Effect of adenoid size on the post-adenoidectomy hypernasality in children with a normal palate.

PURPOSE: Adenoidectomy, either alone or with tonsillectomy, is a common surgical procedure in the field of pediatric otorhinolaryngology. Resonance function may be altered postoperatively in the form of hypernasality, which is usually transient. This study aimed to investigate the effect of adenoid size on post-adenoidectomy hypernasality in children with a normal palate. METHODS: Seventy-one children with different degrees of adenoid hypertrophy were included in this prospective observational study. Endoscopic assessment of the adenoid size and preoperative and postoperative evaluation of speech (at 1 and 3 months) with auditory perceptual assessment (APA) and nasometry were performed. RESULTS: APA showed preoperative hyponasality in 59.1% of children and was found to be significantly related to the adenoid size, with more hyponasality in grades 3 and 4. One month postoperatively, hypernasality was detected in 26.7% of patients and was found to be related to the preoperative adenoid size with higher hypernasality in grades 3 and 4. Three months postoperatively, all patients had gained normal nasality except one (1.4%) who was subjected to a longer follow-up period. Nasometric assessment showed significant differences at the three visits (pre, 1, and 3 months postoperatively), with a negative correlation between the grade of adenoid size and nasalance scores preoperatively and a significant positive correlation between them at 1 month postoperatively. However, no significant correlation was detected at 3 months postoperatively. CONCLUSION: Transient hypernasality may develop in some patients after adenoidectomy, especially in children with a larger preoperative adenoid size. However, transient hypernasality generally resolves spontaneously within 3 months.

Characterization of litigation after tonsillectomy in the United States.

BACKGROUND: Tonsillectomy is a common procedure performed for both adults and children. When unfavorable outcomes occur during perioperative events, patients may seek compensation through medical malpractice or medical negligence litigation. An understanding of these cases can help physicians and involved health care providers avoid risk and improve patient satisfaction. The aims of this study were to identify reasons for litigation after tonsillectomy and to examine outcomes of tonsillectomy-related litigation in the United States. METHODS: All available court decisions associated with medical malpractice and negligence after tonsillectomy in the Westlaw Campus Research legal database were reviewed. The plaintiff' relationship to the patient, patient characteristics, state where the tonsillectomy took place, specialty of the defendant(s), allegations, and adjudicated case outcomes were obtained from case documents and analyzed. RESULTS: Forty-two relevant judicial opinions written between 1986 and 2020 in 24 states were included. Twenty-two (52.4 %) of the cases involved female patients, and 24 (57.1 %) involved pediatric patients. Otolaryngology, anesthesiology, primary care, emergency medicine, orthodontics, and pharmacy were the disciplines involved in the negligence claims. Claims involved postoperative management in 18 (42.9 %) of the cases and intraoperative misadventure in 17 (40.5 %) of the cases. Six (14.3 %) of the 42 patients experienced an anesthesia complication, and 11 (26.2 %) experienced a surgical complication. Eleven (26.2 %) patients experienced postoperative bleeding. All cases involved postoperative concerns, and death occurred in 14 (33.3 %) of the patients. Overall, 21 (45.7 %) of the rulings were for the defendant. CONCLUSIONS: Postoperative management and intraoperative misadventure are commonly cited reasons for legal action after tonsillectomy procedures in the United States. All litigation surrounding tonsillectomy arose if concerns were present postoperatively. Thorough communication and attentive postoperative management are critical in order to avoid complications and patient injury, including death, associated with tonsillectomy.

Tonsillectomy: Post-Operative Hemorrhage Reduction Strategy in Jos, North Central Nigeria.

