Tonsillectomy Research Articles

Transoral robotic surgery for management of cervical unknown primary squamous cell carcinoma: Updates on efficacy, surgical technique and margin status

ImportanceManagement of cervical unknown primary squamous cell carcinoma (CUP) has evolved with the introduction of transoral robotic surgery (TORS). Objectives1. To describe the efficacy of TORS lingual and palatine tonsillectomy in identifying the primary site of malignancy. 2. To explore how the extent of surgery affects diagnostic yield. 3. To report margin status of TORS resections. Design, setting and participantsA retrospective, single-center cohort study utilizing a prospectively collected database of CUP patients in a high-volume tertiary referral center. Patient underwent operative laryngoscopy plus TORS as clinically indicated. Main outcomes and measuresPrimary end point was successful identification of the primary. The extent of surgery and margin status were also examined. ResultsFrom 2010–2016, 64 patients with CUP were treated. The primary tumor was found in 51 patients (80%). Fourteen patients (22%) were identified with operative laryngoscopy alone. Fifty patients underwent TORS lingual tonsillectomy ± palatine tonsillectomy with 37 primary tumors identified (74%). The primary was located in the lingual tonsil in 32 patients (86%) and palatine tonsil in 5 patients (10%, p<0.001). Negative margins were achieved in 19 patients (51%). The deep margin was the most commonly positive margin (47%, p=0.049). Conclusion and relevanceOperative laryngoscopy with TORS is efficacious, localizing the primary in 80% of patients. If a margin was positive, it was most commonly the deep margin. This study provides valuable information that can help standardize surgical technique, further increasing the diagnostic yield and decreasing the negative margin rate of TORS for CUP.

Comparative study between sevoflurane and isoflurane on the perioperative and postoperative bleeding of adenotonsillectomy patients

Objective The aim of this study was to compare the effects of volatile anesthetics isoflurane and sevoflurane on intraoperative and postoperative bleeding in patients who underwent tonsillectomy and adenoidectomy. Patients and methods A total of 64 children classified as American Society of Anesthesiologists class I or II, aged between 2 and 16 years, who were scheduled for tonsillectomy and adenoidectomy were included in this prospective randomized double-blind study. The patients were randomized into two groups, isoflurane group and sevoflurane group, with each including 32 patients. They received balanced general anesthesia with isoflurane concentration 1.2% or sevoflurane concentration 2%. In all patients, the amount of intraoperative blood loss in milliliters was measured by the suction bottle, as well as by weighing the used sponges for each patient. The duration of operation and recovery time were recorded. Results Isoflurane caused significantly lower amount of perioperative bleeding compared with sevoflurane (P=0.03). No significant difference was observed between the two groups in terms of age, BMI, and operation duration, Conclusion Anesthesia with isoflurane can lead to a lower amount of intraoperative bleeding compared with sevoflurane. Therefore, isoflurane may be preferred as an inhalational agent for maintenance of general anesthesia during tonsillectomy and adenoidectomy operations.

Adenotonsillar surgeries in Kaduna, Nigeria

Background: Adenotonsillar surgeries are the most common otolaryngology procedures in the pediatric age group worldwide. Aims: The aim is to evaluate the prevalence, indications, complications, and postoperative symptoms resolution after adenotonsillectomy in pediatric patients in our center. Settings and Design: A retrospective study was conducted in a tertiary health facility in Kaduna, Nigeria. Methodology: The medical records of all children that had surgical procedures from January 2009 to December 2012 were extracted. A total of 232 pediatric patients had adenotonsillectomy of a total of 312 who underwent surgical procedures over 4 years. Forty-eight patients did not meet criteria for inclusion in this study. Therefore, 184 patients satisfied the inclusion criteria for this study. Data were analyzed descriptively with Statistical Package for Social Sciences version 16. Results: The mean age at the time of surgery was 3.5 ± 2.43 years. There were 102 males and 82 females in a ratio of 1:0.8. The main indications were obstructive, pharyngeal, and otologic symptoms. The duration of follow-up after adenotonsillectomy range from 4 weeks to 6 months, 177 (96.19%) had complete resolution of symptoms after surgery, 7 (3.80%) had an additional treatment for rhinosinusitis. Four patients had immediate mild postoperative bleeding (reactionary hemorrhage). No deaths were recorded within the period under review. Conclusions: Adenotonsillar surgeries are common otolaryngology procedures in our hospital, mainly done on account of obstructive symptoms. They are rewarding procedures in terms of symptoms resolution and safety.

