Episodes Of Sore Throat Research Articles

Long-Term Results From Tonsillectomy in Adults.

Tonsillectomy is performed more than 400 000 times in the European Union each year, making it one of the most common operations. Nonetheless, there have been only a few long-term studies of quality of life after tonsillectomy. In 2004, data on the quality of life after tonsillectomy were obtained from adult German-speaking tonsillectomy patients by means of the Glasgow Benefit Inventory and a questionnaire specifically designed for that study. The present study concerns the further followup of these patients, sometimes many years later. 114 patients with recurrent tonsillitis were included in this descriptive study. Of the 114 patients, 97 (85%) provided further data at 14 months, and 71 (62%) at ca. 7 years. The Glasgow Benefit Inventory revealed postoperative improvement of quality of life at 14 months and at 7 years, with median values of 16.67 points (quartile 11.11/25) and 13.89 points (quartile 8.33/25) (p=0.168). The mean number of annual episodes of sore throat fell from 10 preoperatively to 2 postoperatively (p=0.0001). The number of visits to the doctor, the intake of analgesic drugs and antibiotics, and the number of medical absences from work also declined significantly over the period of observation. Tonsillectomy was associated with a longlasting improvement of health and quality of life, and with lower utilization of medical resources. The 62% response rate at 7 years leaves the question open whether patients with a favorable postoperative course may have been more likely than others to participate in the study.

Streptococcal pharyngitis in schoolchildren in Bamako, Mali.

Group A streptococcus (GAS) pharyngitis is associated with high rates of rheumatic heart disease in developing countries. We sought to identify guidelines for empiric treatment of pharyngitis in low-resource settings. To inform the design of GAS vaccines, we determined the emm types associated with pharyngitis among African schoolchildren. Surveillance for pharyngitis was conducted among children 5-16 years of age attending schools in Bamako, Mali. Students were encouraged to visit a study clinician when they had a sore throat. Enrollees underwent evaluation and throat swab for isolation of GAS. Strains were emm typed by standard methods. GAS was isolated from 449 (25.5%) of the 1,759 sore throat episodes. Painful cervical adenopathy was identified in 403 children (89.8%) with GAS infection and was absent in 369 uninfected children (28.2%). Emm type was determined in 396 (88.2%) of the 449 culture-positive children; 70 types were represented and 14 types accounted for 49% of isolates. Based on the proportion of the 449 isolates bearing emm types included in the 30-valent vaccine (31.0%) plus nonvaccine types previously shown to react to vaccine-induced bactericidal antibodies (44.1%), the vaccine could protect against almost 75% of GAS infections among Bamako schoolchildren. Two promising strategies could reduce rheumatic heart disease in low-resource settings. Administering antibiotics to children with sore throat and tender cervical adenopathy could treat most GAS-positive children while reducing use of unnecessary antibiotics for uninfected children. Broad coverage against M types associated with pharyngitis in Bamako schoolchildren might be achieved with the 30-valent GAS vaccine under development.

Quiz Page February 2015: Renal Colic in an Adolescent

A 17-year-old boy was evaluated for renal colic without stone passage. He had normal physical and mental development, with surgical repair for cryptorchidism at the age of 4 years. In early childhood, he experienced episodes of sore throat accompanied by diffuse joint pain, diagnosed as acute rheumatic fever. Starting in adolescence, he experienced arthritis of the metatarsophalangeal joints, wrists, fingers, and knees. He also reported episodes of renal colic since the age of 12 years. The patient was an only child of a nonconsanguineous union.

Tonsillectomy or adenotonsillectomy versus non-surgical treatment for chronic/recurrent acute tonsillitis.