BACKGROUND: Post-tonsillectomy hemorrhage (PTH) is one of the more life-threatening /lethal complications and the leading malpractice claims/convictions in Oto-laryngological practice. OBJECTIVE: A Study on PTH reduction strategy in Jos, North Central Nigeria. STUDY DESIGN: Prospective Cohort Study. METHODS: Participants who met the criteria under GA had dissection Tonsillectomy ± Adenoidectomy between August 1, 2017-July 31, 2019 at the Jos University Teaching Hospital, Nigeria, were enrolled. Data analysis was by SPSS version 21.0 Chicago, IL, USA. RESULTS: We studied 96 participants with a M:F = 1.7:1. Age range was 9months-51years with a Median = 3.0years. Snoring-83(86.5%), Nasal obstruction - 71(74.0%), Mouth breathing -18(18.8), OSA(S) - 17(17.7%) were main features. Seventy-Eight (81.2%) were Grade III & IV and 71(75.0%) had Adenoid Nasopharyngeal Ratio >0.5. Mean INR was 1.22 ± 0.24 where 28(29.2%) were abnormal. Post-operative blood loss was 10ml - 250ml with Median = 35ml. There was a correlations between the Brodsky's grading with Tonsil volume and between Tonsil grade with volume of blood loss. An estimated 76.0% had the surgery within 60mins. We practice 'awake' extubation. Incidence of Primary PTH of 3.1% with no secondary PTH or mortality. CONCLUSION: We established that blood loss was directly proportional to the tonsil size which brings new insights in PTH prevention. Our use of specific agents for GA, technique/ expertise, pillar infiltration with Lignocaine, 'awake extubation, liberal post-operative analgesia with systemic antibiotics may be responsible for the low incidence of PTH in this series.

CONTEXTE: L'hémorragie post-amygdalectomie (HPT) est l'une des complications les plus mortelles et l'une des principales réclamations/convictions pour faute professionnelle dans la pratique de l'oto-laryngologie. OBJECTIF: Étude de la stratégie de réduction des hémorragies pulmonaires à Jos, dans le centre-nord du Nigeria. PLAN DE L'ÉTUDE: Étude de cohorte prospective. MÉTHODES: Les participants qui répondaient aux critères de l'AG ont subi une amygdalectomie ± adénoïdectomie par dissection entre le 1er août 2017 et le 31 juillet 2019 à l'hôpital universitaire de Jos, au Nigeria, ont été inscrits. L'analyse des données a été effectuée par SPSS version 21.0 Chicago, IL, USA. RÉSULTATS: Nous avons étudié 96 participants avec un rapport M:F = 1,7:1. La fourchette d'âge était de 9 mois à 51 ans avec une médiane de 3,0 ans. Le ronflement - 83 (86,5%), l'obstruction nasale - 71 (74,0%), la respiration buccale - 18 (18,8), le SAOS(S) - 17 (17,7%) étaient les principales caractéristiques. Soixante-dix-huit (81,2%) étaient de grade III et IV et 71 (75,0 %) avaient un rapport adénoïdenasopharyngé >0,5. L'INR moyen était de 1,22 ± 0,24 et 28 (29,2%) étaient anormaux. La perte de sang postopératoire était de 10ml -250ml avec une médiane de 35ml. Il y avait une corrélation entre le classement de Brodsky et le volume de l'amygdale et entre le classement de l'amygdale et le volume de la perte de sang. Environ 76,0% des patients ont été opérés dans les 60 minutes. Nous pratiquons l'extubation "éveillée". Incidence de l'HTP primaire de 3,1% sans HTP secondaire ni mortalité. CONCLUSION: Nous avons établi que la perte de sang était directement proportionnelle à la taille de l'amygdale, ce qui apporte de nouvelles perspectives dans la prévention de l'HTP. Notre utilisation d'agents spécifiques pour l'AG, notre technique/expertise, l'infiltration des piliers avec de la lignocaïne, l'extubation éveillée, l'analgésie postopératoire libérale avec des antibiotiques systémiques peuvent être responsables de la faible incidence d'HTP dans cette série. Mots-clés: Dissection de l'amygdalectomie, Perte de sang, Stratégie de réduction, Résultat.

Delayed onset of tooth decay in a routine pediatric adenotonsillectomy.

Adenotonsillectomy is a common pediatric surgical procedure with a well-defined safety profile. Major complications from this procedure include bleeding/hemorrhage, infection, pain leading to dehydration, and airway obstruction or edema. Though rare, oral endotracheal intubation and oral retractor placement may result in injuries to the teeth and the surrounding soft tissue. We describe a rare case of delayed tooth decay in a 3-year-old female following an otherwise routine adenotonsillectomy.

What is the influence of tonsillectomy on the level of periodontal pathogens on the tongue dorsum and in periodontal pockets.