Transoral robotic surgery for the pediatric head and neck surgeries

Pediatric robotic surgery is a relatively new technology that has been shown to be safe and feasible for a number of pediatric procedures. Our literature analysis was performed using Pubmed database between January 2005 and December 2015, using key words: "robotic," "robotic surgery," "TORS," "pediatric," "children," "head and neck," and "da Vinci". We selected only publications in English. Eight published reports met the selection criteria. We totally found 41 patients, and the age range was between 2months and 19years. The cases are 16 only lingual tonsillectomy, nine base of tongue and lingual tonsillectomy, two malignant disease in the oropharynx (high-grade undifferentiated sarcoma and biphasic synovial sarcoma), one tongue base thyroglossal duct cyst, 11 laryngeal cleft cyst, one posterior glottic stenosis, and one congenital true vocal cord paralysis surgeries. One intraoperative complication was reported. No patient needed postoperative tracheotomy. Hospital duration time had a range of 1-16days. TORS is new for pediatric patients in head and neck areas, and there were few reports. It is becoming increasingly used in head and neck surgeries and those reports above are encouraging for pediatric robotic airway surgeries in otolaryngology in the future.

Specified data for tonsil surgery in Germany.

Background: Tonsillectomy rates vary considerably among different states, regions, and times. This study was conducted to identify the prevalence of “chronic” tonsillitis, peritonsillar abscess, hypertrophy of the tonsils with and without adenoids in absolute and relative numbers in an 80 million people nation. Moreover, the number and rates of different surgical procedures to resolve either “chronic” tonsillitis, peritonsillar abscess, or upper airway obstruction due to (adeno)tonsillar hypertrophy over several years was evaluated in this study (tonsillectomy, adenotonsillectomy, tonsillotomy, abscess tonsillectomy, transoral incision and drainage). Finally, the post-tonsillectomy hemorrhage rate was calculated and analyzed in relation to age and gender.Material and methods: Calculations were based on data as published by the Federal Institute of Statistics or on request, if needed. The latest data were provided for 2013.Results: The total number of the aforementioned diseases (stratified by ICD-10) decreased from 142,574 (in 2000) to 87,624 in 2013 (38.5%). Tonsillectomy, with or without adenoidectomy, was performed in a total of 833,896 patients between 2006 and 2013 in Germany. The yearly number decreased continually from 120,993 in 2006 to 84,332 procedures in 2013 (30.3%). The most significant decrease was registered in patients younger than 20 years of age for this time period: 70.92 per 10,000 in 2010 to 58.68 per 10,000 in 2013. If all age groups were included, the rate decreased from 13.34 per 10,000 to 10.90 per 10,000. In contrast, an increasing number of tonsillotomies was observed between 2007 (4,659 procedures) and 2013 (11,493). The cumulated number of procedures was 59,049. A constant number of 15,000 cases with peritonsillar abscess were diagnosed per year in Germany (19 patients per 100,000). The prevalence increased significantly at an age of 15 years and there was a preponderance of female patients below that age. Compared to the transoral incision and drainage, a 2.8-fold greater number of abscess tonsillectomies were performed annually. Post-tonsillectomy hemorrhage was experienced in 5.98% of all patients after 245,721 procedures in 2010 and 2013 (all indications, except tonsillotomy). Bleeding complications had occurred less frequently in female patients (5.06% vs. 7.02%). Finally, a considerable increase of post-tonsillectomy hemorrhage in patients older than 10 years of age was registered in male patients only.Conclusion: Chronic tonsillitis was less frequently diagnosed and surgically treated in terms of tonsillectomy (with or without adenoidectomy), particularly in female patients. In contrast, the number of tonsillotomies increased continually, particularly in male patients. Peritonsillar abscess was diagnosed and surgically treated in a constant number of patients in the yearly comparison. Most of these patients were scheduled for abscess tonsillectomy, and only a 2.8-fold smaller number for transoral incision and drainage. Independent from the indication for surgery, post-tonsillectomy hemorrhage was clearly associated with male gender and age (>10 years). The study reveals a dramatic change mandating further surveillance in insurance companies and authorities in the national health system of an 80 million people nation. (Tab. 1)

