Anaesthesia management of a patient with Bethlem Myopathy for elective tonsillectomy: a case report.

BACKGROUND: Bethlem Myopathy is a collagen VI-related myopathy presenting as a rare hereditary muscular disorder with progressive muscular weakness and joint contractures. Despite its milder clinical course relative to other myopathies, anaesthetic management can be challenging. High arched palates and fixed flexion deformities may contribute to a difficult airway. A progressive decline in pulmonary function can present later into adulthood. This respiratory decline can carry secondary cardiovascular consequences due to the progressive nature of restrictive lung disease, including right sided heart disease and pulmonary hypertension. We describe a case of a male patient with Bethlem Myopathy undergoing anaesthesia, to contribute to the limited body of literature on this condition and enhance awareness and guidance amongst anaesthesiologists on approaching patients with this condition. This is the first case report within the literature of its kind. CASE PRESENTATION: This case details a 33-year-old male with Bethlem Myopathy undergoing tonsillectomy. Diagnosed in childhood following developmental delays, the patient had no prior anaesthetic exposure and no family history of anaesthetic complications. Anaesthetic induction was achieved without complications, avoiding depolarizing muscle relaxants and careful airway management. Extreme care was taken in patient positioning to prevent complications. The surgery proceeded without incident and muscle paralysis was reversed with Suggammadex, resulting in no adverse post-operative respiratory complications. The patient was discharged on the first post-operative day without any respiratory or cardiovascular compromise. CONCLUSIONS: Bethlem Myopathy, while often exhibiting a mild clinical course, can present anaesthetic challenges. Awareness of potential complications including a difficult airway, cardiovascular and respiratory implications as well as the need for specialised monitoring and positioning is crucial to ensure a safe peri-operative course.

Absorption and pharmacokinetics of bupivacaine after bilateral topical administration in tonsillar fossae for posttonsillectomy pain relief.

No previous studies have investigated the systemic absorption of bupivacaine when used topically for posttonsillectomy pain. The present study was undertaken to investigate the pharmacokinetics of bupivacaine after administration by a swab in the tonsillar fossae over 4 min after tonsillectomy. Eleven adult patients undergoing elective tonsillectomy were recruited. After removal of both tonsils, each of the two tonsillar fossae was covered with a swab moistened with 2 mL of bupivacaine 5 mg/mL, that is, a total of 20 mg bupivacaine. Blood samples were drawn after 0, 5, 10, 20, 30, 45, and 60 min. Bupivacaine was analyzed with an ultra-high-performance liquid chromatography-tandem mass spectrometry method. The highest single measured bupivacaine serum concentration was 23.2 ng/mL and took place 10 min after drug administration. Mean (±SD) Cmax was 11.4 ± 6.0 ng/mL and mean tmax was 11.3 ± 4.7 min. Mean t1/2 was 31.6 ± 9.3 min. As the toxic concentration threshold has been reported to be in the interval 1500-4500 ng/mL, the concentrations measured were well below 2% of the lowest cited toxic threshold. In conclusion, this study shows that applying 4 mL of bupivacaine 5 mg/mL by a swab in the tonsillar fossae posttonsillectomy yields very low plasma concentrations, suggesting its safe application without any risk of systemic toxic effects.

Adenotonsillectomy for Obstructive Sleep Apnea in Children.

Obstructed breathing is the most common indication for tonsillectomy in children. Although tonsillectomy is performed frequently worldwide, the surgery is associated with a number of significant complications such as bleeding and respiratory failure. Complication risk depends on a number of complex factors, including indications for surgery, demographics, patient comorbidities, and variations in perioperative techniques. While polysomnography is currently accepted as the gold standard diagnostic tool for obstructive sleep apnea, studies evaluating outcomes following surgery suggest that more research is needed on the identification of more readily available and accurate tools for the diagnosis and follow-up of children with obstructed breathing.

Coblation versus BiZact extra-capsular tonsillectomy in adults: a randomized control trial.

