Large Tonsils Research Articles

Transoral robotic surgery: Tongue base reduction and supraglottoplasty for obstructive sleep apnea

A transoral robotic version of Chabolle's tongue base reduction with hyoid epiglottoplasty for obstructive sleep apnea syndrome is described. The main tongue base and supraglottic surgical steps are pointed out, as well as the indications and potential complications. The advantages and limits of this minimally invasive approach are discussed.

Predictors of Tonsillectomy after Previous Adenoidectomy for Upper Airway Obstruction

(1) Characterize risk factors for subsequent tonsillectomy in pediatric patients undergoing primary adenoidectomy for upper airway obstruction. (2) Compare rates of subsequent tonsillectomy between adenoidectomy patients with and without upper airway obstruction. Historical cohort study with a nested case-control study. Cohort data were analyzed using Kaplan-Meier plots and a multiple regression model. Case-control data were analyzed using logistic regression. Patients undergoing adenoidectomy without tonsillectomy at the University of Missouri between 1995 and 2010 were identified using billing records and selected chart review. A nested case-control study with detailed chart review was conducted to determine predictors of subsequent tonsillectomy in patients with upper airway obstruction. Of 1291 patients identified in the historical cohort, 7.8% later underwent tonsillectomy. Age younger than 3 years (P = .027), female sex (P < .0001), and upper airway obstruction (P = .001) were found to be significant predictors of subsequent tonsillectomy. In the nested case-control study, potential predictors investigated included adenoidectomy indications, symptoms, smoke exposure, weight, comorbidities, and tonsil size at the time of adenoidectomy. Of these, only tonsil size was significant, with an increased odds of future tonsillectomy of 2.5 (P = .01) for each unit increase in tonsil size. Patients undergoing adenoidectomy for upper airway obstruction are likely to be at an increased risk of subsequent tonsillectomy when compared with those with other indications. Within this subgroup of patients with upper airway obstruction, young age, female sex, and large tonsil size may further increase the risk of subsequent tonsillectomy.

Skin Prick Test and Tonsil Size in Children: Any Relation?

We hypothesized, allergic reactions of the tonsillar mucosa may cause secondary lymphoid hypertrophy in children. To evaluate this, we compared tonsil sizes and skin prick test results. Children of ages 6-12years were divided into two groups according to the results of the skin prick tests (SPT), as atopic and non-atopic groups. All tonsil sizes were evaluated by the same observer using the Brodsky L. Scala. No statistically meaningful difference was found between the tonsil sizes of the atopic and the non-atopic groups of children. No statistically meaningful correlation was found between tonsil sizes and allergen sensitivity degrees. Even though some highly allergic children were observed to have large tonsils, it was not statistically meaningful. Since no correlation is found between SPT and tonsil sizes, allergy may not be an etiologic factor of tonsillar hypertrophy in children.

Predictors of Tonsillectomy after Previous Adenoidectomy for Upper Airway Obstruction

Objective: 1) Characterize risk factors for subsequent tonsillectomy in pediatric patients undergoing primary adenoidectomy for upper airway obstruction.2) Compare rates of subsequent tonsillectomy between adenoidectomy patients with and without upper airway obstruction. Method: A retrospective cohort of patients undergoing adenoidectomy without tonsillectomy at the University of Missouri between 1995 and 2010 was examined using billing records and selected chart review. A nested case-control study with detailed chart review was then conducted to determine predictors of subsequent tonsillectomy in patients with upper airway obstruction. Results: Of 1291 patients identified in the retrospective cohort, 7.8% later underwent tonsillectomy. Using a fitted multiple logistic regression model, age less than 3 years ( P = .027), female sex ( P &lt; .0001), and upper airway obstruction ( P = .001) were all found to be significant predictors of subsequent tonsillectomy. In the nested case-control study, potential predictors investigated included adenoidectomy indications, symptoms, smoke exposure, weight, comorbidities, and adenoid and tonsil size at the time of adenoidectomy. Of these, only tonsil size was significant, with each increase in size of 1 (eg, from 2+ to 3+) associated with an increased odds of future tonsillectomy of 2.5 ( P = .01). Conclusion: Patients undergoing adenoidectomy for upper airway obstruction are at increased risk of subsequent tonsillectomy when compared with those with other indications. Within this subgroup of patients with upper airway obstruction, young age, female sex, and large tonsil size may further increase the risk of subsequent tonsillectomy after previous adenoidectomy.