Obstructive sleep apnea and asthma.

Both asthma and obstructive sleep apnea (OSA) are common conditions involving the adults and children population, and have significant impact on the healthcare system. For the last few decades a lot of data emerged in terms of the prevalence between asthma and OSA. The prevalence ranges from 38% up to as high as 70%. Based on the current concepts of bidirectional relationship of OSA and asthma, it is sensible to assume that treating one disorder will result in the other's better control and vice versa. This review will look into the pathogenesis of concomitant OSA and asthma and whether the first line OSA therapy will result in better control of asthma in patients with concomitant OSA. There is growing evidence that continuous positive airway pressure (CPAP) in adults and adenotonsillectomy in children which are recommended as first line treatment of OSA can improve their asthma symptoms. However, further confirmation is necessary with larger randomized control trials to further evaluate both conditions and the treatment effects.

The Challenges of Pediatric Anesthesia for Ambulatory Adenotonsillectomy

Purpose of review With a prevalence of about 10%, pediatric sleep-disordered breathing (PSDB) contributes to significant epidemiological burden. The first line of management is adenotonsillectomy (AT), which restores airflow and leads to resolution of symptoms in over 80% of children. Providing safe and effective administration of general anesthesia in this ‘at risk’ population can be a challenge in the ambulatory setting.

Tonsillectomy for incomplete PFAPA?

Tonsillectomy for incomplete PFAPA?

Adenotonsillectomy outcomes regarding bone age and osteocalcin in treatment of obstructive sleep apnea syndrome in children.

To investigate the effect of adenotonsillectomy (AT) on bone development, quality of life and polysomnography evaluation in children with obstructive sleep apnea syndrome (OSA). Preoperative and postoperative (6 months) physical examination, PSG, bone age (BA) and osteocalcin (OC) evaluation were performed on the selected OSA children (n=92) and the healthy children (n=87). The OSA children were also scored based on the OSA 18-item questionnaire. A two-year follow-up was conducted to evaluate BA and OC changes. After AT, 81 (88.04%) OSA children recovered completely, eight (8.70%) achieved remarkable improvements, and three (3.26%) achieved moderate improvements. In the OSA children, postoperative OSA 18-item score and the scores of the five domains were significantly higher than preoperative ones. Compared with the preoperative, body mass index (BMI), weight for age Z-sores, height for age Z-sores, weight for height Z-sores and BMI Z-score in the OSA group 6 months after the operation were significantly increased, but no significant difference was detected between the OSA and the control group. The changes of BA and chronological age in the OSA group were significantly different from those in the control group. Two years after AT, BA between the two groups was no longer significantly different. Preoperative serum OC in the OSA group was lower than that in the control group, but increased to normal levels 6 months after AT. Correlation analysis showed serum OC levels were negatively correlated with apnea hyponea index, obstructive apnea index, arousal index, and lowest oxygen saturation. After AT, bone growth and development in children with OSA recovered gradually, and the serum OC levels decreased to the normal level. Therefore, preventive measures and positive treatments should be applied to minimize the negative effects of OSA in children.