Surgical removal of the tonsils, with or without adenoidectomy (adeno-/tonsillectomy), is a common ENT operation but the indications for surgery are controversial.To determine the effects of tonsillectomy, with and without adenoidectomy, in patients with chronic/recurrent acute tonsillitis.The Cochrane Ear, Nose and Throat Disorders Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2008, issue 2), MEDLINE (1966 to 2008), EMBASE (1974 to 2008), bibliographies, and additional sources were searched for published and unpublished trials. The date of the last search was 11 April 2008.Randomised controlled trials comparing tonsillectomy, with or without adenoidectomy, with non-surgical treatment in adults and children with chronic/recurrent acute tonsillitis. We included trials which used reduction in the number and severity of tonsillitis and sore throat as main outcome measures.Two authors applied the inclusion/exclusion criteria independently.This review includes five studies: four undertaken in children (719 participants) and one in adults (70 participants). Good information about the effects of tonsillectomy is only available for children and for effects in the first year following surgery.Children were divided into two subgroups: those who are severely affected (based on specific criteria which are often referred to as the 'Paradise criteria') and those less severely affected.For more severely affected children adeno-/tonsillectomy will avoid three unpredictable episodes of any type of sore throat, including one episode of moderate or severe sore throat in the next year. The cost of this is a predictable episode of pain in the immediate postoperative period.Less severely affected children may never have had another severe sore throat anyway and the chance of them so doing is modestly reduced by adeno-/tonsillectomy. For them, surgery will mean having an average of two rather than three unpredictable episodes of any type of sore throat. The cost of this reduction is one inevitable and predictable episode of postoperative pain. The 'average' patient will have 17 rather than 22 sore throat days but some of these 17 days (between five and seven) will be in the immediate postoperative period. Whilst the concept of the 'average' patient is attractive, in practice, wide variability is likely.One reason why the impact of surgery is so modest, is that many untreated patients get better spontaneously. There is a trade-off for the physician and patient who must weigh up a number of different uncertainties: what proportion of my throat symptoms are attributable to my tonsils, and will I get better without any treatment? Similarly, the potential 'benefit' of surgery must be weighed against the risks of the procedure.Adeno-/tonsillectomy is effective in reducing the number of episodes of sore throat and days with sore throats in children, the gain being more marked in those most severely affected. The size of the effect is modest, but there may be a benefit to knowing the precise timing of one episode of pain lasting several days - it occurs immediately after surgery as a direct consequence of it.It is clear that some children get better without any surgery, and that whilst removing the tonsils will always prevent 'tonsillitis', the impact of the procedure on 'sore throats' due to pharyngitis is much less predictable.

The role of tonsillectomy for recurrent sore throats in children: A qualitative study

IntroductionDecisions regarding tonsillectomy for children with recurrent sore throats are mainly based on guidelines that take the number of sore throat episodes into consideration. Anecdotally, parents report a number of additional factors that change after the operation. With this in mind, the first follow up tonsillectomy qualitative study was undertaken to identify what the operation truly offers this group of children. Materials and methodsTen families were interviewed between 3 and 14 months after their child's operation. A narrative method was utilised. Interviews with families were transcribed and analysed to identify key themes that had changed due to the operation. ResultsThemes identified included an improvement in general and specific symptoms. Psychosocial aspects such as education, socialising, family consequences and psychological consequences were also important factors that families noticed. ConclusionTonsillectomy has much more to offer families and children than an improvement in the numbers of episodes of sore throats and this study could form the basis of a specific quality of life assessment tool.

Herpes iris of Bateman.

An 11-year-old boy presented with mildly painful erythematous rash and vesiculobullous lesions over the trunk and in the oral cavity of three days duration. One day prior, he started developing vesiculobullous lesions over his arms. Ten days prior, he had an episode of sore throat and mild fever, for which he received azithromycin. There was no history of similar lesions in the past or family history of similar lesions. On examination, ‘target’ lesions were noted over the trunk, oral cavity and genitalia [Figure 1a]. The arms were notable for a distinctive type of lesion, characterized by central bulla over an erythematous background and a ring of vesicles at the margin [Figure 1b]. Systemic examination did not reveal any abnormality. Routine blood examination revealed mild leukocytosis and elevated ESR. Based on classical target lesions and mucosal involvement, clinical diagnosis of erythema multiforme major (EMM) was made. Our case was notable for ‘Herpes iris of Bateman’ lesions over the upper extremities. The boy was treated conservatively and all lesions subsided within 2 weeks with mild hyperpigmentation.

Predictors of suppurative complications for acute sore throat in primary care: prospective clinical cohort study

Objective To document whether elements of a structured history and examination predict adverse outcome of acute sore throat.Design Prospective clinical cohort.Setting Primary care.Participants 14 610 adults with acute sore throat...