BACKGROUND: For periodontal treatment, the full mouth disinfection approach suggests disinfection of oral soft tissues, such as tongue and tonsils concomitant to scaling and root planning since patients might benefit from treatment of these oral niches either. Periodontopathogenes in tonsillar tissue support this hypothesis. This prospective controlled clinical study investigated the change in the oral flora of patients who underwent tonsillectomy. Pockets were tested for eleven bacterial species before and six weeks after the surgical intervention. METHODS: Fifty generally healthy adults were included in this study. The test group consisted of 25 patients with tonsillectomy. The control group included 25 patients with otorhinolarynologic surgery without involvement of the oral cavity. Clinical parameters such as probing pocket depth, bleeding-on-probing index and plaque index were registered the evening before surgery. Also bacterial samples from the gingival sulcus and dorsum linguae were taken, and an additional sample from the removed tonsils in the test group. Six weeks after the intervention microbial samples of pockets and tongue were taken again. Data were tested for significant differences using Wilcoxon rank and Whitney-u-test. RESULTS: No relevant intra- or intergroup differences were found for the change of the eleven investigated species. CONCLUSION: Based on the results of the present study, tonsillectomy does not seem to have an immediate relevant effect on the bacterial flora of tongue or periodontium. This study design was approved by the ethical committee of Zurich (KEK-ZH-Nr.2013-0419). TRIAL REGISTRATION: The trial was retrospectively registered in the German Clinical Trials Register ( DRK00014077 ) on February 20, 2018.

The effectiveness of combined tonsillectomy and anterior palatoplasty in the treatment of snoring and obstructive sleep apnoea (OSA).

The prevalence of obstructive sleep apnoea (OSA) is increasing due to a rising rate of obesity. Multiple surgical techniques used to address obstruction at the palatal level have been associated with significant morbidities. Few studies have reported good outcomes of anterior palatoplasty (AP) in mild-to-moderate OSA. The aim of this study is to investigate the effectiveness of combining tonsillectomy and anterior palatoplasty in the treatment of snoring and OSA. All patients with snoring and OSA treated with tonsillectomy and anterior palatoplasty were analyzed. The primary outcome was reduction of the apnoea hypopnoea index (AHI) with surgical success criteria; reduction of AHI by ≥50% and AHI ≤10. The secondary outcomes measured were patients' Epworth Sleepiness Scale (ESS) and snoring visual analogue scale (VAS) scores. Thirty one patients completed the study, where 19% had mild, 42% moderate, and 39% had severe OSA. The mean surgical success rate was 45% at 3 months and 32% at 1-year post-operatively. There was a significant reduction of ESS and VAS at 3 months and 1-year post-operatively (p < 0.05). Combination of tonsillectomy and anterior palatoplasty could be considered as a treatment option for snoring and OSA in selected groups of patients (mild-to-moderate OSA with mainly retropalatal obstruction). The surgical success was found to reduce with time, and BMI optimization should be emphasized as part of post-operative care.

Posterior plica perforation: rare complication of adenotonsillectomy.

Tonsillectomy is one of the most common operations performed by otolaryngologists. Some extraordinary complications of this surgery are massive bleeding, taste perception disorders due to glossopharyngeal nerve damage, hematoma of the mouth floor, jugular vein thrombosis, Grisel syndrome, cervical osteomyelitis, nasopharyngeal stenosis, pulmonary edema, infection, and lingual artery pseudoaneurysm. In this clinical report, an 8-year-old girl presented with a posterior plica perforation after adenotonsillectomy performed 1 week previously and this complication has led to velopharyngeal insufficiency. This rare complication may result from traumatic damage or excessive cauterization of the posterior plica.

Effects of glossopharyngeal nerve block on pain control after tonsillectomy: a systemic review and meta-analysis.