Assessment of the body posture of mouth-breathing children and adolescents

To investigate associations between mouth breathing (MBr), nose breathing (NBr) and body posture classification and clinical variables in children and adolescents, by comparing patients with mouth breathing syndrome with a control group of similar age. This was an observational, analytical, controlled, cross-sectional study conducted at a university hospital. Children aged 5 years or more were recruited to one of two groups: healthy controls (NBr) or an MBr group. The MBr group comprised patients with a diagnosis of mouth breathing syndrome confirmed by clinical examination by a physician plus nasal endoscopy. The control group comprised healthy volunteers of the same age, with NBr confirmed by medical examination. All participants underwent postural assessment. Data were analyzed using the Mann-Whitney nonparametric test, the chi-square test and Fisher's exact test, to a significance level of 0.05%. A total of 306 MBr and 124 NBr were enrolled. Mouth breathers were more likely to be male (p = 0.0002), have more frequent and more severe nasal obstruction and larger tonsils (p = 0.0001) than NBr. Mouth breathers also exhibited higher incidence rates of allergic rhinitis (p = 0.0001), of thoracic respiratory pattern (p = 0.0001), high-arched palate (p = 0.0001) and unfavorable postural classifications (p = 0.0001) with relation to the control group. Postural classification scores were directly proportional to nasal obstruction (p = 0.0001) and male sex (p = 0.0008). Postural problems were significantly more common among children in the group with mouth breathing syndrome, highlighting the need for early interdisciplinary treatment of this syndrome.

Differences between the ovine tonsils based on an immunohistochemical quantification of the lymphocyte subpopulations

In sheep, the pharyngeal first defence line against oral and inhaled antigens is organized in six tonsils. Since tonsils are regarded as secondary lymphoid tissue and part of the acquired immune system which is subjected to induction through contact with antigens, an evaluation of the different lymphocyte populations in tonsils is useful to determine a tendency of the specific tonsils to more inductive or more effective immunity. By means of immunohistochemistry, different lymphocyte populations were quantified and localized using a panel of eight antibodies, i.e. anti-CD45, anti-CD21, anti-CD2, anti-CD3, anti-CD4, anti-CD8, anti-WC1 and anti-Ki67. The CD21+ B lymphocytes were localized within the tonsillar lymphoid follicles. The CD2+/CD3+ T lymphocytes were numerous in the interfollicular regions and were aligned underneath and within the epithelium but were also observed at the CD21+ pole of the lymphoid follicles. Near the lingual and tubal tonsils, and the tonsil of the soft palate, the CD45+ cells around the seromucous glands and in the lamina propria were mainly CD3+ T cells. In all tonsils, the WC1+ gamma delta T cells formed a small lymphocyte population which harboured the lamina propria and the interfollicular region. The relative percentages of the different lymphocyte populations of the large palatine and pharyngeal tonsils, which are macroscopically the most developed, were comparable. In contrast, the lingual tonsil was significantly different from the other tonsils not only by its small size and lack of lymphoid follicles, but also by the lymphocyte populations. Based on the lymphocyte populations, the ovine tonsils can be divided in three groups with the tonsil of the soft palate, the tubal and paraepiglottic tonsil forming an intermediate between the palatine and pharyngeal tonsils as true tonsils on the one side, and the lingual tonsil as a scattered lymphocyte aggregation on the other side.