Radiotherapy Characteristics and Outcomes for Head and Neck Carcinoma of Unknown Primary vs T1 Base-of-Tongue Carcinoma

Transoral robotic surgery- or transoral laser microsurgery-assisted lingual tonsillectomy may improve the identification rate of hidden base-of-tongue (BOT) carcinoma presenting as head or neck carcinoma of unknown primary (CUP) site. To evaluate the potential impact of lingual tonsillectomy in CUP site by comparing differences in radiotherapy volumes, dosimetry, and clinical outcomes for CUP site and T1-category BOT carcinoma. Retrospective study of 115 patients treated at a tertiary cancer center between January 1, 2005, and December 31, 2013, that included patients with BOT carcinoma (category T1N1-3M0) and CUP site (category T0N1-3M0) with known p16 status. Fifty-four patients with T1-category BOT carcinoma (50 [92.6%] p16-positive) were treated with definitive intensity-modulated radiotherapy (IMRT), including 34 (63%) who received concurrent chemotherapy. Sixty-one patients with CUP site (38 [62.3%] p16-positive) received definitive (42 [68.9%]) or postoperative (19 [31.1%]) IMRT, including 22 (36%) who received concurrent chemotherapy. Definitive or postoperative IMRT, with or without concurrent chemotherapy. Characteristics of mucosal clinical target volume (CTV-T), nodal CTV, and organ-at-risk dosimetry; local, regional, and distant control; cause-specific and overall survival; and Radiation Therapy Oncology Group grade 3 or higher late toxic effects. Of 115 participants, 104 (90.4%) were male; mean (SD) age was 59 (10) years. High-dose CTV-T was prescribed in all 54 patients with BOT carcinoma and 23 (37.7%) with CUP site (effect size [Δ], 62%; 95% CI, 50%-74%). Low-dose CTV-T included mucosal pharyngeal sites outside the oropharynx in no patients with BOT carcinoma and 26 (42.6%) (95% CI, 30%-54%) with CUP site, with greater low-dose CTV-T volume in CUP site than BOT carcinoma (113 vs 84 cm3; Δ, 30 cm3; 95% CI, 10-49 cm3). Bilateral neck irradiation was used in 53 of 54 patients (98.1%) with BOT carcinoma and 46 of 61 (75.4%) with CUP site (Δ, 23%; 95% CI, 12% to 34%). Patients with BOT carcinoma received a higher maximum dose to the mandible (71 vs 67.2 Gy; Δ, 3.8 Gy; 95% CI, 1.6 to 6 Gy), with a nonsignificantly higher maximum dose (66.1 vs 62.8 Gy; 3.2 Gy; 95% CI, -0.1 to 6.5 Gy) and lower mean dose to the larynx (43.8 vs 47.1 Gy; 3.3 Gy; 95% CI, -0.3 to 6.9 Gy). There were no significant differences in local control, regional control, distant control, cause-specific survival, and overall survival between the BOT carcinoma and CUP site groups stratified by p16 status. Grade 3 Radiation Therapy Oncology Group late toxic effects occurred in 2 patients (3.3%) with CUP site (both neck fibrosis) and 5 (9.3%) with BOT carcinoma (2 neck fibrosis, 2 osteoradionecrosis, and 1 dysphagia). Intensity-modulated radiotherapy for CUP site or T1-category BOT carcinoma had similar clinical outcomes. Identifying hidden BOT primary carcinoma with novel approaches (eg, transoral robotic surgery and transoral laser microsurgery) may lead to changes in the radiotherapy target volume and dose prescription. Studies are needed to investigate the effect of these differences on quality of life and functional outcomes.