INTRODUCTION: Tonsillectomy is a frequently performed otolaryngological procedure and is associated with significant postoperative pain and bleeding. A number of studies have investigated methods to reduce pain and bleeding. Coblation and BiZact devices have both been claimed to have favourable pain outcomes following tonsillectomy. This study was designed to investigate these two techniques in a direct comparison of postoperative pain and bleeding. METHODS: In this single blinded, randomized control trial, 61 patients were randomly assigned to undergo tonsillectomy with either the BiZact or Coblation device. Pain scores were collected for 14 days postoperatively using a Visual Analogue Score scale. Secondary outcome data was collected for duration of surgery, intra-operative bleeding, return to normal, and secondary bleeding rates. RESULTS: Coblation was found to have lower postoperative pain on day 1 (P < 0.05). BiZact was found to have lower postoperative pain on day 7 (P < 0.05) and day 11 (P < 0.05). Pain scores for other days were not significant. There was no significant difference in set-up time, procedural time and return to normal activities. The BiZact group had a longer time to achieve haemostasis (P < 0.001) and greater intraoperative blood loss (P < 0.01). There was a trend towards more significant secondary bleeding in the BiZact arm, however, this study was not adequately powered to assess this finding. CONCLUSION: Both Coblation and BiZact devices appear to provide a safe and effective method for tonsillectomy in adults. Reduced pain on day 1 may make Coblation more suitable for day-case surgery.

Risk of post-tonsillectomy hemorrhage among COVID-19 positive pediatric patients.

OBJECTIVE: COVID-19 infection has been demonstrated to increase risk for post-operative bleeding. This study investigated the impact of COVID-19 infection on post-tonsillectomy hemorrhage in pediatric patients, a potentially devastating complication. STUDY DESIGN: Retrospective cohort study. METHODS: The TriNetX database was queried for pediatric patients who underwent tonsillectomy and evaluated for outcomes of primary and secondary post-tonsillectomy hemorrhage. RESULTS: Among subjects 18 years and younger, 1226 were COVID-19 positive and 38,241 were COVID-19 negative in the perioperative period. There was statistically significant increased risk of bleeding with perioperative COVID-19 infection at postoperative days 1, 5, and 10. Additionally, when assessing the role of COVID-19 infection before or after surgery, the risk of bleeding remained statistically significant at all three time points, however these results did not suggest that infection before surgery confers more/less risk compared to infection after. CONCLUSION: The results of this investigation suggest that the presence of COVID-19 in the perioperative period may pose an increased risk for acute or delayed post tonsillectomy hemorrhage. This study employed a large, diverse population and is the first to address this clinical question.

Surgical Management of Pediatric Obstructive Sleep Apnea Beyond Tonsillectomy & Adenoidectomy: Tongue Base and Larynx.

Pediatric patients with persistent obstructive sleep apnea (OSA) after adenotonsillectomy often have additional sites of upper airway obstruction such as the tongue base or larynx. Sleep endoscopy and cross-sectional, dynamic imaging can be used to direct surgical management of persistent OSA. The tongue base is one of the most common sites of obstruction in children with persistent OSA, especially for patients with Trisomy 21. Lingual tonsillectomy, tongue suspension, and/or posterior midline glossectomy may be used to address lingual tonsil hypertrophy and tongue base obstruction. Epiglottopexy and/or supraglottoplasty may be used to address laryngomalacia and epiglottic prolapse resulting in OSA.

Neurostimulation for Pediatric Obstructive Sleep Apnea.

Up to 80% of children with Down syndrome (DS) are affected by obstructive sleep apnea (OSA), and only 16% to 30% will have resolution of their OSA with adenotonsillectomy. Hypoglossal nerve stimulation is a well-established therapy for adults with OSA and was recently approved by the Food and Drug Administration for use in children with DS and residual OSA. There is robust experience with this therapy in adults that has led to well-established care pathways. However, given the challenges inherent to caring for a complex pediatric population, these pathways are not directly transferrable to children with DS.

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.

Pain management after tonsil surgery in children and adults-A national survey related to pain outcome measures from the Swedish Quality Register for tonsil surgery.