Myoglobinuria as first clinical sign of a primary alpha-sarcoglycanopathy

Myoglobinuria is a frequent complication of metabolic myopathies and may also occur in Duchenne and Becker dystrophies but is not a typical sign of limb-girdle muscular dystrophy. We describe an unusual presentation of alpha-sarcoglycanopathy with myoglobinuria at the onset of the disease. The boy presented an episode of dark urine, identified as presence of blood by a urine dipstick, occurred 10 days after an episode of fever and sore throat treated with antibiotics. He was admitted to the hospital and investigated for post-infectious nephritis, but further analysis revealed the presence of myoglobinuria. Immunohistochemistry on muscle tissue revealed absent expression of α-sarcoglycan confirmed by detection of a homozygous mutation in the alpha-sarcoglycan gene. Myoglobinuria has been previously reported four times in sarcoglycanopathies but only once in alpha-sarcoglycanopathy. The present observation reinforces the idea that the myoglobinuria should be considered a manifestation of a primary sarcoglycanopathy even as the only recognizable sign at the debut of the disease.

Sore throat

Asore throat is a very common presenting complaint. In Scotland it has been estimated that as many as 51 per 1000 patients per year attend their GP or practice nurse with the symptom. However, the incidence of sore throat is much higher; it is estimated that only one in every 18 episodes of sore throat leads to a GP consultation. A sore throat can be the presenting symptom in a variety of acute and chronic conditions. This article describes the features and management of those conditions which are common and/or serious.

A review on the mechanism of sore throat in tonsillitis

Sore throat is a common condition associated with acute upper respiratory tract infection, and recurrent episodes of infection may result in chronic tonsillitis. The current UK and USA guidelines for tonsillectomy use the incidence of sore throat episodes as an indication for surgery. However, the mechanism of sore throat is poorly described in the literature. This review will provide basic information for the clinician regarding: the causes, pathophysiology and neurophysiology of sore throat; the mechanism of inflammation; and the role of transient receptor potential ion channels as nociceptors involved in sore throat. The review will present new ideas on the mechanism of ice therapy as an analgesic for post-tonsillectomy pain, and the role of vanilloid and cold receptors.

Tonsillectomy under threat: auditing the indications for performing tonsillectomy

The 2009 McKinsey National Health Service report considered that tonsillectomy was relatively ineffective and often unjustified, and that its frequently could be greatly reduced. ENTUK argued against this, for severe recurrent tonsillitis. This study audited clinical indications for tonsillectomy. CRITERIA AND STANDARDS: Current guidelines state that patients with recurrent tonsillitis must have disabling sore throat episodes five or more times per year, and symptoms for at least a year, to justify tonsillectomy. Seventeen recurrent tonsillitis patients receiving tonsillectomy were audited prospectively. Indications were poorly documented in the referral letter, so surgeons agreed to list specified tonsillectomy criteria when scheduling patients for tonsillectomy. A pro forma reminder was distributed to all clinics, and the next 100 scheduled tonsillectomy patients were audited. In the first audit, all 17 tonsillectomies were justified but only two (11.8 per cent) had documented indications. In the second audit, 85 per cent of patients had all essential criteria, which were documented in the listing letter. Tonsillectomy risks being removed from the UK essential otolaryngological surgical register, risking increased patient morbidity and work absence, despite valid supporting evidence of efficacy for recurrent tonsillitis. All UK otolaryngology units should strictly adhere to the ENTUK and Scottish Intercollegiate Guidelines Network recommendations for tonsillectomy, and should document essential criteria in the listing letter, to strengthen the advocacy argument for tonsillectomy as essential, valid treatment for recurrent tonsillitis.

True Hamartoma of the Tonsil

An 18-year-old male patient presented with recurrent episodes of sore throat, fever, dysphagia, and foreign body sensation in throat of 3years duration. An episode of acute tonsillitis was clinically documented and a polypoidal lesion was seen arising from the right tonsil. The patient underwent a tonsillectomy and the histopathological examination of the mass revealed it to be a true benign hamartoma of the tonsil.