Tonsillar size in 2‐ to 14‐year‐old children with and without snoring

Few investigations have assessed tonsillar size in children of variable age, sleep-disordered breathing (SDB) status and degree of adiposity. This study evaluated the size of tonsils in young and older, lean and obese children, without or with snoring. Children attending the Emergency Department or Pulmonology Clinic were recruited and tonsillar size was scored 1-4. Snoring >or=1 night/week was considered diagnostic of SDB and body mass index z-score >or=1.645 was defined as obesity. Age was analyzed as dichotomous variable (<or=7 years old vs. >7 years old). 362 children (2-14 years old) were recruited; 78 (21.5%) were obese and 108 (29.8%) had SDB. SDB-but not age or obesity-was significantly related to tonsillar size (P = 0.001). There was not enough evidence to support the presence of interactions between SDB and age or obesity regarding the size of tonsils (P = 0.157 and P = 0.978, respectively). Young subjects without SDB had larger tonsils than older subjects without SDB (1.9 +/- 0.7 vs. 1.7 +/- 0.8; P = 0.017), whereas age did not affect tonsillar size in children with SDB (P = 0.78). Young and older children with SDB have similar tonsillar size. In contrast, older subjects without snoring have smaller tonsils than young subjects without snoring. Tonsillar enlargement in children with SDB probably occurs in early childhood without change in older age.

Natural history and predictors for progression of mild childhood obstructive sleep apnoea

Aims:The natural history of mild childhood obstructive sleep apnoea (OSA) was examined and factors associated with disease progression were identified.Methods:Subjects were recruited from an epidemiological study which examined the prevalence...

Failure of LMA in a child with normal airway because of large tonsil – An unrecognized cause: case report

The Laryngeal Mask Airway (LMA) is a supraglottic airway device that was invented by Dr. Archie Brain, a British anesthetist. The Classic LMA is the original LMA and is considered a general purpose device. It has been used extensively for different general surgical, urologic, orthopedic and ophthalmic procedures. It has also proved useful in place of endotracheal intubation in difficult airway situations in children. It has also gained wide usage for airway resuscitation and rescue . LMA has many advantages over endotracheal tube like: increased speed and ease of placement by inexperienced personnel, increased speed of placement by anaesthetists, improved haemodynamic stability at induction and during emergence, minimal increase in intraocular pressure following insertion, reduced anaesthetic requirements for airway tolerance, lower frequency of coughing during emergence, improved oxygen saturation during emergence, and lower incidence of sore throat in adults. But in some cases it is more difficult to insert LMA than intubation even in MPG 1 cases. Here we are presenting a case report of such unrecognized obstruction as, an enlarge palatine tonsil, which made impossible to insert LMA even though the child was of mallampati class I.

Protocol for research on obstructive sleep apnea syndrome (OSAS) among epilepsy patients in University Science Malaysia Hospital