OBJECTIVE: The primary aim of this study was to describe the current practice regarding pain management in relation to tonsil surgery among Ear Nose and Throat (ENT) clinics in Sweden. The secondary aim was to determine the impact of the provider's regime of rescue analgesics on the pain related Patient Reported Outcome Measures (pain-PROMs) from the Swedish Quality Register for Tonsil Surgery (SQTS). MATERIALS & METHODS: A descriptive cross-sectional study originating from a validated web-based questionnaire. The survey enrolled one respondent from each ENT clinic (47/48 participated) nationally. Pain-PROMs from the SQTS, recorded from October 2019 to October 2022, were included (8163 tonsil surgeries). RESULTS: Paracetamol was used by all enrolled ENT clinics as preemptive analgesia. The addition of COX inhibitors was used in 40% of the clinics. Betamethasone was usually administered, to prevent pain and nausea (92%). All clinics gave postdischarge instructions on multimodal analgesia with COX inhibitors and paracetamol. Rescue analgesics were prescribed after tonsillectomy for 77% of adults, 62% of older children, 43% of young children and less often after tonsillotomy. The most frequently prescribed rescue analgesic was clonidine in children (55%) and oxycodone in adults (72%). A high proportion of patients reported contact with health care services due to postoperative pain (pain-PROMs/ SQTS). Tonsillectomy procedures were associated with the highest rates of contacts (children/adolescents 13-15%; adults 26%), while tonsillotomy were associated with lower rates, (5-7% of children/adolescents). There was no significant difference in the frequency of health care contacts due to pain regarding whether clinics routinely prescribed rescue analgesics or not after tonsillectomy. CONCLUSION: The Swedish analgesic regimen after tonsil surgery is good overall. Nevertheless, there is a need for increased awareness and knowledge to achieve optimal patient recovery. Pain-PROM data demonstrate the call for improvement in pain management after tonsil surgery.

The relationship between posttonsillectomy bleeding to hemogram and coagulation parameters.

PURPOSE: Tonsillectomy is a common surgery performed for indications such as chronic tonsilitis, tonsil hypertrophy and obsructive sleep apnea. Although posttonsillectomy bleeding (PTB) is rare and can be controlled with simple interventions in many patients, it is one of the most feared complications of tonsillectomy surgery. In our study, we investigated the effects of changes in hemogram and coagulation values and seasonal effects on PTB. METHODS: Pediatric and adult patients who underwent tonsillectomy with cold knife method between August 2020 and August 2023 in our clinic were retrospectively reviewed. Demographic data, hemogram and coagulation values of the patients in the control and study groups were recorded and the differences between the two groups in terms of these parameters were evaluated. RESULTS: Our study included 991 patients aged 1-51 years. The rate of PTB was calculated as 2.82%. No patient with primary PTB was found. The duration of bleeding development was 7.03 days. Age, WBC and neutrophil values were statistically significantly higher in the study group. There were no significant differences between two groups in terms of gender, season and other hemogram and coagulation parameters. CONCLUSIONS: Age, high WBC and neutrophil levels were determined as possible risk factors for PTB. Seasonal and gender distribution, aPTT and INR values were similar in the two groups. In order to prevent and predict bleeding, detailed infection investigation should be performed and the risk of bleeding should be considered to increase with increasing age.

Absceso periamigdalino bilateral. Reporte de un caso y revisión de las controversias en el diagnóstico y tratamiento / Bilateral peritonsillar abscess. A case report and review of controversies surrounding diagnosis and management

La presentación bilateral del absceso periamigdalino es poco frecuente. Su abordaje es controversial y se discute si realizar amigdalectomía en caliente versus diferida. Se presenta el caso de un paciente de sexo masculino, de 14 años, con odinofagia, trismo y fiebre. Presentaba hipertrofia amigdalina bilateral, pilares abombados y edema de paladar blando. Tomografía computada: hipertrofia amigdalina bilateral, con realce poscontraste, ambas con colección, edema con moderada estenosis faríngea. Se decidió internación para tratamiento endovenoso y amigdalectomía con drenaje bilateral. Resolución completa del cuadro con alta a las 48 horas. Ante la presencia de un absceso periamigdalino, debe considerarse la posibilidad de un absceso contralateral oculto. Debe ser diagnosticado y tratado adecuadamente para prevenir complicaciones. La amigdalectomía en caliente podría ser un tratamiento seguro y debería ser considerado en pacientes que serán sometidos a anestesia para drenaje. La decisión final debe ser determinada para cada caso en particular.

