ASD uniquely.

Gross Pathology of Routine Pediatric Tonsillectomy Specimens: Optimizing the Value of Patient Care.

OBJECTIVE: This investigation seeks to evaluate the effect of gross pathologic analysis on our management of patients undergoing routine tonsillectomy and to evaluate charges and reimbursement. STUDY DESIGN: Retrospective chart review from 2005 through 2016. SETTING: Academic medical center. SUBJECTS AND METHODS: Participants were pediatric patients aged 14 years and younger undergoing tonsillectomy for either sleep-disordered breathing or tonsillitis, with tonsillectomy specimens evaluated by pathology, and without any risk factors for pediatric malignancy. Records were reviewed for demographics, surgical indications, and pathology. Abnormal reports prompted an in-depth review of the chart. Charges and reimbursement related to both hospital and professional fees for gross tonsil analysis were evaluated. RESULTS: From 2005 to 2016, 3183 routine pediatric tonsillectomy cases were performed with corresponding specimens that were sent for gross analysis revealing no significant pathologic findings; 1841 were males and 1342 were females. Ten cases underwent microscopy by pathologist order, revealing normal tonsillar tissue. The mean charge per patient for gross analysis was $60.67 if tonsils were together as 1 specimen and $77.67 if tonsils were sent as 2 separate specimens; respective reimbursement amounts were $28.74 and $35.90. CONCLUSIONS: Gross pathologic analysis did not change our management of routine pediatric tonsillectomy patients. Foregoing the practice at our institution would eliminate $19,171.72 to $24,543.72 in charges and $9081.40 to $11,344.40 in reimbursement per year. Eliminating this test would improve the value of patient care by saving health care resources without compromising clinical outcomes.

Opioid prescription and postoperative outcomes in pediatric patients.

OBJECTIVES/HYPOTHESIS: To determine if the amount of opioid prescribed and postoperative outcomes after adenotonsillectomy changed following implementation of mandated opioid consent forms. STUDY DESIGN: Retrospective cohort study. METHODS: Patients undergoing adenotonsillectomy 6 months before and after implementation of mandated opioid consent forms at a tertiary-care pediatric hospital were studied. Demographics, operative data, weight-based opioid dosage, and postoperative outcome measures, including nursing calls, emergency department (ED) visits, hospital readmission, and bleed rates, were collected and analyzed. RESULTS: Of 300 patients, opioid prescription was provided for 211 patients (70.3%), 112 preconsent (74.7%) and 99 postconsent (66.0%). Mean (standard deviation) total opioid prescribed (milligrams/kilogram) was significantly higher preconsent 4.8 (5.6) than postconsent 3.2 (4.7), (P = .003). There were no differences between number of nursing calls (P = .134) or ED visits (P = .083). Interestingly, preconsent patients had more hospital readmission for pain/dehydration (odds ratio OR: 368, P = .016) and bleeding concerns (OR: 244, P = .003). CONCLUSIONS: A mandated consent form prior to opioid prescription was associated with decreased overall opioid prescription without resultant increase in postoperative complications in pediatric patients. These data provide support for minimizing opioid prescription on a systems-based level. LEVEL OF EVIDENCE: 4 Laryngoscope, 129:1477-1481, 2019.

Assessment of the Association Between Post-tonsillectomy Hemorrhage and Weather Conditions.

BACKGROUND: The most common complication after tonsillectomy is bleeding. We investigated whether performing the procedure during the summer or the winter affects the bleeding rate. OBJECTIVES: To investigate whether there is an association between meteorological conditions and the occurrence of post-tonsillectomy hemorrhage (PTH) in the southern Israel Negev region. METHODS: All patients who underwent tonsillectomy from 2001-2013 at the Soroka Medical Center were included. We collected patient demographic data and indications for surgery. Meteorological data were obtained from a weather station operated by the Israel Ministry of Environmental Protection. RESULTS: Of 4438 patients who underwent tonsillectomy, with or without adenoidectomy, 432 (9.73%) experienced hemorrhage. Patients who suffered from PTH were significantly older: median age 9.61 years vs.4.7 years, P < 0.0001. When comparing patients without PTH to those who bled within 0-3 days after surgery, there was a higher risk for bleeding during the warmer seasons: relative risk (RR) 1.38, 95% confidence interval ([95%CI] 1.07-1.77), RR 1.45 (95%CI 1.17-1.80), and 1.62 (95%CI 1.27-2.06) comparing the winter to spring, summer, and fall, respectively. A statistically significant positive association was also found with the average temperature on the day of surgery. Bleeding more than 3 days after surgery was less likely in summer: RR 0.82, 95%CI 0.69-0.97. We found no association with temperature on the day of surgery and PTH after postoperative day 3. CONCLUSIONS: Seasonality, and to an extent temperature, seem to play only a minor role in PTH.