Sleep dysfunction and sleep disorders are among the most common and the most underdiagnosed conditions in all of medicine, contributing to significant impairment in countless individuals, sometimes on a daily basis. Sleep-related dysfunction is particularly common in many types of neurologic dysfunction, including movement disorders such as Parkinson's disease, degenerative disorders such as Alzheimer's disease, and stroke. Perhaps no area, however, involves the number and diversity of interactions as exist between sleep and epilepsy.1 Sleep disorders are common in the general population, so it is not surprising that they are also common in epilepsy patients. When patients with epilepsy were compared with control patients using the Epworth Sleepiness Scale, epilepsy patients were drowsier. A difference was not seen, however, when a sleep apnea scale was included, emphasizing the importance of this condition. The study demonstrates that excessive daytime sleepiness is common in both epilepsy subjects and control subjects, and that much of this may be due to treatable conditions (particularly sleep apnea).2 Obstructive sleep apnea syndrome (OSAS) is a disorder of abnormal respiration during sleep that results in a combination of hypoxemia and hypercapnia. The syndrome can be caused by obstruction of the upper airway during sleep, by abnormality in regulation of breathing by the central nervous system, or by a combination of obstructive and central problems.3 The apneic episodes lead to hypoxemia and to chronic sleep deprivation because multiple arousals during the apneic episodes cause sleep fragmentation. Sleep deprivation and hypoxia can decrease the seizure threshold in epilepsy patients. In many epilepsy patients without sleep apnea, seizures may occur on arousal. 4 Under the University Science Malaysia research university grant (RU Grant) epilepsy study project , we have developed a research protocol to study the prevalence of obstructive sleep apnea syndrome in epilepsy patients. The research protocol has been approved by the University Science Malaysia Research Ethics Committee (Human) Health Campus. All epilepsy patients, both male and female who attended the neurology clinic in University Science Malaysia Hospital (HUSM) and who agree to participate in this study will be included. This protocol involved the assessment of sleepiness in epilepsy patients by using the Berlin and Epworth questionaires. The second step is the careful and meticulous examination of patients by otorhinolaryngologists to identify any obvious obstructive cause from the nose down to the upper airway. The possible causes are long, bulky uvula, large hypertrophied palatal tonsils, large tongue and narrow pharynx, nasal septal deviation, nasal polyps, or collapse of the nasal valve on inspiration. Less common are a retrognathic mandible, vocal cord disorders, laryngeal or tracheal abnormalities. All of the subjects will then undergo an overnight polysomnography test in HUSM sleep laboratory. The obstructive apnea is defined as absence of airflow detected by the end tidal nasal cannula with presence of chest wall movement. The number and duration of obstructive apneas of any length will be quantified. The apnea index (AI) is defined as the number of obstructive apneas of any length per hour of sleep, is calculated for each Protocol for research on obstructive sleep apnea syndrome (OSAS) among epilepsy patients in University Science Malaysia Hospital 2 of 3 subject. Central apnea is defined as the absence of airflow detection with absence of chest wall movement. Mixed apnea is defined as apneas having both central and obstructive component. The lowest and highest oxygen saturation (SaO2) and the number of desaturation of more than four percent will be quantified. The total sleep time for each subject will also be quantified. The OSAS will be divided into mild, moderate and severe. Mild OSAS is defined as AI more than 1 but less than 15, moderate OSAS AI between 15 to 30 and severe OSAS when AI more than 30. Patients diagnosed as OSAS will be treated accordingly and the outcome measurement study will be carried out. By having this research protocol, it is our hope that both epilepsy and previously undiagnosed OSAS will be treated properly and accordingly. CORRESPONDENCE TO Dr Baharudin Abdullah Dept ORL-HNS, School of Medical Sciences, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia. Tel: +609-7664110 Fax: +609-7653370 Email: baharudin@kb.usm.my

Round and round we go: sedation – what is it, who does it, and have we made things safer for children?