Clinical Practice Guideline: Tonsillectomy in Children

Tonsillectomy is one of the most common surgical procedures in the United States, with more than 530,000 procedures performed annually in children younger than 15 years. Tonsillectomy is defined as a surgical procedure performed with or without adenoidectomy that completely removes the tonsil including its capsule by dissecting the peritonsillar space between the tonsil capsule and the muscular wall. Depending on the context in which it is used, it may indicate tonsillectomy with adenoidectomy, especially in relation to sleep-disordered breathing. This guideline provides evidence-based recommendations on the preoperative, intraoperative, and postoperative care and management of children 1 to 18 years old under consideration for tonsillectomy. In addition, this guideline is intended for all clinicians in any setting who interact with children 1 to 18 years of age who may be candidates for tonsillectomy. The primary purpose of this guideline is to provide clinicians with evidence-based guidance in identifying children who are the best candidates for tonsillectomy. Secondary objectives are to optimize the perioperative management of children undergoing tonsillectomy, emphasize the need for evaluation and intervention in special populations, improve counseling and education of families of children who are considering tonsillectomy for their child, highlight the management options for patients with modifying factors, and reduce inappropriate or unnecessary variations in care. The panel made a strong recommendation that clinicians should administer a single, intraoperative dose of intravenous dexamethasone to children undergoing tonsillectomy. The panel made a strong recommendation against clinicians routinely administering or prescribing perioperative antibiotics to children undergoing tonsillectomy. The panel made recommendations for (1) watchful waiting for recurrent throat infection if there have been fewer than 7 episodes in the past year or fewer than 5 episodes per year in the past 2 years or fewer than 3 episodes per year in the past 3 years; (2) assessing the child with recurrent throat infection who does not meet criteria in statement 2 for modifying factors that may nonetheless favor tonsillectomy, which may include but are not limited to multiple antibiotic allergy/intolerance, periodic fever, aphthous stomatitis, pharyngitis and adenitis, or history of peritonsillar abscess; (3) asking caregivers of children with sleep-disordered breathing and tonsil hypertrophy about comorbid conditions that might improve after tonsillectomy, including growth retardation, poor school performance, enuresis, and behavioral problems; (4) counseling caregivers about tonsillectomy as a means to improve health in children with abnormal polysomnography who also have tonsil hypertrophy and sleep-disordered breathing; (5) counseling caregivers that sleep-disordered breathing may persist or recur after tonsillectomy and may require further management; (6) advocating for pain management after tonsillectomy and educating caregivers about the importance of managing and reassessing pain; and (7) clinicians who perform tonsillectomy should determine their rate of primary and secondary posttonsillectomy hemorrhage at least annually. The panel offered options to recommend tonsillectomy for recurrent throat infection with a frequency of at least 7 episodes in the past year or at least 5 episodes per year for 2 years or at least 3 episodes per year for 3 years with documentation in the medical record for each episode of sore throat and 1 or more of the following: temperature >38.3°C, cervical adenopathy, tonsillar exudate, or positive test for group A β-hemolytic streptococcus.

Recurrent tonsillitis in adults: quality of life after tonsillectomy.

The aim of this study was to assess the effect of tonsillectomy in adults with recurrent tonsillitis on their quality of life and on their use of medical resources. 114 patients who had had at least three episodes of acute tonsillitis in the 12 months preceding tonsillectomy were evaluated pre- and postoperatively with a questionnaire developed by the authors, and with the Glasgow Benefit Inventory. 97 patients (85%) filled out the questionnaires completely. The Glasgow Benefit Inventory revealed an improvement in the overall score (+19) and in the partial scores for general well-being (+18) and physical health (+39). The degree of support from friends and family was unchanged (±0). Significant decreases were observed in visits to a physician, analgesic and antibiotic consumption, days off from work, and episodes of sore throat. The number of visits to a physician because of sore throat decreased from an average of five preoperatively to one postoperatively; the number of episodes of sore throat, from seven to two; and the number of days taken off from work, from twelve to one per year. 65% of the patients surveyed took analgesics for sore throat preoperatively, 7% postoperatively. 95% took antibiotics for sore throat preoperatively, 22% postoperatively. Although this study had a number of limitations (small size, retrospective design, short follow-up), it was able to show that tonsillectomy for adults with recurrent tonsillitis improves health and quality of life and reduces the need to consume medical resources.

Comparison of case note review methods for evaluating quality and safety in health care

