Post-tonsillectomy haemorrhage rates are related to technique for dissection and for haemostasis. An analysis of 15734 patients in the National Tonsil Surgery Register in Sweden.

OBJECTIVES: To analyse post-tonsillectomy haemorrhage (PTH) rates related to technique for dissection and haemostasis. STUDY DESIGN: Register study from the National Tonsil Surgery Register in Sweden (NTSRS). METHODS: All patients, subjected to tonsillectomy (TE) without adenoidectomy from 1 March 2009 to 26 April 2013, were included in the study. The surgeon reports data about technique and early PTH, while late PTH is reported by the patient in a questionnaire 30 days after surgery. RESULTS: 15734 patients with complete data concerning technique for dissection and for haemostasis were identified in the NTSRS. Techniques used were cold steel dissection with uni- or bipolar diathermy haemostasis (65.3%), diathermy scissors (15.7%), coblation (9.1%), cold steel dissection with cold haemostasis (7.4%) and ultrascision (2.5%). Early and late PTH were reported in 3.2% and 9.4% of the cases, respectively, and return to theatre (RTT) in 2.7%. The rates for PTH and RTT related to technique were analysed. Compared with cold dissection+ cold haemostasis, late PTH rate was 2.8 times higher after cold dissection + hot haemostasis, 3.2 times higher after coblation, 4.3 times higher after diathermy scissors and 5.6 times higher after ultrascision. The risk for RTT was higher for all hot techniques except for coblation, while ultrascision resulted in a lower risk for early PTH. CONCLUSIONS: All hot techniques resulted in a higher risk for late PTH compared with cold steel dissection +cold haemostasis. The risk for RTT was higher for all hot techniques except for coblation, while ultrascision resulted in a lower risk for early PTH. An early PTH was associated with an increased risk for late PTH.

Development of craniofacial and dental arch morphology in relation to sleep disordered breathing from 4 to 12 years. Effects of adenotonsillar surgery.

OBJECTIVES: To study the development of craniofacial and dental arch morphology in children with sleep disordered breathing in relation to adenotonsillar surgery. SUBJECTS AND METHODS: From a community-based cohort of 644 children, 393 answered questionnaires at age 4, 6 and 12 years. Out of this group, 25 children who were snoring regularly at age 4 could be followed up to age 12 together with 24 controls not snoring at age 4, 6 and 12 years. Study casts were obtained from cases and controls and lateral cephalograms from the cases. Analysis regarding facial features and dento-alveolar development was performed. RESULTS: Children snoring regularly at age 4 showed reduced transversal width of the maxilla and more frequently had anterior open bite and lateral cross-bite than the controls. These conditions persisted for most cases at age 6, by which time 18/25 had been operated for snoring. In most of the cases, surgery cured the snoring temporarily, but their width of the maxilla was still smaller by age 12-even when nasal breathing was attained. At age 12, the frequency of lateral cross-bite was much reduced and anterior open bite was resolved, both in cases and controls. The children who snored regularly at age 12 operated or not operated, showed a long face anatomy and were oral breathers (this applied even to those who were operated). The seven cases who were not operated and the five who were still snoring in spite of surgery at age 12, did not have reduced maxillary width as compared to the controls. CONCLUSION: Dento-facial development in snoring children is not changed by adenotonsillar surgery regardless of symptom relief. If snoring persists or relapses orthodontic maxillar widening and/or functional training should be considered. Collaboration between otorhinolaryngologist, orthodontists and speech and language pathologists is strongly recommended.

The development of sleep disordered breathing from 4 to 12 years and dental arch morphology.

OBJECTIVE: To track the development of sleep disordered breathing (SDB) as well as dento-facial morphology in cohort of children by having them complete a questionnaire at ages 4, 6 and 12. Clinical examination, sleep studies (at ages 4 and 12) and orthodontic evaluation were carried out on all who were reported to snore regularly and children who did not snore at all. RESULTS: Out of the original group of 615 children, 64% (393) answered the inquiry on all three occasions. Of those, 27 snored regularly and 231 did not snore at all at the age of 12. There were differences between those groups on all answers, especially prevalence of oral breathing: 78% versus 5% (p<0.001). The prevalence of OSA decreased from 3.1% at the age of 4 to 0.8% at age 12 and the severity decreased from a mean AHI 14.8 at 4 to a mean AHI of 1.95 at age 12. The minimum prevalence of snoring regularly was estimated to 4.2% at 12 years compared to 5.3% at 4, calculated for the original cohort of 644 children. The odds for a child who snored regularly at 4 or 6 years to be snoring regularly also at age 12 was 3.7 times greater than for a not snoring child in spite of surgery (OR 3.7, 95% CI 2.4-5.7). 63 children had undergone surgery due to snoring by age 12. 14 of them never snored and 17 snored regularly at the age 12. The dental arch was narrower in the children snoring regularly at 4, 6 and 12 years compared to not snoring children. Cross-bites were more common among snoring children than among non-snoring children, at 4 and 6 as well as at 12. CONCLUSION: The prevalence of regular snoring is about the same from 4 to 12 years independent of surgery, but the prevalence of OSA decreased considerably. The children snoring regularly generally have a narrower maxilla compared to children not snoring. Surgery in young children is necessary but "cures" the snoring only temporary.