The safety and efficacy of pediatric lingual tonsillectomy

ObjectiveLingual tonsillar hypertrophy is recognized as a cause of persistent obstructive sleep apnea (OSA) after adenotonsillectomy in children. However, little has been reported regarding the complications, postoperative course and effectiveness of lingual tonsillectomy (LT). Our objective was to review the safety and effectiveness of LT in children. MethodsRetrospective review of children undergoing LT from January 2009 to December 2015 at a tertiary children's hospital. Complications, postoperative course and polysomnographic (PSG) outcomes were recorded for all patients. ResultsWe identified 92 children (mean age = 8.6 years, 50% female) who underwent LT; 43.5% had a syndromic diagnosis. The most common complications were emergency department presentation for bleeding (4.4%) and poor oral intake (3.3%). The readmission rate was 4.4% including 2 children (2.2%) who required operative control of hemorrhage. No children required unplanned reintubation or ICU admission. In children with PSG data (n = 18), the median apnea-hypopnea index (AHI) decreased from 8.5 to 3.8 events/hour (p = 0.022) and the median obstructive AHI (oAHI) decreased from 8.3 to 3.1 events/hour (p = 0.021). In addition, the oxygen saturation nadir increased from 83.8% to 89.0% (p = 0.0007). After surgery the percentage of patients with oAHI<5 events/hour increased from 27.8% to 61.1% (p = 0.08). ConclusionsReadmission and bleeding rates after lingual tonsillectomy in children were similar to that seen with tonsillectomy. Polysomnographic data showed that lingual tonsillectomy resulted in a significant reduction of both AHI and oAHI with a postoperative oAHI <5 achieved in 61% of patients.

An update on tonsillotomy studies

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

Temporal trends in inpatient pediatric sleep apnea surgery: 1993-2010.

We sought to characterize changes in the patterns of inpatient surgical sleep care over time and ascertain if these changes were consistent with previously reported trends in adult surgical sleep care. Repeated cross-sectional study. Discharge data from the U.S. Nationwide Inpatient Sample for 125,691 nasal, palatal, or hypopharyngeal procedures in children for sleep-disordered breathing or obstructive sleep apnea (OSA) from 1993 to 2010 were analyzed using cross-tabulations and multivariate regression modeling. Inpatient surgical sleep procedures increased from 45,671 performed in 1993 to 2000 (study period 1) to 80,020 in 2001 to 2010 (study period 2). Overall, patients were commonly male (61.3%), privately insured (46.8%), 2 to 6 years old (39.4%), and white (36.4%). Obesity was reported in 4.6% and 6.7% of children during study periods 1 and 2, respectively (P < .0001). Tonsillectomy (with and without adenoidectomy) was the most commonly performed procedure in both study periods. With the exception of uvulopalatopharyngoplasty and tracheostomy, all sleep procedures increased over time; however, multilevel surgery did not significantly increase (P = .28). Children who underwent sleep surgery during study period 2 were more likely to receive a supraglottoplasty (P = .0125) and to undergo procedures at high-volume hospitals (P = .0311), and less likely to undergo a tracheostomy (P < .0001). These data reflect changing trends in the surgical management of pediatric OSA, with significant increases in nasal and hypopharyngeal procedures, particularly lingual tonsillectomy and supraglottoplasty. Unlike the trend in adults, multilevel surgery in children with sleep disordered breathing or OSA has not yet been integrated into routine clinical practice. 2C Laryngoscope, 127:1235-1241, 2017.