To examine the clinical effectiveness and cost-effectiveness of tonsillectomy/adeno-tonsillectomy in children aged 4-15 years with recurrent sore throats in comparison with standard non-surgical management. A pragmatic randomised controlled trial with economic analysis comparing surgical intervention with conventional medical treatment in children with recurrent sore throats (trial) and a parallel non-randomised cohort study (cohort study). Five secondary care otolaryngology departments located in the north of England or west of Scotland. 268 (trial: 131 allocated to surgical management; 137 allocated to medical management) and 461 (cohort study: 387 elected to have surgical management; 74 elected to have medical management) children aged between 4 and 15 years on their last birthday with recurrent sore throats. Participants were stratified by age (4-7 years, 8-11 years, 12-15 years). Treatment was tonsillectomy and adeno-tonsillectomy with adenoid curettage and tonsillectomy by dissection or bipolar diathermy according to surgical preference within 12 weeks of randomisation. The control was non-surgical conventional medical treatment only. The primary clinical outcome was the reported number of episodes of sore throat in the 2 years after entry into the study. Secondary clinical outcomes included: the reported number of episodes of sore throat; number of sore throat-related GP consultations; reported number of symptom-free days; reported severity of sore throats; and surgical and anaesthetic morbidity. In addition to the measurement of these clinical outcomes, the impact of the treatment on costs and quality of life was assessed. Of the 1546 children assessed for eligibility, 817 were excluded (531 not meeting inclusion criteria, 286 refused) and 729 enrolled to the trial (268) or cohort study (461). The mean (standard deviation) episode of sore throats per month was in year 1 - cohort medical 0.59 (0.44), cohort surgical 0.71 (0.50), trial medical 0.64 (0.49), trial surgical 0.50 (0.43); and in year 2 - cohort medical 0.38 (0.34), cohort surgical 0.19 (0.36), trial medical 0.33 (0.43), trial surgical 0.13 (0.21). During both years of follow-up, children randomised to surgical management were less likely to record episodes of sore throat than those randomised to medical management; the incidence rate ratios in years 1 and 2 were 0.70 [95% confidence interval (CI) 0.61 to 0.80] and 0.54 (95% CI 0.42 to 0.70) respectively. The incremental cost-effectiveness ratio was estimated as 261 pounds per sore throat avoided (95% confidence interval 161 pounds to 586 pounds). Parents were willing to pay for the successful treatment of their child's recurrent sore throat (mean 8059 pounds). The estimated incremental cost per quality-adjusted life-year (QALY) ranged from 3129 pounds to 6904 pounds per QALY gained. Children and parents exhibited strong preferences for the surgical management of recurrent sore throats. The health of all children with recurrent sore throat improves over time, but trial participants randomised to surgical management tended to experience better outcomes than those randomised to medical management. The limitations of the study due to poor response at follow-up support the continuing careful use of 'watchful waiting' and medical management in both primary and secondary care in line with current clinical guidelines until clear-cut evidence of clinical effectiveness and cost-effectiveness is available. Current Controlled Trials ISRCTN47891548.

Cochrane review: Tonsillectomy or adeno‐tonsillectomy versus non‐surgical treatment for chronic/recurrent acute tonsillitis

AbstractBackgroundSurgical removal of the tonsils, with or without adenoidectomy (adeno‐/tonsillectomy), is a common ENT operation but the indications for surgery are controversial.ObjectivesTo determine the effects of tonsillectomy, with and without adenoidectomy, in patients with chronic/recurrent acute tonsillitis.Search strategyThe Cochrane Ear, Nose and Throat Disorders Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2008, issue 2), MEDLINE (1966 to 2008), EMBASE (1974 to 2008), bibliographies, and additional sources were searched for published and unpublished trials. The date of the last search was 11 April 2008.Selection criteriaRandomised controlled trials comparing tonsillectomy, with or without adenoidectomy, with non‐surgical treatment in adults and children with chronic/recurrent acute tonsillitis. We included trials which used reduction in the number and severity of tonsillitis and sore throat as main outcome measures.Data collection and analysisTwo authors applied the inclusion/exclusion criteria independently.Main resultsThis review includes five studies: four undertaken in children (719 participants) and one in adults (70 participants). Good information about the effects of tonsillectomy is only available for children and for effects in the first year following surgery.Children were divided into two subgroups: those who are severely affected (based on specific criteria which are often referred to as the 'Paradise criteria') and those less severely affected.For more severely affected children adeno‐/tonsillectomy will avoid three unpredictable episodes of any type of sore throat, including one episode of moderate or severe sore throat in the next year. The cost of this is a predictable episode of pain in the immediate postoperative period.Less severely affected children may never have had another severe sore throat anyway and the chance of them so doing is modestly reduced by adeno‐/tonsillectomy. For them, surgery will mean having an average of two rather than three unpredictable episodes of any type of sore throat. The cost of this reduction is one inevitable and predictable episode of postoperative pain. The 'average' patient will have 17 rather than 22 sore throat days but some of these 17 days (between five and seven) will be in the immediate postoperative period. Whilst the concept of the 'average' patient is attractive, in practice, wide variability is likely.One reason why the impact of surgery is so modest, is that many untreated patients get better spontaneously. There is a trade‐off for the physician and patient who must weigh up a number of different uncertainties: what proportion of my throat symptoms are attributable to my tonsils, and will I get better without any treatment? Similarly, the potential 'benefit' of surgery must be weighed against the risks of the procedure.Authors' conclusionsAdeno‐/tonsillectomy is effective in reducing the number of episodes of sore throat and days with sore throats in children, the gain being more marked in those most severely affected. The size of the effect is modest, but there may be a benefit to knowing the precise timing of one episode of pain lasting several days ‐ it occurs immediately after surgery as a direct consequence of it.It is clear that some children get better without any surgery, and that whilst removing the tonsils will always prevent 'tonsillitis', the impact of the procedure on 'sore throats' due to pharyngitis is much less predictable.Plain Language SummaryTonsillectomy for chronic or recurrent acute tonsillitisTonsillectomy is a common procedure. Children severely affected by recurrent tonsillitis may benefit from it but these benefits must be considered in the light of the risks of surgery and the possibility that they my 'grow out' of the problem. In less severely affected children the potential benefits are even more modest.