The effect of uvulopalatopharyngoplasty without tonsillectomy using local anaesthesia: a prospective long-term follow-up.

This paper presents the long-term effect of restricted surgery for snoring and sleep apnoea. Patients with obstructive sleep apnoea (OSAS) (19) or heavy snoring (HS) (36) were studied prospectively for five to seven years after uvulopalatopharyngoplasty without tonsillectomy performed by regular surgical technique using local anaesthesia (LUPP). Five years after surgery, 90 per cent answered a questionnaire. All OSAS patients were offered a polysomnography, and the HS patients were offered a sleep study. Eighty per cent still showed a positive effect on daytime somnolence, and 77 per cent on snoring. Side-effects were reported by 40 per cent; most common was choking (20 per cent) the first year. Eighteen per cent had local problems such as globus sensation. The polysomnography showed that 80 per cent were still 'responders' with an apnoea index (AI) reduction of > 50 per cent. None of the HS patients had developed OSAS. In conclusion, LUPP in selected patients with OSAS or HS has a good long-term effect. Side-effects are common, but diminish with time.

Using the carbon dioxide laser for tonsillotomy in children.

Carbon dioxide laser tonsillotomies were performed on 33 children aged 1-12 years for the relief of obstructive symptoms due to tonsillar hyperplasia. As opposed to conventional tonsillectomy, only the protruding part of each tonsil was removed. A carbon dioxide laser delivering 20 W was used for the excision. Twenty-one children were seen in active short-term follow-up and the records of all the children were checked for possible surgery related events up to 20-33 months after surgery. Laser tonsillotomy was uniformly effective in relieving the obstruction, with good hemostasis. The tonsillar remnants healed completely within 2 weeks. No major adverse events occurred. Post-operative pain appeared slight and easily controlled. There was no gain in operating time compared with conventional tonsillectomy. The laser tonsillotomies were in most cases done in day surgery. No recurrence of obstructive problems was reported up to 20-33 months after surgery. It was concluded that tonsillotomy, using a carbon dixoide laser, is a valid treatment for obstructive symptoms caused by enlarged tonsils, which can be performed with little bleeding and post-operative pain. The improved hemostasis may enable a shift from in-patient to day surgery.

[Many persons with snoring problems and apnea are untreated. A review of therapeutic methods]. / Många snarkare och apnoiker obehandlade. Genomgång av terapimetoderna.

As sleep apnoea and snoring are very disabling conditions both for patients and their families, and hazardous for drivers and others in traffic, there is good reason to treat snoring problems. Treatment should be individualised, always beginning conservatively--i.e., positional training, weight reduction if necessary, more sleep if sleep deficiency is present, and a review of any muscle-relaxant or mucolytic medication. Sleep registration will demonstrate the extent of any sleep apnoea syndrome, which is of decisive importance for further choice of treatment. Mild apnoics and social snorers may initially be offered an occlusal splint if their dental status allows. Otherwise, in such cases surgery is a form of treatment yielding immediate results, though the patient must be forewarned of the discomfort which can occur in isolated cases. For patients with sleep apnoea syndrome of marked or intermediate severity, continuous positive airway pressure (CPAP) treatment should be available. If the patient can not tolerate CPAP treatment, the occlusal splint alternative can be tried. For patients who can not have CPAP or occlusal splint treatment, tracheostomy is a possibility. This treatment may be lifelong, but if weight reduction is achieved postoperatively, it may be possible to remove the tracheostomy.

Breathing obstruction in relation to craniofacial and dental arch morphology in 4-year-old children.

The prevalence of breathing obstruction was determined in a cohort of 4-year-old children. Craniofacial morphology was studied in obstructed children and compared with data from a control group of 4-year-old children with ideal occlusion. Dental arch morphology was compared in obstructed and non-obstructed children in the group. Parents of 95.5 per cent of the study base of 644 children answered a questionnaire concerning their child's nocturnal behaviour and related questions. The 48 children who, based on parental report, snored every night or stopped breathing when snoring (the 'snoring group'), showed a higher rate of disturbed sleep, mouth-breathing, and a history of throat infections as compared with the rest of the cohort. These children were examined by both an orthodontist and an otorhinolaryngologist and, when indicated, they were also monitored in a sleep laboratory. Twenty-eight of the children were diagnosed as having a breathing obstruction (4.3 per cent of the cohort) and six children (0.9 per cent) had sleep apnoea (mean apnoea-hypopnoea index of 17.3), using the same definition as that for adults. Cephalometric values among the obstructed children differed from those of a Swedish sample of the same age with ideal occlusion. Thy had a smaller cranial base angle and a lower ratio of posterior/anterior total face height. Small, but not significant differences were seen for NSL-ML and NL-ML. Compared with 48 asymptomatic children from the same cohort, the obstructed children had a narrower maxilla, a deeper palatal height, and a shorter lower dental arch. In addition, the prevalence of lateral crossbite was significantly higher among the obstructed children.