In this issue of Pediatric Anesthesia several papers and commentaries authored by anesthesiologists and nonanesthesiologists describe different perspectives regarding sedation ⁄ analgesia for children in the UK and the USA. I will provide historical perspectives from the USA and then examine these reports to see how they compare with current USA practice. I had the good fortune of being the co-author of the first Sedation Guideline (pediatric or adult) supported by any organization. This initial attempt at providing guidance for a systematic and safe approach to procedural sedation was a result of a number of sedation accidents in children undergoing dental procedures. We worked closely with our pediatric dental colleagues and developed joint guidelines (1,2). Unfortunately we adopted terminology that had been approved by the National Institutes of Health, i.e., the phrase conscious sedation (3). This resulted in much confusion particularly since the intended appropriate (purposeful) response to physical stimulus or verbal command was often miss-interpreted to mean any movement at all in response to any stimulus including painful stimuli! As time passed the American Academy of Pediatrics (AAP) recognized that sedation was provided by many specialists besides dental practitioners so the original guideline was revised in 1992 (4). A special emphasis was placed on a systems approach modeled after our specialty (anesthesiology). Points of interest included: (i) informed consent (parents needed to know that sedative ⁄ analgesics can cause harm); (ii) a presedation history was required (how would the child s underlying medical conditions affect the safety of sedation?); (iii) a focused airway examination (was there an airway abnormality or large tonsils that might affect airway patency or complicate airway management?); (iv) proper fasting prior to elective procedures and the need to balance the risk of sedation in children who required urgent or emergent procedures was described; (v) appropriate monitoring especially continuous pulse oximetry during the procedure and into the recovery period was required for the first time; (vi) appropriate monitoring by an independent observer whose only responsibility was to watch the patient was required during deep sedation; (vii) appropriate staffing and monitoring were required during recovery; and (viii) the children had to be returned to their presedation level of consciousness prior to discharge. With this 1992 revision, the dental community separated from the AAP and published their own specialty specific guideline which deviated significantly from that of the AAP (5–7). In 2002, the AAP published an addendum so that the AAP, the American Society of Anesthesiologists (ASA) and the Joint Commission of Accreditation of Healthcare Organizations all used the same terminology. The phrase conscious sedation was changed to sedation ⁄ analgesia and then changed again to moderate sedation (8,9). Children sedated in all venues including private offices were considered to fall under these guidelines. In particular, the updated guideline states that children aged <6 years usually require a state of pharmacologic coma, i.e., deep sedation to successfully complete most procedures without major psychologic trauma to both provider or child. A clear emphasis was made that sedative medications were only to be administered under the safety net of medical supervision (no home Pediatric Anesthesia 2008 18: 3–8 doi:10.1111/j.1460-9592.2007.02403.x

The effect of mode of breathing on craniofacial growth--revisited

It has been maintained that because of large adenoids, nasal breathing is obstructed leading to mouth breathing and an 'adenoid face', characterized by an incompetent lip seal, a narrow upper dental arch, increased anterior face height, a steep mandibular plane angle, and a retrognathic mandible. This development has been explained as occurring by changes in head and tongue position and muscular balance. After adenoidectomy and change in head and tongue position, accelerated mandibular growth and closure of the mandibular plane angle have been reported. Children with obstructive sleep apnoea (OSA) have similar craniofacial characteristics as those with large adenoids and tonsils, and the first treatment of choice of OSA children is removal of adenoids and tonsils. It is probable that some children with an adenoid face would nowadays be diagnosed as having OSA. These children also have abnormal nocturnal growth hormone (GH) secretion and somatic growth impairment, which is normalized following adenotonsillectomy. It is hypothesized that decreased mandibular growth in adenoid face children is due to abnormal secretion of GH and its mediators. After normalization of hormonal status, ramus growth is enhanced by more intensive endochondral bone formation in the condylar cartilage and/or by appositional bone growth in the lower border of the mandible. This would, in part, explain the noted acceleration in the growth of the mandible and alteration in its growth direction, following the change in the mode of breathing after adenotonsillectomy.

Adiposity in relation to age as predictor of severity of sleep apnea in children with snoring

Correlation between obesity and obstructive sleep apnea has been documented in both adults and children. This investigation evaluated importance of body mass index (BMI) in relation to age as predictor of severity of obstructive sleep-disordered breathing (SDB). Children with habitual snoring referred for polysomnography were recruited. BMI Z score (> or =1.036 vs <1.036, i.e. at risk for overweight or overweight vs normal) was assessed as predictor of severity of SDB (apnea-hypopnea index [AHI] >five vs < or =five episodes per hour) at different ages (< or =6 vs >6 years). Two hundered eighty-four participants were recruited: 75 young children (4.6 +/- 1 years) with high BMI (1.9 +/- 0.7); 95 young subjects (4.5 +/- 1.1 years) with low BMI (-0.2 +/- 1.3); 55 older children (9.2 +/- 1.8 years) with high BMI (1.8 +/- 0.5); and 59 older participants (9.7 +/- 2.2 years) with low BMI (-0.2 +/- 1.1). Odds ratios for AHI >5 in young/high BMI children, young/low BMI subjects, and older/high BMI subjects relative to older/low BMI participants were: 6.5 (95% confidence interval 2.1-19.9), 7.3 (2.4-22) and 2 (0.6-7.3), respectively. Large tonsil size was associated with young age (odds ratio 1.97; 1.2-3.3). Among children with habitual snoring, adiposity does not predict severity of obstructive SDB in early childhood probably due to the prominent role of adenotonsillar hypertrophy. However, it may have a more important contribution to severity of SDB in older children.