The bilateral presentation of peritonsillar abscess is uncommon. Its management is controversial and it has been argued whether a quinsy tonsillectomy or an interval tonsillectomy should be performed. Here we describe the case of a 14-year-old boy with sore throat, trismus, and fever. He had bilateral tonsillar hypertrophy, convex arches, and soft palate edema. Computed tomography: bilateral tonsillar hypertrophy, with post-contrast enhancement, both with collection, edema with moderate pharyngeal stenosis. The patient was hospitalized for intravenous therapy and tonsillectomy with bilateral drainage resulting in a complete resolution of his condition and discharge at 48 hours. In the presence of a peritonsillar abscess, an unsuspected contralateral abscess should be considered. It should be diagnosed and managed adequately to prevent complications. Quinsy tonsillectomy could be safe and should be considered in patients who will undergo anesthesia for abscess drainage. The final decision should be made for each patient on an individual basis.

Supplemental oxygen requirement after tonsillectomy in children >3 years of age.

INTRODUCTION: The indications for postoperative admission after tonsillectomy in children >3 years of age are less well defined than for children <3 years old, and typically include severe obstructive sleep apnea (OSA), obesity, comorbidities, or behavioral factors. Inpatient care after tonsillectomy typically consists of respiratory monitoring and support, as respiratory compromise is the most common complication after pediatric tonsillectomy. We aim to evaluate risk factors associated with postoperative oxygen supplementation and to identify high risk populations within the admitted population who use additional resources or require additional interventions. METHODS: Retrospective chart review of patients between the ages of 3 and 18 years old who underwent tonsillectomy by four surgeons at a tertiary care children's hospital was performed. Data including demographics, comorbidities, surgical intervention, pre- and postoperative AHI, admission, postoperative oxygen requirement, and postoperative complications was collected and analyzed. RESULTS: There were 401 patients included in the analysis. Of the patients in this study, 65.59% were male, 43.39% were Latino, and 53.87% were ages 3 to 7. Of the 397 patients with a record for supplemental oxygen, 36 (9.07%) received supplemental oxygen. The LASSO regression odds ratios (OR) found to be important for modeling supplemental oxygen use (in decreasing order of magnitude) are BMI ≥35 (OR = 2.30), pre-op AHI >30 (OR = 2.28), gastrointestinal comorbidities (OR = 2.20), musculoskeletal comorbidities (OR = 1.91), cardiac comorbidities (OR = 1.20), pulmonary comorbidities (OR = 1.14), and BMI 30 to <35 (OR = 1.07). Female gender was found to be negatively associated with risk of supplemental oxygen use (OR = 0.84). Age, race, AHI ≥15-30, neurologic comorbidities, syndromic patients, admission reason, and undergoing other procedures concomitantly were not found to be associated with increased postoperative oxygen requirement. CONCLUSION: BMI ≥30, pre-op AHI >30, male gender, and gastrointestinal, musculoskeletal, cardiac, and pulmonary comorbidities are all associated with postoperative supplemental oxygen use. Age, race, AHI ≥15-30, neurologic comorbidities, syndromic patients, admission reason, and undergoing other procedures concomitantly were not found to be associated with increased postoperative oxygen requirement.

A comparative study of BiZact™ tonsillectomy versus cold steel dissection technique in adults: Analysis of operating time, intraoperative blood loss, postoperative bleeding rate and pain.

OBJECTIVES: To analyse operating time, intraoperative blood loss, postoperative bleeding rate and pain when using the relatively new BiZact™ tonsillectomy device compared to the commonly used cold steel dissection technique with bipolar cautery in adults. DESIGN: Retrospective case control study. Parameters analysed for significant association with technique were operating time, intraoperative blood loss, wound pain on postoperative days 1-4 and rate of post-tonsillectomy bleeding (PTB). SETTING: Monocentric study at a department of otolaryngology and head and neck surgery at a tertiary centre in Germany. PARTICIPANTS: A total of 183 patients who underwent a bilateral tonsillectomy with either the BiZact™ tonsillectomy device or the cold dissection technique with bipolar cautery for haemostasis. MAIN OUTCOME MEASURES: Operating time, intraoperative blood loss, postoperative pain on the first to fourth postoperative day (numeric rating scale: 0-10) (PTB, primary bleeding ≤24 h, secondary bleeding >24 h postoperative; Stammberger scale). RESULTS AND CONCLUSION: The BiZact™ tonsillectomy device leads to a significant shorter operating time with less intraoperative blood loss compared to cold steel dissection with bipolar haemostasis. No benefits with regards to PTB or postoperative pain could be observed. The use of the BiZact™ device provides major benefits in clinical routine and stands up to conventional tonsillectomy techniques.