BACKGROUND: We investigated the role of perioperative intraoral glossopharyngeal nerve block to minimize postoperative pain in patients undergoing tonsillectomy through a meta-analysis of the relevant literature. METHODS: We retrieved eight studies from PubMed, Scopus, Embase, Web of Science, and Cochrane databases up to August 2023. We compared perioperative glossopharyngeal nerve block with a control group, in order to examine postoperative pain, analgesic use, and other postoperative morbidities. RESULTS: Postoperative pain was significantly reduced at 1-4 h (SMD -1.26, 95% CI [-2.35; -0.17], I2 = 94.7%, P = 0.02) and 5-8 hours (SMD -1.40, 95% CI [-2.47; -0.34], I2 = 96.1%, p = 0.01) in the treatment groups compared to the control group. However, glossopharyngeal nerve block showed no efficacy in reducing pain or use of analgesic drugs after 12 h compared to the control group. The incidences of postoperative bleeding (OR 0.95, 95% CI [0.35; 2.52], I2 = 0.0%), local agent toxicity (OR 4.14, 95% CI [0.44; 38.63], I2 = 0.0%), nasal problems (OR 1.25, 95% CI [0.60; 2.61], I2 = 0.0%), postoperative nausea and vomiting (OR 1.35, 95% CI [0.78; 2.33], I2 = 0.0%), swallowing difficulty (OR 1.61, 95% CI [0.76; 3.42], I2 = 56.0%), and voice change (OR 3.11, 95% CI [0.31; 30.80], I2 = 0.0%) were not significantly different between the treatment and control groups. The treatment group showed higher prevalence of respiratory problems and dry mouth compared to control without statistical significance, but a significant increase in throat discomfort (p = 0.02). CONCLUSION: Intraoral glossopharyngeal nerve block for tonsillectomy did not significantly impact postoperative pain management and was associated with some adverse effects with increases in respiratory problems, dry mouth, and throat discomfort compared to controls.

Surgical Management of Pediatric Obstructive Sleep Apnea Beyond Adenotonsillectomy: The Nose, Nasopharynx, and Palate.

While adenotonsillectomy is the primary treatment of pediatric obstructive sleep apnea (OSA), persistent OSA after surgery is common and may be due to residual obstruction at the nose, nasopharynx, and/or palate. Comprehensive evaluation for persistent pediatric OSA ideally includes clinical examination (with or without awake nasal endosocpy) as well as drug-induced sleep endoscopy in order to accurately identify sources of residual obstruction. Depending on the site of obstruction, some of the surgical management options include submucous inferior turbinate resection, septoplasty, adenoidectomy, and expansion sphincter pharyngoplasty.

Oral rinses, mouthwashes and sprays for improving recovery following tonsillectomy.

BACKGROUND: This is an update of a Cochrane review first published in The Cochrane Library in Issue 1, 2010 and previously updated in 2011.Tonsillectomy is the surgical removal of lymphoid tissue, the palatine tonsil, which is located at the back of the throat. It is still commonly performed for patients who have recurrent bouts of acute tonsillitis. Although tonsillectomy is considered a fairly minor procedure, pain and bleeding are two of the most common complications; either may delay recovery and can on occasion lead to hospital readmission. Postoperative tonsillectomy medication should provide an adequate reduction in morbidity while minimising side effects, therefore topical agents would seem to be an ideal, safe option. A number of mouthwashes and topical sprays are available which offer pain relief or can help to reduce bleeding in the immediate postoperative period. OBJECTIVES: To assess the effects of oral rinses, mouthwashes and sprays in improving recovery following tonsillectomy. SEARCH METHODS: We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the most recent search was 4 July 2013. SELECTION CRITERIA: We included randomised controlled trials in which oral rinses, mouthwashes and sprays, used pre- and postoperatively, have been compared with placebo in adults or children undergoing tonsillectomy, with or without adenoidectomy. DATA COLLECTION AND ANALYSIS: Two review authors selected trials for inclusion, assessed the risk of bias and extracted data independently. MAIN RESULTS: We included seven trials (593 participants; 397 children and 196 adults). The period of follow-up ranged from 24 hours to two weeks. Few of the trials provided reliable data for the pre-specified primary outcomes and none for the secondary outcomes. The risk of bias was high in most of the included trials. Lidocaine spray appeared to be more effective than saline spray at reducing the severity of pain until the third postoperative day. A small number of participants experienced a burning or stinging sensation with benzydamine spray but not sufficient to discontinue usage. AUTHORS' CONCLUSIONS: Poor reporting quality and inadequate data did not permit comprehensive and reliable conclusions to be made. Future trials should be well-constructed and pay more attention to the methods used to assess outcomes, the timing of the assessments, and the quality of reporting and subsequent analysis of the data.

[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.

Pitfalls of operative management of secondary post-tonsillectomy haemorrhage--a case report.