Cost-Effectiveness Analysis of Intracapsular Tonsillectomy and Total Tonsillectomy for Pediatric Obstructive Sleep Apnea.

PURPOSE: We performed an economic evaluation using a decision-tree model to analyze the relative cost effectiveness from the United States Centers for Medicare and Medicaid Services (CMS) perspective of two different methods of tonsillectomy (traditional total tonsillectomy and partial intracapsular) for pediatric obstructive sleep apnea (OSA). MATERIALS AND METHODS: Procedural costs were drawn from published literature and Medicare values. Effectiveness and probabilities were drawn from medical literature. Primary intervention was monopolar-technique total tonsillectomy or microdebrider-assisted partial intracapsular tonsillectomy. Secondary interventions included operative control of hemorrhage, treatment of severe dehydration, or revision tonsillectomy. The decision model starts with pediatric patients with OSA, choosing between total and partial tonsillectomy. Outcomes were measured by costs (US dollars), effectiveness [quality-adjusted life year (QALY)], and a willingness-to-pay threshold of US$100,000/QALY. Base case analysis, probabilistic sensitivity analysis (PSA) and deterministic sensitivity analyses were performed. Primary outcome was incremental cost-effectiveness ratio (ICER) for each of the two tonsillectomy techniques. RESULTS: Base case analysis demonstrated that total tonsillectomy was more cost effective at US$12,453.40 per QALY gained. In PSA, 82.84% of the simulations show total tonsillectomy to be the more cost-effective strategy. Deterministic sensitivity analyses showed that when the rate of OSA recurrence is lower than 3.12%, partial tonsillectomy would be more cost effective. When the failure rate of partial tonsillectomy is below 1.0%, it is more cost effective even when total tonsillectomy is 100% successful. CONCLUSION: Study results suggest that overall monopolar-technique total tonsillectomy is more cost effective. However, with varying adjustments for disutility caused by procedural complications, intracapsular tonsillectomy could become a more cost-effective technique for treating pediatric OSA.

Comparison of Pediatric Intracapsular Tonsillectomy and Extracapsular Tonsillectomy: A Cost and Utility Decision Analysis.

Objectives To use decision analysis modeling to compare utility and cost outcomes of intracapsular tonsillectomy (ICT) and extracapsular tonsillectomy (ECT). To use sensitivity analysis to determine the most important factors influencing outcomes favoring one surgical method versus another. Study Design Decision analysis model. Setting Hypothetical cohort. Subjects and Methods A decision analysis model was created with computer software comparing the results of ICT and ECT. The model featured complications with completion tonsillectomy, such as postsurgical bleed, dehydration, and tonsillar regrowth. Outcomes were quantified with a utility scale ranging from 0.95 (1 surgical procedure without complications) to 0.55 (ICT, regrowth requiring completion ECT, post-ECT bleeding). Costs measured out-of-pocket costs for an insured patient and factored in different recovery times for ECT versus ICT. Results Based on baseline parameters, ECT had higher cumulative utility than ICT. Utility model results were highly dependent on the value of having a single uncomplicated surgery, as well as on the tonsillar regrowth rate. Utility was equal at a regrowth rate of 1.64%; rates above this value favored ECT. The base cost model showed that ICT ($4177.92) was less expensive than ECT ($4546.91), although ICT with regrowth had the highest outcome cost ($8393.91). ECT and ICT costs were equal at a tonsil regrowth rate of 17.8% and at a recovery period of 7.4 days. Conclusion Utility decision modeling based on best estimates for baseline parameters suggests that ECT may be slightly superior to ICT, but cost analysis suggests the opposite. However, the comparative results are highly dependent on subtle changes in the tonsil regrowth rate and the potential difference in recovery time.