Expression of mucosal chemokines TECK/CCL25 and MEC/CCL28 during fetal development of the ovine mucosal immune system

CCL25/TECK and CCL28/MEC are CC chemokines primarily expressed in thymic dendritic cells and mucosal epithelial cells. The cognate receptors of CCL25 and CCL28, CCR9 and CCR10, respectively, are mainly expressed on T and B lymphocytes. In human, mouse and pig, CCL25 and CCL28 play a key role in the segregation and the compartmentalization of the mucosal immune system through recruitment of immune cells to specific locations. However, little is known about their role in the ontogeny of the mucosal immune system during fetal development. In the present paper, we report the cloning and the sequencing of ovine CCL25, CCL28, CCR9 and CCR10 and the subsequent assessment of their mRNA expression by q-polymerase chain reaction in several tissues, including thymus, gut-associated lymphoid tissue and mammary gland, from young and adult sheep and in the fetal lamb during the development of the immune system. CCL25 mRNA was highly expressed in thymus and gut while CCL28 mRNA was more expressed in large intestine, trachea, tonsils and mammary gland, especially at the end of gestation. These results are consistent with observations in other species suggesting similar roles for these chemokines in sheep. In fetuses, mRNA of CCL25, CCL28 and their receptors are expressed early in the thymus and mucosal tissues, including the small intestine and the nasal mucosa. Furthermore, their expression increased towards the end of gestation. Consequently, we hypothesize that CCL25 and CCL28 play an important role in the lymphocyte colonization of fetal tissues, enabling the development of a functional immune system.

Physical findings in the upper airways related to obstructive sleep apnea in men and women

Conclusions. There are gender differences when it comes to the risk factors for sleep apnea. Large tonsils, a high tongue and a wide uvula are risk factors for sleep apnea in men, while large tonsils and a retrognathic mandible are risk factors in women. Upper airway abnormalities including mandibular retrognathia are, however, unable to predict sleep apnea among snorers being investigated for suspected sleep apnea. Objectives. To identify gender-specific risk factors for obstructive sleep apnea and the diagnostic performance from physical upper airway examinations among snoring men and women investigated because of suspected sleep apnea. Patients and methods. The dimensions of the uvula, tonsils, velopharynx and tongue, and nasal septal deviation, mandibular position, neck circumference, weight, and height were systematically scored in 801 consecutive snoring patients (596 men and 205 women), who had been referred for a primary sleep apnea recording. Results. In men, large tonsils, a high tongue, and a wide uvula were independent factors associated with an apnea-hypopnea index of >15. In women, large tonsils and mandibular retrognathia were independent factors associated with an apnea-hypopnea index of >15. The positive predictive values for upper airway abnormalities ranged between 0.20 and 0.25 in men and between 0.09 and 0.15 in women.

Malignancy in Asymmetrical but Otherwise Normal Palatine Tonsils

An abnormally large tonsil may be a sign of malignancy. We retrospectively analyzed the case files of 87 patients who had asymmetrically sized but otherwise normal tonsils and no risk factors for cancer to determine if asymmetry is associated with a higher incidence of malignancy. We found 2 cases (2.3%) of malignancy among these patients. One patient had high-grade non-Hodgkin's lymphoma in the larger tonsil, and the other had lymphocyte-rich Hodgkin's lymphoma. Both patients were older than 50 years, and neither had a history of recurrent tonsillitis. We believe that although the incidence of cancer in our series was small, it is significant. Therefore, we recommend routine excision of abnormally large tonsils. Moreover when making such a recommendation to a patient, it is essential that the patient have a clear understanding of the risk and benefit of having a tonsil removed solely because of asymmetry.