Long-term effects of adenotonsillectomy in children with attention deficit hyperactivity disorder.

STUDY OBJECTIVES: Adenotonsillectomy (AT) improves short-term symptoms of attention deficit hyperactivity disorder (ADHD) in children; however, its long-term effects remain unclear. We aimed to verify the therapeutic long-term effects of AT in children with ADHD. METHODS: This retrospective control study included children ages < 18 years who were diagnosed with ADHD and receiving ADHD medications. Participants were divided into groups depending on whether AT was performed (AT [+] or AT [-] groups) and matched 1:1 for age, sex, and year and month of diagnosis using randomized nonreplacement selection. RESULTS: Among patients with ADHD (n = 171,112), 3,615 underwent AT. In both groups, the number of drugs taken gradually increased before and decreased after the AT date (ATD). There was no difference in the number of drugs used before (P = .88) and after ATD (P = .06). Before ATD, the average number of outpatient visits (nOV) did not change in both groups (AT [+]: P = .12; AT [-]: P = .71). After ATD, the average number of outpatient visits decreased only in the AT (+) group (P = .001). However, there was no difference in the average number of outpatient visits between the two groups before (P = .47) and after ATD (P = .17). Before ATD, methylphenidate doses between the groups were not different (P = .06); however, a significant increase was noted after ATD in the AT (+) group (P < .001). CONCLUSIONS: AT does not result in significant long-term therapeutic effects in terms of medication use and health care utilization in children with ADHD. CITATION: Lee J, Choi A, Kim S, Kim K. Long-term effects of adenotonsillectomy in children with attention deficit hyperactivity disorder. J Clin Sleep Med. 2024;20(5):727-733.

Central and mixed apneas in children with obstructive sleep apnea: effect of adenotonsillectomy.

PURPOSE: Investigate the effect of adenotonsillectomy on mixed apnea index (MAI) and central apnea index (CAI) in children with moderate-to-severe obstructive sleep apnea syndrome (OSAS). METHODS: Observational retrospective analysis of polysomnographic data in children diagnosed with moderate-to-severe OSAS and without comorbidity, submitted to adenotonsillectomy. RESULTS: Data were available for 80 children, 55 boys and 25 girls, with a median age of 3.6 years (2.1-5.9). Before surgery AHI was 14.1 (11.0-18.4) per hour, with a median preoperative OAI of 7.1 (4.1-10.6), MAI of 1.2 (0.6-1.6) and CAI of 1.0 (0.4-2.0). Adenotonsillectomy caused significant improvements in MAI, from 1.2 (0.6-1.6) to 0.5 (0.1-0.8) (p < 0.001) and CAI from 1.0 (0.4-2.0) to 0.5 (0.1-0.9) (p < 0.001). This represents a normalization of MAI in 91.7% and CAI in 75.6% of children that had an abnormal value prior surgery. CONCLUSION: Non obstructive apneas are common in children with OSAS. Adenotonsillectomy caused significant decrease not only in OAI, but also in MAI and CAI in children with moderate-to-severe OSAS.

Incidence and predictors of readmission following tonsillectomy in pediatric population.