INTRODUCTION: The authors present a potential complication associated with the surgical management of post-tonsillectomy haemorrhage using absorbable cellulose haemostatic dressings. The article discusses the deficiencies of our current understanding of how best to manage this common and potentially life-threatening ENT emergency. CASE REPORT: A 40-year-old man presented to Accident-and-Emergency with a post-tonsillectomy haemorrhage on the 7th postoperative day. The bleeding was managed surgically, with suturing of the faucial pillars incorporating a piece of Surgicel into the closure. Two days later the patient experienced an episode of partial airway obstruction, due to a piece of dislodged haemostatic material, owing to failure of the closure. The techniques used in the operative management of post-tonsillectomy bleeding are not formally evaluated or discussed in the current literature, and in some cases are unreliable or even potentially hazardous. Further discussion, research, and formulation of a more stepwise approach would be of considerable benefit.

Management of obstructive sleep apnea syndrome type 1 in children and adolescents - A French consensus.

This document is the outcome of a group of experts brought together at the request of the French Society of Sleep Research and Medicine to provide recommendations for the management of obstructive sleep apnea syndrome type 1 (OSA1) in children. The recommendations are based on shared experience and published literature. OSA1 is suspected when several nighttime respiratory symptoms related to upper airway obstruction are identified on clinical history taking. A specialist otolaryngologist examination, including nasofibroscopy, is essential during diagnosis. A sleep study for OSA1 is not mandatory when at least two nighttime symptoms (including snoring) are noted. Therapeutic management must be individualized according to the location of the obstruction. Ear, nose, and throat (ENT) surgery is often required, as hypertrophy of the lymphoid tissues is the main cause of OSA1 in children. According to clinical findings, orthodontic treatment generally associated with specialized orofacial-myofunctional therapy might also be indicated. Whatever treatment is chosen, follow-up must be continuous and multidisciplinary, in a network of trained specialists.

The influence of obstructive sleep apnea syndrome on orthodontic treatment decisions in children and adolescents. Part 1: OSA phenotypes, treatment temporality and reciprocal effects on growth / L'influence du syndrome d'apnées obstructives du sommeil sur la décision thérapeutique orthodontique chez l'enfant et l'adolescent. Partie 1 : Phénotypes du SAOS, temporalité des traitements et effets réciproques sur la croissance

Introduction: Pediatric OSAS is a complex condition, comprising a plurality of clinical signs, complicated by the phenomena of growth. Its etiology is dominated by the hypertrophy of lymphoid organs, but obesity and certain craniofacial and neuromuscular tone abnormalities also contribute. Material and Method: The authors summarize the interrelations between pediatric OSAS endotypes, phenotypes and orthodontic anomalies. They report clinical practice recommendations on the multidisciplinary management of pediatric OSAS and define the place and timing of orthodontics. Results: There is an indication for treatment of pediatric OSAS for an OAHI greater than 5/h, regardless of comorbidity, as well as for symptomatic children, whose OAHI is between 1-5/h. The first line of treatment is adenotonsillectomy, but it does not always normalize the OAHI. Complementary treatments are often necessary: early orthodontics (rapid maxillary expansion, myofunctional appliances), oral reeducation, as well as the management of obesity and allergies. Careful watching, without treatment is possible for mild cases with few symptoms, as pediatric OSAS tends to resolve naturally with growth. Discussion: The therapeutic approach is stratified, depending on the severity of OSAS and the child's age. In terms of orthodontic repercussions, obesity is associated with earlier maturation and some facial morphological differences, while oral hypotonia and nasal obstruction can alter facial growth, promoting mandibular hyperdivergence and maxillary deficiency. Conclusion: Orthodontists are in a privileged position for the detection, follow-up and certain treatments of OSAS.