Insurance Coverage and Acute Care Revisits After Pediatric Ambulatory Tonsillectomy.

We investigated whether patterns of health insurance coverage were associated with 30-day all-cause acute care revisits after ambulatory tonsillectomy at a free-standing quaternary-care pediatric hospital. Insurance patterns were classified from past encounters as continuous private, continuous Medicaid, Medicaid-to-private change, or private-to-Medicaid change. Among 478/675 boys/girls (age 9 ± 4 years) selected for analysis, 148 (13%) had 30-day revisits, whereas 96 (8%) changed from Medicaid to private insurance, and 99 (9%) changed from private insurance to Medicaid. Revisits were most common in the private-to-Medicaid group, compared with continuous private coverage (19% vs 10%; 95% CI of difference: 1%-18%; P = .007). The private-to-Medicaid group was most likely to be overweight, have symptoms of sleep disordered breathing, and have more past clinical encounters. In multivariable analysis, the greater risk of acute care revisits among children with private-to-Medicaid change in coverage was attributable to greater comorbidity burden and past health care utilization.

Impact of the Korean Diagnosis-Related Groups payment system on the outcomes of adenotonsillectomy: A single center experience.

OBJECTIVES: To report outcomes with regard to clinical aspects and medical costs of adenotonsillectomy and tonsillectomy at a single institution before and after implementation of the Diagnosis-Related Groups (DRG) payment system in Korea. METHODS: We retrospectively reviewed the records of patients treated with adenotonsillectomy or tonsillectomy between July 2012 and June 2014. The Korean DRG payment system was applied to seven groups of specific diseases and surgeries including adenotonsillectomy and tonsillectomy from July 2013 at all hospitals in Korea. We divided patients into four groups according whether the fee-for-service (FFS) or DRG payment system was implemented and operation type (FFS-adenotonsillectomy (AT), DRG-AT, FFS-tonsillectomy (T), and DRG-T). RESULTS: A total of 1402 patients were included (485 FFS-AT, 490 DRG-AT, 203 FFS-T, and 223 DRG-T). The total medical cost of the DRG-AT group was significantly lower than that of the FFS-AT group (1191±404 vs. 1110±279 USD, P<0.05). There were no significant differences in length of hospital stay or postoperative complications among groups. CONCLUSION: The Korean DRG system for adenotonsillectomy and tonsillectomy reduced medical costs and clinical outcomes were not significantly altered by the adoption of the DRG system. LEVEL OF EVIDENCE: 4.

Cost-effectiveness of Coblation compared with cold steel tonsillectomies in the UK.

OBJECTIVE: This study aimed to estimate the cost-effectiveness of Coblation compared with cold steel tonsillectomy in adult and paediatric patients in the UK. METHOD: Decision analysis was undertaken by combining published clinical outcomes with resource utilisation estimates derived from a panel of clinicians. RESULTS: Using a cold steel procedure instead of Coblation is expected to generate an incremental cost of more than £2000 for each additional avoided haemorrhage, and the probability of cold steel being cost-effective was approximately 0.50. Therefore, the cost-effectiveness of the two techniques was comparable. When the published clinical outcomes were replaced with clinicians' estimates of current practice, Coblation was found to improve outcome for less cost, and the probability of Coblation being cost-effective was at least 0.70. CONCLUSION: A best-case scenario suggests Coblation affords the National Health Service a cost-effective intervention for tonsillectomy in adult and paediatric patients compared with cold steel procedures. A worst-case scenario suggests Coblation affords the National Health Service an equivalent cost-effective intervention for adult and paediatric patients.

Assessment of weight gain following adenotonsillectomy in children with Down syndrome.