Parent Experience of Care and Decision Making for Children Who Snore

Sleep-disordered breathing (SDB) is prevalent and has an impact on the physical and behavioral health of children. Adenotonsillectomy (AT), the primary treatment, is subject to unexplained variation in utilization, which may be reduced by improving physician-patient communication and decision quality for this elective procedure. To identify factors are associated with parental experience and decision making in pediatric SDB and AT surgery. In this qualitative study, parents of children with prior SDB evaluation participated in semistructured, audiorecorded interviews. Open-ended questions regarded experiences of having a child with SDB, communication with pediatric clinicians and surgeons, and experiences with AT surgery. Recordings were transcribed and analyzed for emergent themes using grounded theory methodology. Eleven parents of children ages 2 to 17 years who had previously been diagnosed or treated for SDB were identified via purposive sampling and interviewed between January and April 2015. Interviews were conducted at locations convenient for the participants and separate from the pediatric clinic. A goal of this study was to ascertain how parents perceived sharing decisions with their physicians. Themes of parental experiences and treatment decision-making processes with pediatric SDB. Overarching themes were inclusive of (1) clinical factors of SDB and AT and (2) clinician interpersonal behaviors and communication. Parents described an urgency that led them to seek evaluation or treatment, including fear that the child would stop breathing, or behavioral and/or cognitive delays. Parents often viewed surgery as a "last resort" and had explored alternate therapies prior to seeing the surgeon. Nearly all parents feared anesthesia more than AT surgery itself. Parents described satisfaction when physicians provided them with options, engaged their child in conversation, depicted SDB visually, and were responsive or accessible to questions. Parents regarded a trusting relationship with their pediatrician, confidence in the surgeon, and inclusion in decision making as important. While clinical factors were influential for decision making, interpersonal factors helped parents feel comfortable and influenced their overall experience. Shared decision making, in which parents receive evidence-based information allowing them to accurately perceive risks, benefits, and alternatives about SDB treatment in the setting of trusting clinician-family relationships, may reduce parental decision conflict and improve decision quality toward AT surgery.

148: Evaluation of the Rationale for Lingual Tonsillectomy in the Diagnostic Work-Up of Head and Neck Squamous Cell Carcinoma of Unknown Primary: Impact of Identifying Small Tongue Base Primary Tumours on IMRT Characteristics and Clinical Outcomes

148: Evaluation of the Rationale for Lingual Tonsillectomy in the Diagnostic Work-Up of Head and Neck Squamous Cell Carcinoma of Unknown Primary: Impact of Identifying Small Tongue Base Primary Tumours on IMRT Characteristics and Clinical Outcomes

Polysomnographic outcomes following lingual tonsillectomy for persistent obstructive sleep apnea in down syndrome.

Lingual tonsil hypertrophy is a common cause of persistent airway obstruction in patients with Down syndrome (DS) following adenotonsillectomy (T&A); however, little is known about the effect of lingual tonsillectomy (LT) on polysomnographic outcomes in these patients. Our objective was to describe changes in sleep-related respiratory outcomes following LT in children with DS and persistent obstructive sleep apnea (OSA) following T&A. Retrospective case series. We included all children with DS who underwent polysomnography before and after LT at a tertiary care center from 2003 to 2013. Nonparametric analysis of variables was performed. Forty patients with DS underwent LT; 21 met inclusion criteria. The mean age at surgery was 9.3 ± 4.3 years and 47.6% were female. The median apnea-hypopnea index (AHI) was 9.1 events/hour (range, 3.8 to 43.8 events/hour) before surgery and 3.7 events/hour (range, 0.5 to 24.4 events/hour) after surgery. The median improvement in overall AHI and the obstructive AHI (oAHI) were 5.1 events/hour (range, -2.9 to 41) and 5.3 events/hour (range, -2.9 to 41), respectively (P <.0001). The mean oxygen saturation nadir improved from 84% to 89% (P =.004). The mean time with CO2 > 50 mm Hg, central index, and percentage of rapid eye movement sleep were not significantly different. After surgery, the oAHI was <5 events/hour in 61.9% and ≤1 in 19% of patients. In children with DS, persistent OSA after T&A and lingual tonsil hypertrophy, LT significantly improved AHI, oAHI, and O2 saturation nadir. We recommend that children with DS should be evaluated for lingual tonsil hypertrophy if found to have persistent OSA following T&A. 4 Laryngoscope, 2016 127:520-524, 2017.

Outcome of adenotonsillectomy in children with Down syndrome and obstructive sleep apnoea

ObjectiveTo evaluate the outcome of adenotonsillectomy (AT) in a cohort of children with Down syndrome (DS) and obstructive sleep apnoea (OSA).DesignRetrospective, cross-sectional study.SettingTertiary care centre.PatientsChildren with DS and OSA, without...