Introduction: Le syndrome d'apnées obstructives du sommeil (SAOS) pédiatrique est une pathologie complexe, comportant une pluralité de signes cliniques, compliqués par les phénomènes de croissance. Son étiologie est dominée par l'hypertrophie des organes lymphoïdes, mais l'obésité, certaines anomalies cranio-faciales ou du tonus neuromusculaire y contribuent. Matériel et méthode: Les auteurs font la synthèse des interrelations entre endotypes, phénotypes du SAOS pédiatrique et anomalies orthodontiques. Ils résument les recommandations sur la prise en charge pluridisciplinaire du SAOS, définissant la place des traitements orthodontiques. Résultats: Une indication de traitement du SAOS pédiatrique existe pour un indice d'apnées/hypopnées obstructives (IAHO) supérieur à 5/h, indépendamment de comorbidité, ainsi que pour les enfants symptomatiques, avec un IAHO entre 1 et 5/h. La première ligne de traitement est l'adéno-amygdalectomie, qui ne permet pas toujours de normaliser l'IAHO. Des traitements complémentaires sont souvent nécessaires : orthodontie précoce (expansion maxillaire rapide, appareils myofonctionnels), rééducation orale/hygiène nasale, ainsi que la prise en charge de l'obésité et des allergies. Une surveillance attentive sans traitement est possible pour les cas peu sévères et peu symptomatiques, car le SAOS a tendance à se résoudre naturellement avec la croissance. Discussion: L'approche thérapeutique est stratifiée, en fonction de la sévérité du SAOS et de l'âge de l'enfant. Au niveau des répercussions orthodontiques, l'obésité est associée à une maturation plus précoce et à des différences morphologiques faciales, alors que l'hypotonie orale et l'obstruction nasale peuvent favoriser l'hyperdivergence mandibulaire et la déficience maxillaire. Conclusion: Les orthodontistes sont dans une position privilégiée pour le dépistage, le suivi et certains traitements du SAOS.

Opioid dose and postoperative respiratory adverse events after adenotonsillectomy in medically complex children.

STUDY OBJECTIVES: Obstructive sleep-disordered breathing is commonly treated with adenotonsillectomy. Our study objective was to describe perioperative opioid dosing in children with a range of medical complexity evaluated for obstructive sleep-disordered breathing undergoing adenotonsillectomy and to investigate its association with postoperative respiratory adverse events (PRAEs). METHODS: A retrospective chart review of children who underwent adenotonsillectomy and had preoperative polysomnography performed was conducted. PRAEs included requiring oxygen, jaw thrust, positive airway pressure, or mechanical ventilation. Multivariable logistic regression was performed to examine for associations between covariates and PRAEs. RESULTS: The cohort included 374 children with obstructive sleep-disordered breathing, median (interquartile range) age 6.1 (3.9, 9.3) years; 344 (92%) had obstructive sleep apnea (apnea-hypopnea index > 1 events/h) while 30 (8%) had a normal polysomnogram (apnea-hypopnea index < 1 events/h). The median (interquartile range) postoperative morphine-equivalent dose administered was 0.17 (0.09, 0.25) mg/kg. Sixty-six (17.6%) experienced at least 1 PRAE. Multivariable modeling identified the following predictors of PRAE: younger age at surgery (odds ratio 0.90, 95% confidence interval 0.83, 0.98), presence of cardiac comorbidity (odds ratio 2.07, 95% confidence interval 1.09, 3.89), and presence of airway anomaly (odds ratio 3.48, 95% confidence interval 1.30, 8.94). Higher total apnea-hypopnea index and morphine-equivalent dose were associated with PRAE risk, and an interaction between these variables was detected (P = .01). CONCLUSIONS: This study identified opioid dose in morphine equivalents to be a strong predictor of PRAE. Additionally, severity of obstructive sleep apnea and postoperative morphine-equivalent dose contributed together and independently to the occurrence of PRAEs. Attention to opioid dosing, particularly among medically complex children with obstructive sleep-disordered breathing, is required to mitigate risk of PRAEs. CITATION: Tsampalieros A, Murto K, Barrowman N, et al. Opioid dose and postoperative respiratory adverse events after adenotonsillectomy in medically complex children. J Clin Sleep Med. 2022;18(10):2405-2413.

Tonsillectomy as a risk factor of periodontitis: A population-based cohort study.