Prospective Surveillance of Streptococcal Sore Throat in a Tropical Country

Acute rheumatic fever and rheumatic heart disease cause a high burden of disease in Fiji and surrounding Pacific Island countries, but little is known about the epidemiology of group A streptococcal (GAS) pharyngitis in the region. We designed a study to estimate the prevalence of carriage of beta-hemolytic streptococci (BHS) and the incidence of BHS culture-positive sore throat in school aged children in Fiji. We conducted twice-weekly prospective surveillance of school children aged 5 to 14 years in 4 schools in Fiji during a 9-month period in 2006, after an initial phase of pharyngeal swabbing to determine the prevalence of BHS carriage. We enrolled 685 children. The prevalence of GAS carriage was 6.0%, while the prevalence of group C streptococcal (GCS) and group G streptococcal (GGS) carriage was 6.9% and 12%, respectively. There were 61 episodes of GAS culture-positive sore throat during the study period equating to an incidence of 14.7 cases per 100 child-years (95% CI, 11.2-18.8). The incidence of GCS/GGS culture-positive sore throat was 28.8 cases per 100 child-years (95% CI, 23.9-34.5). The clinical nature of GAS culture-positive sore throat was more severe than culture-negative sore throat, but overall was mild compared with that found in previous studies. Of the 101 GAS isolates that emm sequence typed there were 45 emm types with no dominant types. There were very few emm types commonly encountered in industrialized nations and only 9 of the 45 emm types found in this study are emm types included in the 26-valent GAS vaccine undergoing clinical trials. GAS culture-positive sore throat was more common than expected. Group C and group G streptococci were frequently isolated in throat cultures, although their contribution to pharyngeal infection is not clear. The molecular epidemiology of pharyngeal GAS in our study differed greatly from that in industrialized nations and this has implications for GAS vaccine clinical research in Fiji and other tropical developing countries.

Impact of laryngeal mask airway cuff pressures on the incidence of sore throat in children

Hyperinflation of laryngeal mask airway cuffs can cause harm to the upper airway mainly by exerting high pressures on pharyngeal and laryngeal structures thus impairing mucosal perfusion. Although cuff manometers can be used to guide the monitoring of cuff pressures, their use is not routine in many institutions. In a prospective audit, we assessed the incidence of sore throat following day-case-surgery in relation to the intracuff pressure within the laryngeal mask airway. Four hundred children (3-21 years) were consecutively included in this study. The laryngeal mask airway was inflated as deemed necessary by the attending anesthetist. Cuff pressures were measured using a calibrated cuff manometer (Portex Limited, Hythe, Kent, UK, 0-120 cm H2O, pressures exceeding the measurement range were set at 140 cm H2O for statistical purposes) at induction of anesthesia. Forty-five children (11.25%) developed sore throat, 32 (8%) sore neck and 17 (4.25%) sore jaw. Of those that developed sore throat, 56.5% had cuff pressures exceeding >100 cm H2O. In contrast, when cuff pressures were <40 cm H2O, there were no episodes of sore throat, whilst there was only a 4.6% occurrence of sore throat if cuff pressures were between 40-60 cm H2O. We have demonstrated that intra cuff pressure in laryngeal mask airways is closely related to the development of sore throat with higher pressures increasing its likelihood. Hence, cuff pressures should be measured routinely using a manometer to minimize the incidence of sore throat.