BACKGROUND: Tonsillectomy is one of the most common surgical procedures performed in the pediatric population. This study aims to estimate the incidence rate of readmission post tonsillectomy in pediatrics and identify the causes and predictors contributing to the readmission post-surgery. METHODS: A retrospective cohort study included 1280 pediatric patients (18 years or younger) who underwent tonsillectomy at a tertiary hospital in 2019 and 2020. The study sample was divided into two groups based on readmission and were compared using the appropriate statistical tests. Significant variables (p-value≤0.05) were included in the logistic regression model to determine the predictors of readmission following tonsillectomy in these patients. RESULTS: The readmission rate following tonsillectomy was 6.3 % (95 % confidence interval 5.1-7.9). The causes of readmission included poor oral intake followed by bleeding and vomiting, 55.6 %,49.4 %, and 13.6 %, respectively. In the multivariable logistic regression model, the only significant predictor of post-tonsillectomy readmission was the use of a single postoperative analgesia (OR: 57.27, P = 0.000). CONCLUSION: The readmission rate following tonsillectomy in this study was relatively high. The most common causes contributing to readmission post tonsillectomy were poor oral intake and hemorrhage. The study also revealed a significant association between the utilization of single postoperative analgesia and an increased likelihood of readmission.

Artificial intelligence and ChatGPT: An otolaryngology patient's ally or foe?

BACKGROUND: As artificial intelligence (AI) is integrating into the healthcare sphere, there is a need to evaluate its effectiveness in the various subspecialties of medicine, including otolaryngology. Our study intends to provide a cursory review of ChatGPT's diagnostic capability, ability to convey pathophysiology in simple terms, accuracy in providing management recommendations, and appropriateness in follow up and post-operative recommendations in common otolaryngologic conditions. METHODS: Adenotonsillectomy (T&A), tympanoplasty (TP), endoscopic sinus surgery (ESS), parotidectomy (PT), and total laryngectomy (TL) were substituted for the word procedure in the following five questions and input into ChatGPT version 3.5: "How do I know if I need (procedure)," "What are treatment alternatives to (procedure)," "What are the risks of (procedure)," "How is a (procedure) performed," and "What is the recovery process for (procedure)?" Two independent study members analyzed the output and discrepancies were reviewed, discussed, and reconciled between study members. RESULTS: In terms of management recommendations, ChatGPT was able to give generalized statements of evaluation, need for intervention, and the basics of the procedure without major aberrant errors or risks of safety. ChatGPT was successful in providing appropriate treatment alternatives in all procedures tested. When queried for methodology, risks, and procedural steps, ChatGPT lacked precision in the description of procedural steps, missed key surgical details, and did not accurately provide all major risks of each procedure. In terms of the recovery process, ChatGPT showed promise in T&A, TP, ESS, and PT but struggled in the complexity of TL, stating the patient could speak immediately after surgery without speech therapy. CONCLUSIONS: ChatGPT accurately demonstrated the need for intervention, management recommendations, and treatment alternatives in common ENT procedures. However, ChatGPT was not able to replace an otolaryngologist's clinical reasoning necessary to discuss procedural methodology, risks, and the recovery process in complex procedures. As AI becomes further integrated into healthcare, there is a need to continue to explore its indications, evaluate its limits, and refine its use to the otolaryngologist's advantage.

Effect of monopolar diathermy power settings on postoperative pain, wound healing, and tissue damage after tonsillectomy: a randomized clinical trial.

This study aimed to assess the impact of varying monopolar diathermy power settings on postoperative pain, hemorrhage, and wound healing following tonsillectomy. A single-center, prospective, randomized, double-blinded, controlled clinical study was conducted. During bilateral tonsillectomy procedures, one tonsil received low-power settings (15 W, cutting/blend) while the other tonsil received high-power settings (35 W, cutting/blend). Postoperative pain scores (0-10) and wound healing scores (0-3) were evaluated immediately after surgery and at 1, 2, and 4 weeks postoperatively using the visual analog scale. Additionally, histological analysis was performed on electrically resected tonsil tissues to assess tissue damage in the tonsil bed. The allocation of high and low power settings to each side was randomized. Results showed that 1 week after the surgery, the high-power group experienced significantly higher pain scores (mean ± standard deviation: 4.84 ± 2.21) compared to the low-power group (3.56 ± 2.24, p = 0.049). Moreover, the high-power side exhibited slower wound healing during the initial 1-2 weeks postoperatively, as indicated by lower wound scores at 2 weeks (high-power: 1.96 ± 0.64; low-power: 2.43 ± 0.59, p = 0.008). Furthermore, histological analysis revealed significantly deeper tissue degradation on the high-power side compared to the low-power side (p < 0.001), with mean depths of 565.2 ± 291.0 µm and 156.0 ± 36.8 µm, respectively. In conclusion, these findings suggest that when employing monopolar diathermy in tonsillectomy, lower power settings can lead to improved outcomes in terms of postoperative pain, wound healing, and tissue damage.Trial registration: CRIS identifier: KCT0005670 (cris.nih.go.kr, registration date: 11/12/2020).