BACKGROUND: To determine whether patients who had undergone tonsillectomy would have higher risks of postoperative periodontitis. METHODS: Data were collected from the Taiwan Longitudinal Health Insurance Dataset from 1999 to 2013, a population-based cohort study consisting of cases of newly-onset sleep apnoea, chronic diseases of tonsils and adenoids, peritonsillar abscess, and periodontal diseases. A total of 1482 tonsillectomy cases and 14,796 non-tonsillectomy controls were selected. Propensity score matching37 between the tonsillectomy group and the non-tonsillectomy group was conducted to exclude the confounding effect resulting from indications of tonsillectomy. Cox proportional hazard model and subgroup analyses were conducted to identify subpopulations at risk of tonsillectomy-associated periodontitis, and a sub-outcome analysis was applied to identify the subtype of tonsillectomy-associated periodontitis. RESULTS: A total of 648 patients who had undergone tonsillectomy and 648 out of 6509 propensity score-matched controls were retrieved, among which 230 cases in the tonsillectomy group were associated with post-surgical periodontitis (adjusted HR = 1.31, 95% CI = 1.08 to 1.59). The association persisted in a subpopulation of patients with periodontitis who received mechanical and surgical treatments for periodontitis (adjusted HR = 1.33, 95% CI = 1.09 to 1.63). The incidence of periodontitis was significantly high in the individuals who underwent tonsillectomy and was particularly high in those that were below 12 years of age (HR = 1.58, 95% CI = 1.10 to 2.27). The risk of periodontitis increased 4 years after tonsillectomy (HR = 1.82; 95% CI = 1.29 to 2.59). The majority of post-tonsillectomy periodontitis was aggressive and acute periodontitis (HR = 1.37; 95% CI = 1.10 to 1.71). CONCLUSIONS: Tonsillectomy performed in pediatric patients of < 12 years old, increased the risk of developing periodontitis. Aggressive and acute periodontitis as a long-term, postoperative adverse event took place at 4 years or longer after tonsillectomy.

Comparison of Clinical and Functional Outcome of Cold Steel Dissection versus Coblation Technique in Tonsillectomy.

BACKGROUND: To ameliorate the intra and post-op morbidities associated with newer techniques for tonsillectomy like coblation has been introduced in the recent past. This study was aimed to compare the cold steel dissection with the coblation technique with regards to its effectiveness and safety. METHODS: An observational comparative study was carried out in 90 patients undergoing tonsillectomy between July 2018 to December 2019. Forty-five patients in each group of cold steel dissection and coblation were compared between the operative time, intraoperative blood loss, post-operative pain, post-operative bleeding and return to work. Intraoperative blood loss was measured using a standard sized gauge piece whereas post-operative pain was measured using a visual analogue scale (0-10) at first and third day of surgery. RESULTS: The age and sex were comparable between the groups. The mean operation time (31.40±4.52 min versus 17.02±3.11 min), intraoperative blood loss (27.20±7.16 ml vs 9.73±5.52 ml), post-operative pain in day 1 (8.02±1.27 vs 4.98±1.03), post-operative pain in day 3 (4.80±0.89 vs 2.76±0.74) and time needed to return to work in days (10. 31±1.29 vs 6.76±1.20) were statistically significant in coblation group (p<0.000). Primary and secondary post-operative haemorrhage rates were similar in both the groups. There was no return to theatre for hemostasis. CONCLUSIONS: Coblation tonsillectomy significantly reduces operation time, intraoperative blood loss, post-operative pain (day1 and 3) and time required to return to work . This technique doesn't differ from cold steel dissection tonsillectomy in terms of primary and secondary post-operative hemorrhage.

[Preliminary study on efficacy and safety of submucosal plasma ablation of inferior turbinate in children with allergic rhinitis complicated with obstructive sleep apnea syndrome].

Objective:This study aimed to investigate the long-term clinical efficacy and safety of inferior turbinate submucosal plasma ablation combined with or without tonsillar and adenoid surgery in children with allergic rhinitis（AR） combined with obstructive sleep apnea syndrome（OSAS） who were ineffective after conservative systemic treatment. Methods:A total of 43 children with AR complicated with OSAS who met the inclusion criteria among 68 children hospitalized from January 2019 to February 2022 were retrospectively analyzed. The data were collected, including the clinical characteristics, surgical methods perioperative management and prevention and treatment of complications. Moreover, one year follow-up was performed to compare the VAS scores of children before and after surgery, and to evaluate their mid-term and long-term outcomes. Results:The average operation time was 36 minutes, meanwhile, the intraoperative blood was limited. The symptoms of nasal congestion, runny nose, sleep snoring, and mouth breathing were significantly improved after operation, and the results were satisfactory after one-year follow-up without complications such as bleeding, hematoma, intraoperative adhesion, and nasal dryness. Conclusion:Submucosal plasma ablation of inferior turbinate with or without tonsillectomy adenoidectomy in children with AR can effectively improve the clinical symptoms of AR combined with OSAS children who are ineffective after conservative treatment. It can improve the symptoms of sleep-disordered breathing such as sleep snoring and mouth breathing, with good mid-and long-term curative effects and fewer complications, which is an effective and safe treatment for children with AR combined with OSAS.