Extracts from The Cochrane Library: Tonsillectomy for chronic/recurrent acute tonsillitis

The "Cochrane Corner" is a quarterly section in the Journal that highlights systematic reviews relevant to otolaryngology-head and neck surgery, with invited commentary to highlight implications for clinical decision making. This installment features a Cochrane Review entitled "Tonsillectomy or adeno-tonsillectomy versus non-surgical treatment for chronic/recurrent acute tonsillitis," which concludes modest efficacy in children for sore throat days and episodes, with greater benefit for those with more severe illness.

Clinical Challenges and Images in GI

Question: A 65-year-old man was admitted because of progressive dysphagia, resulting in a 25-kg weight loss over the last 5 months. Five years before, he had an episode of sore throat, which subsided after 2 months. He had undergone partial gastrectomy for a benign gastric ulcer and was been found to have dilated cardiomyopathy, which prompted the implantation of a biventricular cardiac pacemaker. Physical examination and routine laboratory tests were within normal limits. A barium swallow study demonstrated a filling defect from the cervical esophagus down to the stomach, with a corrugated appearance (Figure A). The esophagogastroscopy showed a mass protruding into the esophagus (Figure B). Endoscopic biopsy done at the proximal site of the lesion showed a normal esophageal mucosa. Computed tomography (CT) is shown in Figure C. What might be the diagnosis and the appropriate therapeutic approach?View Large Image Figure ViewerDownload Hi-res image Download (PPT)View Large Image Figure ViewerDownload Hi-res image Download (PPT) Look on page 1019 for the answer and see the Gastroenterology website (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. The CT scan with hydrosoluble oral contrast showed a polypoid lesion of 5 cm in diameter and 23 cm long arising in the cervical esophagus, occupying the entire esophagus and prolapsing through the esophagogastric junction into the stomach (Figure D). Because of size of the mass and the presence of a short, hypervascularized stalk, an endoscopic approach was thought to be inappropriate. In consideration of the patient's clinical conditions, esophagectomy was ruled out. It was decided to use a left side cervical approach, through which the pedicle was resected; however, it was not possible to take the mass out. Thus, a right thoracotomy was performed, followed by 5-cm longitudinal incision of the esophageal wall to enter the lumen from which the mass was taken out (Figure E). Histologic examination was consistent with liposarcoma. The patient had an uneventful postoperative course without any complication and was discharged on postoperative day 12.View Large Image Figure ViewerDownload Hi-res image Download (PPT) At 6 months follow-up, a CT scan of the chest and upper abdomen as well as an upper GI endoscopy showed no tumor recurrence or distal metastases. Esophageal liposarcoma is an extremely rare entity, the present case representing the 21st described in the literature to date.1Will U. Lorenz P. Urban H. et al.Curative endoscopic resection of a huge pedunculated esophageal liposarcoma.Endoscopy. 2007; 39: E15-E16Crossref PubMed Scopus (16) Google Scholar, 2Garcia M. Buitrago E. Bejarano P.A. et al.Large esophageal liposarcoma: a case report and review of the literature.Arch Pathol Lab Med. 2004; 128: 922-925PubMed Google Scholar, 3Mandell D.L. Brandwein M.S. Woo P. et al.Upper aerodigestive tract liposarcoma: report on four cases and literature review.Laryngoscope. 1999; 109: 1245-1252Crossref PubMed Scopus (37) Google Scholar, 4Boggi U. Viacava P. Naccarato A.G. et al.Giant pedunculated liposarcomas of the esophagus: literature review and case report.Hepatogastroenterology. 1997; 44: 398-407PubMed Google Scholar Neither barium swallow nor esophagogastroscopy are helpful diagnostic tools. Only CT scan with hydrosoluble contrast swallow allowed us to define the anatomic relationship of the mass with the esophageal wall. Almost all cases in the literature have been approached by a cervicotomy, but in 15 cases a second access such as a laparotomy or thoracolaparotomy was necessary to remove the tumor, as in our case. Only 4 patients underwent esophagectomy. Unfortunately, avoiding esophagectomy increases the risk of an R1 resection. Esophageal liposarcoma management remains vague; therapeutic options range from less invasive endoscopic excision to radical esophagectomy.