Trans-oral robotic surgery (TORS) for the treatment of lingual tonsillitis. When conventional therapies fail.

Lingual tonsillitis is an underestimated but serious health problem. This paper describes the feasibility and efficacy of the trans-oral robotic surgical approach in cases of lingual tonsillitis. From February 2012 to April 2014, 10 patients affected by lingual tonsillitis resistant to medical treatments underwent transoral robotic lingual tonsillectomy at the authors' Institution. The surgical robotic procedure was completed in all cases and there was no need to change the operative approach once started. The mean set-up time was 13.2 ± 5.2 min, while mean operating time was 28 ± 12 min. The mean amount of tissue removed was 16.5 ± 13 cm3 . No major intra-operative and post-operative complications were registered. After 15.2 ± 12 months of follow-up, no relapses were reported and patients did not complain of any further symptoms. Lingual tonsillitis seems to be safely and effectively managed by trans-oral robotic surgery. The data are encouraging and worthy of further evaluation. Copyright © 2016 John Wiley & Sons, Ltd.

Cognitive Effects of Adenotonsillectomy for Obstructive Sleep Apnea

Research reveals mixed evidence for the effects of adenotonsillectomy (AT) on cognitive tests in children with obstructive sleep apnea syndrome (OSAS). The primary aim of the study was to investigate effects of AT on cognitive test scores in the randomized Childhood Adenotonsillectomy Trial. Children ages 5 to 9 years with OSAS without prolonged oxyhemoglobin desaturation were randomly assigned to watchful waiting with supportive care (n = 227) or early AT (eAT, n = 226). Neuropsychological tests were administered before the intervention and 7 months after the intervention. Mixed model analysis compared the groups on changes in test scores across follow-up, and regression analysis examined associations of these changes in the eAT group with changes in sleep measures. Mean test scores were within the average range for both groups. Scores improved significantly (P < .05) more across follow-up for the eAT group than for the watchful waiting group. These differences were found only on measures of nonverbal reasoning, fine motor skills, and selective attention and had small effects sizes (Cohen's d, 0.20-0.24). As additional evidence for AT-related effects on scores, gains in test scores for the eAT group were associated with improvements in sleep measures. Small and selective effects of AT were observed on cognitive tests in children with OSAS without prolonged desaturation. Relative to evidence from Childhood Adenotonsillectomy Trial for larger effects of surgery on sleep, behavior, and quality of life, AT may have limited benefits in reversing any cognitive effects of OSAS, or these benefits may require more extended follow-up to become manifest.

Attention deficit hyperactivity disorder and sleep disordered breathing in children

Children and adolescents suffering from attention deficit hyperactivity disorder (ADHD) and/or sleep disordered breathing (SDB) may present with similar symptoms, including inattention, irritability, and hyperactivity. SDB is under-diagnosed in young people and is not often recognized in patients with ADHD; we hypothesize that treating sleep disordered breathing in ADHD patients may diminish symptoms and reduce ADHD-focused pharmacotherapy. A Medline search was performed using the criteria for ADHD and SDB. English language publications through January, 2012 were surveyed. Correlation between these two disorders is confounded due to methodological errors in research. The investigations lack consistency due to studies with small sample size, a dearth of diagnostic polysomnography (PSG) to detect SDB, varying definitions for the apnea/hypopnea index, and lack of uniform evaluations to diagnose ADHD. Despite methodological inconsistencies, the data suggests that treating SDB may have a productive impact on treatment outcomes in children with mild ADHD. Patients with ADHD symptomatology should receive SDB screening. In those with comorbid SDB and ADHD, an adenotonsillectomy (AT) may improve the prognosis. Treatment of SDB coexisting with ADHD aims to decrease clinical symptoms, reduce pharmacotherapy, and promote better health.