[Medical aspects of diving--a sport for both women and men]. / Medicinska aspekter på dykning--sporten för både kvinnor och män.

As interest in scuba diving is increasing in both sexes, doctors need to be aware of the risks encountered when diving and about gender-related differences in these risks. Individuals prone to panic attacks, claustrophobia or reckless risk-taking should avoid diving. In tolerating cold, muscle mass is more important than the amount of subcutaneous fat. The risk of decompression disease seems to be slightly greater among women, probably due to their fat distribution. Pregnant women are recommended not to dive, because the risk of birth defects seems to be greater among those who do, and there is a serious risk of fetal decompression disease. All participants in the sport must be responsible for their own diving safety.

Tonsillectomy or tonsillotomy?--A randomized study comparing postoperative pain and long-term effects.

BACKGROUND: tonsillectomy (TE) is currently the most common treatment for children with snoring and sleep apnea. Many of these children have not had any severe throat infections. To cure such children from their obstructive problems, without influencing the immunological function of the tonsils, tonsillotomy (TT) with CO2-laser was performed in a randomized study comparing it to regular tonsillectomy, with special attention to postoperative pain and symptom recurrence. METHOD: 41 children 3.5-8 years-old were included--21 'TT's' and 20 'TE's'. They were all operated under the same anesthesia and followed the same postoperative scheme for analgesia. A visual analogue scale for pain measurements with faces was used for the first 24 h. After that, each day until pain-free, the parents registered the child's pain on a three graded scale, what the child was able to eat, and the amount of analgesic drugs used. RESULTS: all the children were cured from their breathing obstruction. The mean time used for the surgery was the same and no postoperative bleeding was seen in either group. 'TT children' were pain-free after 5 days and 'TE children' after 8 days. Eight to ten days after surgery, the TT-children had gained weight and the TE children lost weight significantly. The TE group used twice as much analgesic drugs as the TT group during the first postoperative week. The TT group was healed with normal-looking, but small tonsils after 8-10 days; the TE group often still showed edema and crusts. At the one-year follow-up 2/21 among the 'TT-children' snored, but did not require re-surgery. CONCLUSION: tonsillotomy is much less painful than TE and children recover more quickly. Results with respect to breathing obstruction are almost the same for both methods at 1-year follow-up.

Long-term follow-up of patients with obstructive sleep apnea treated with uvulopalatopharyngoplasty.

OBJECTIVE: To study the long-term outcome after treatment with uvulopalatopharyngoplasty (UPPP). DESIGN: Long-term follow-up (4-8 years) with polysomnography. SETTING: Referral center for patients with sleep-disordered breathing. PATIENTS: Thirty-four consecutive patients of whom 25 (22 men and 3 women; mean age, 49 years) participated in the follow-up. All patients had obstructive sleep apnea syndrome. INTERVENTION: Uvulopalatopharyngoplasty. MAIN OUTCOME MEASURES: Symptoms and apnea-hypopnea index (AHI) before and after UPPP. Response to treatment defined as a 50% or more reduction in AHI and a postoperative AHI of 10 or less. RESULTS: Reduced prevalence of snoring and daytime sleepiness and reduction in AHI (mean [+/-SD], 40 +/- 26 to 21 +/- 21) at follow-up (P < .001). Sixteen patients (64%) were responders after 6 months and 12 (48%) at the long-term follow-up. Responders had a lower preoperative AHI (25 +/- 7) than did nonresponders (48 +/- 29) (P < .05). None of the 7 patients with preoperative AHI of more than 40 were responders (P < .01). No difference was seen in preoperative body mass index, lung function, ventilatory response to carbon dioxide, computed tomography scan of upper airways, or change in body mass index between responders and nonresponders. CONCLUSIONS: Four to 8 years after UPPP, about half of our patients were clinically and objectively improved. Uvulopalatopharyngoplasty should be reserved for patients with mild or moderate obstructive sleep apnea. After UPPP, long-term follow-up is recommended because some initially successfully treated patients will relapse in the long term.

The epidemiology of sleep related breathing disorder in children.

An epidemiological study of sleep obstruction and its orthodontic consequences is under way on a cohort (500) of 4-year-old children. The parents are asked about the child's snoring, sleep apnea, sucking habits, infections and 'genetic clues'. Dental casts have been made from the first 100 children and the group of children who snore are being compared to the non-snorers. A sleep study, a lateral cephalogram and dental casts are done on all snorers in the cohort. Preliminary results show that 6.2% snore every night by age 4 and another 18% when infected. More children use pacifiers among the snorers than in the non-snoring group (60% vs. 35%). Tonsillar angina is 3 times more common in the snorer group and twice as many of their parents have been adenoidectomized (A) and/or tonsillectomized (T). The dental casts show a significant difference in width of the maxilla and length of the mandible. The children are treated for their breathing obstruction with A or A+T. Two years later, the same cohort will be examined again. The prevalence of snoring and sleep apnea among 4-year-olds will be known as will whether and how treatment for breathing obstruction influences facial development.