An update on diagnosis and management of obstructive sleep apnoea in the first 2†years of life.

The aim of this review is to summarise evidence that became available after publication of the 2017 European Respiratory Society statement on the diagnosis and management of obstructive sleep apnoea syndrome (OSAS) in 1- to 23-month-old children. The definition of OSAS in the first 2 years of life should probably differ from that applied in children older than 2 years. An obstructive apnoea-hypopnoea index >5 events·h-1 may be normal in neonates, as obstructive and central sleep apnoeas decline in frequency during infancy in otherwise healthy children and those with symptoms of upper airway obstruction. A combination of dynamic and fixed upper airway obstruction is commonly observed in this age group, and drug-induced sleep endoscopy may be useful in selecting the most appropriate surgical intervention. Adenotonsillectomy can improve nocturnal breathing in infants and young toddlers with OSAS, and isolated adenoidectomy can be efficacious particularly in children under 12 months of age. Laryngomalacia is a common cause of OSAS in young children and supraglottoplasty can provide improvement in children with moderate-to-severe upper airway obstruction. Children who are not candidates for surgery or have persistent OSAS post-operatively can be treated with positive airway pressure (PAP). High-flow nasal cannula may be offered to young children with persistent OSAS following surgery, as a bridge until definitive therapy or if they are PAP intolerant. In conclusion, management of OSAS in the first 2 years of life is unique and requires consideration of comorbidities and clinical presentation along with PSG results for treatment decisions, and a multidisciplinary approach to treatment with medical and otolaryngology teams.

Bilateral peritonsillar abscess. A case report and review of controversies surrounding diagnosis and management. / Absceso periamigdalino bilateral. Reporte de un caso y revisión de las controversias en el diagnóstico y tratamiento.

The bilateral presentation of peritonsillar abscess is uncommon. Its management is controversial and it has been argued whether a quinsy tonsillectomy or an interval tonsillectomy should be performed. Here we describe the case of a 14-year-old boy with sore throat, trismus, and fever. He had bilateral tonsillar hypertrophy, convex arches, and soft palate edema. Computed tomography: bilateral tonsillar hypertrophy, with post-contrast enhancement, both with collection, edema with moderate pharyngeal stenosis. The patient was hospitalized for intravenous therapy and tonsillectomy with bilateral drainage resulting in a complete resolution of his condition and discharge at 48 hours. In the presence of a peritonsillar abscess, an unsuspected contralateral abscess should be considered. It should be diagnosed and managed adequately to prevent complications. Quinsy tonsillectomy could be safe and should be considered in patients who will undergo anesthesia for abscess drainage. The final decision should be made for each patient on an individual basis.

La presentación bilateral del absceso periamigdalino es poco frecuente. Su abordaje es controversial y se discute si realizar amigdalectomía en caliente versus diferida. Se presenta el caso de un paciente de sexo masculino, de 14 años, con odinofagia, trismo y fiebre. Presentaba hipertrofia amigdalina bilateral, pilares abombados y edema de paladar blando. Tomografía computada: hipertrofia amigdalina bilateral, con realce poscontraste, ambas con colección, edema con moderada estenosis faríngea. Se decidió internación para tratamiento endovenoso y amigdalectomía con drenaje bilateral. Resolución completa del cuadro con alta a las 48 horas. Ante la presencia de un absceso periamigdalino, debe considerarse la posibilidad de un absceso contralateral oculto. Debe ser diagnosticado y tratado adecuadamente para prevenir complicaciones. La amigdalectomía en caliente podría ser un tratamiento seguro y debería ser considerado en pacientes que serán sometidos a anestesia para drenaje. La decisión final debe ser determinada para cada caso en particular.