Oral rinses, mouthwashes and sprays for improving recovery following tonsillectomy.

BACKGROUND: This is an update of a Cochrane Review first published in The Cochrane Library in Issue 1, 2010.Tonsillectomy is the surgical removal of lymphoid tissue, the palatine tonsil, which is located at the back of the throat. It is still commonly performed for patients who have recurrent bouts of acute tonsillitis. Although tonsillectomy is considered a fairly minor procedure, pain and bleeding are two of the most common complications; either may delay recovery and can on occasion lead to hospital readmission. Postoperative tonsillectomy medication should provide an adequate reduction in morbidity while minimising side effects, therefore topical agents would seem to be an ideal, safe option. A number of mouthwashes and topical sprays are available which offer pain relief or can help to reduce bleeding in the immediate postoperative period. OBJECTIVES: To assess the effects of oral rinses, mouthwashes and sprays in improving recovery following tonsillectomy. SEARCH STRATEGY: We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the most recent search was 22 April 2011. SELECTION CRITERIA: We included randomised controlled trials in which mouthwashes, used pre- and postoperatively, have been compared with placebo. DATA COLLECTION AND ANALYSIS: Two review authors selected trials for inclusion, assessed the risk of bias and extracted data independently. MAIN RESULTS: We included six trials (528 participants; 397 children and 131 adults). The period of follow up ranged from 24 hours to two weeks. Few of the trials provided reliable data for the pre-specified primary outcomes and none for the secondary outcomes. Lidocaine spray appeared to be more effective than saline spray at reducing the severity of pain but only until the third postoperative day. A small number of participants experienced a burning or stinging sensation with benzydamine spray but not sufficient to discontinue usage. AUTHORS' CONCLUSIONS: The risk of bias was high in most of the included trials and poor reporting quality and inadequate data did not permit comprehensive and reliable conclusions to be made. Future trials should be well-constructed and pay more attention to the methods used to assess outcomes, the timing of the assessments, and the quality of reporting and subsequent analysis of the data.

Topical Triamcinolone on "Sweet Spots" to Block Dynamic Pain after Tonsillectomy and Uvulo-Palato-Pharyngo-Plasty.

OBJECTIVES: Severe pain on swallowing (or dynamic pain) has long been a problem in patients receiving tonsillectomy and uvulopalatopharyngoplasty for the treatment of obstructive sleep apnea syndrome and/or snoring. We have previously verified that dynamic pain after laser-assisted uvulopalatoplasty could immediately be mitigated by local treatments with topical triamcinolone on the "sweet spots" of the wounds. This study aimed to assess the efficacy of applying triamcinolone on "sweet spot" in surgical incisions instead of whole surgical wounds to alleviate dynamic pain of some oropharyngeal surgeries such as tonsillectomy and uvulopalatopharyngoplasty. METHODS: This study is a retrospective case series based on chart review of the participants. Forty-five subjects (31 males; 12~68 years, mean 34 years) with obstructive sleep apnea syndrome and/or snoring treated with tonsillectomy or uvulopalatopharyngoplasty were studied. Local treatments were done to sweet spots with triamcinolone on the 1st, 2nd, 3rd, and 7th days after the surgery. Evaluation of dynamic pain relief was performed by using a visual analogous scale. RESULTS: Sweet spots treatment led to instantaneous reduction of dynamic pain. The average improvement level was ≥72% (P ≤ .002). No gender effect was noted. CONCLUSION: Dynamic pain after tonsillectomy and uvulopalatopharyngoplasty could immediately be mitigated by local treatments upon sweet spots. Local treatments upon sweet spots were highly suggested to begin early post-operatively and be included in the take-home routines for patients receiving tonsillectomy and uvulopalatopharyngoplasty.