INTRODUCTION: Adenotonsillectomy (T&A) has been associated with postoperative weight gain in children. The purpose of this study is to determine whether a similar association exists in children with Down syndrome (DS). METHODS: The medical records of 311 DS patients were reviewed. Subjects were classified into either a control group or surgical group based on whether they had undergone adenotonsillectomy (T&A). Subjects were excluded if they only had one recorded BMI. Cases were analyzed in a pairwise fashion to maximize available data. 113 total patients with DS were identified: 84 (74.3%) in the control group and 29 (25.7%) in the T&A group. Height, weight, BMI, and Z-score data were compared between the control and T&A groups at 6-month intervals over a 24-month period. RESULTS: Children with DS who underwent T&A were comparable by demographics to children with DS who did not undergo T&A. Mean weight gain at 24 months for the T&A group was 8.07 ± 5.66 kg compared with 5.76 ± 13.20 kg in controls. The median Z-score at 24 months for the T&A group was 1.11 (0.10-1.88) compared with 1.17 (0.80-1.75) in controls. Children undergoing T&A had a stable median Z-score change of 0.09 at 24 months (p = 0.861, compared to baseline) while children who did not undergo T&A had a significantly increased median Z-score of 0.52 (p = 0.035, compared to baseline). Despite this, there were no significant intergroup differences between weight change, BMI, nor Z-score at any interval (p > 0.05). CONCLUSIONS AND RELEVANCE: Children with DS did not have an increased rate of weight gain or increased BMI after T&A. BMI Z-scores were shown to stabilize over 24 months in the T&A group and increase in the control group. While this suggests that T&A provides an added benefit of weight control in patients with DS, the results should be interpreted with caution due to the small sample size and the fact that not all patients had complete follow up across a 24-month period.

Impact of a pediatric anesthesiologist on operating room efficiency during pediatric tonsillectomies and adenotonsillectomies.

We conducted a retrospective case review to determine if the presence of an Accreditation Council for Graduate Medical Education (ACGME) fellowship-trained pediatric anesthesiologist improves efficiency during pediatric tonsillectomies and adenotonsillectomies in hospitals that do not have dedicated pediatric operating rooms and, if so, to determine which specific anesthesia practices might account for such a difference. We reviewed the charts of all patients aged 12 years and younger who had undergone a tonsillectomy or adenotonsillectomy from Jan. 1, 2008, through Aug. 1, 2013, at San Francisco General Hospital. A total of 75 cases met our eligibility criteria. We compiled information on patient demographics, surgical time, anesthesia time, and anesthesia practices. Our primary study outcome was the amount of anesthesia-controlled time (ACT), which is the sum of time spent in induction and emergence. Cases were grouped according to whether the operation was staffed by an ACGME fellowship-trained pediatric anesthesiologist or a general anesthesiologist. Data were analyzed for 1 pediatric anesthesiologist and 23 general anesthesiologists. We found that ACT was significantly shorter during the cases staffed by the ACGME fellowship-trained pediatric anesthesiologist, although there were no major differences in anesthesia practices between the types of anesthesiologist. We suggest that staffing pediatric tonsillectomy operations with a fellowship-trained pediatric anesthesiologist may be an effective strategy for increasing operating room efficiency.

Ultrasonographic assessment of tonsillar volume in children.

OBJECTIVES: Adenotonsillar hypertrophy in children is the most common anatomical abnormality associated with obstructive sleep apnoea. Perioperative complications associated with adenotonsillectomy are more common in children with severe obstructive sleep apnoea. An objective preoperative method to determine the size of tonsils is missing. This study assessed the validity of ultrasound as a tool for measuring tonsillar size in children. METHODS: Single-institution prospective study of twenty-six children aged 2-6 years who underwent elective bilateral tonsillectomy. Trans-cervical ultrasonographic assessment of tonsillar size prior to tonsillectomy operation was performed. We assessed correlation of ultrasonographic and actual tonsillar volume. RESULTS: A total of 52 tonsils from 26 patients were measured. Actual and ultrasonographic mean tonsillar volume (±SD) was 3.9 (±2.1) ml and 3.6 (±2.5) ml, respectively (P = 0.24). Ultrasonographic and actual measurements correlated well (r = 0.89). CONCLUSIONS: This is the first study to show that ultrasound is a suitable objective method for determining tonsillar volume in paediatric patients. Preoperative ultrasound assessment of tonsillar anatomy and size may be an additional and suitable, objective method in the development of a risk stratification system in children with obstructive sleep apnoea undergoing tonsillar surgery.