Tonsil size and body mass index are important factors for efficacy of simple tonsillectomy in obstructive sleep apnoea syndrome

To evaluate the efficacy of simple tonsillectomy to treat obstructive sleep apnoea syndrome (OSAS) in adults. Prospective study. Tertiary referral centre. Thirty patients (28 males) underwent simple tonsillectomy under general anaesthesia. The patients' mean age was 33.2 +/- 6.8 years and body mass index was 30.7 +/- 6.0 kg/m2. Seven patients (23%) were classified with grade 4, 16 patients (53%) with grade 3, and seven patients (23%) with grade 2 according to the tonsil size of Friedman's classification. The number of apnoea episodes per hour (apnoea index), the number of apnoea and hypopnoea episodes per hour (apnoea-hypopnoea index), lowest nocturnal oxygen saturation and oxygen desaturation time were measured during overnight polysomnography before and after surgery. A successful tonsillectomy was defined as an apnoea-hypopnoea index improvement ratio of > or =50% and an apnoea-hypopnoea index <20 after operation. Apnoea-hypopnoea index decreased from 69.0 +/- 28.4/h to 30.1 +/- 24.0/h (P < 0.0001). Simple tonsillectomy was successful in all six patients with body mass index <25 kg/m2. Concerning success rate of simple tonsillectomy with tonsil, size 2 was lowest (42.9%). Eight of the 13 patients who used continuous positive airway pressure before simple tonsillectomy did not use continuous positive airway pressure after simple tonsillectomy because of a significant reduction of excessive daytime sleepiness. Continuous positive airway pressure decreased significantly after simple tonsillectomy from 13.6 +/- 2.5 cmH2O preoperatively to 10.6 +/- 1.3 cmH2O postoperatively (P < 0.05). These data suggest that simple tonsillectomy is a beneficial modality to treat OSAS in selected patients (larger tonsil, low body mass index), even in adults.

Ultracision scissors: An alternative method in tonsillectomy, 400 cases

Objectives: To show that the ultracision curved shears for tonsillectomy is a less hemorrhagic and significantly faster and safer technique than monopolar techniques Methods: A total of 400 patients, 240 children and 160 adults, of which 86 associated with UPP were subjected to tonsillectomy with Ultacision Harmonic Scalpel curved shears shaft length 14 cm CS-14C-Ethicon Endo Surgery in the last 48 months. Results: We divided the patients into 3 groups: 240 children, 74 adults, and 86 adults with UPP. In these groups we present the (1) age distribuition, (2) operating time, (3) pain control, (4) return to work, and (5) complications. Ultracision shears are safer and permit a more blodless and significantly faster dissection in comparisson with bipolar and monopolar surgery. The tissue surrounding the capsule is conserved. The fact that there is practically no blood in the operating field gives the surgean a great sense of security and makes it possible to carry out a very accurate dissection. This combined with the inexistence of blood in the operating fiel makes it the technique of choice in the case of patients with sleep apneia with large tonsils and for UPP. Complications: 4 hemorrhages in 400 cases (1%). Conclusions: Cutting and dissecting with scissors is a very natural gesture for the surgeon. Ultracision scissors offer a safe, efficient, and clean technique that makes tonsilectomy a neat and easy surgical action. The time saving aspect is also important in surgical anaesthetic and cost effectiveness.

Tonsillar size is an important indicator of recurrent acute tonsillitis.

This prospective study was designed to identify important clinical features in patients with recurrent acute tonsillitis. A total of 195 consecutive children aged from 1 to 16 years were examined and a history of recurrent acute tonsillitis recorded. Patients with obstructive sleep apnoea or recent acute tonsillitis were excluded. Tonsil size was measured on the Brodsky scale [Brodsky L. (1989) Paediatr Clin N Am 36, 1551], tonsil symmetry, cervical lymphadenopathy, and hyperaemia of the anterior pillars was recorded. Patients with a history of recurrent tonsillitis had larger tonsils than those without tonsillitis (P < 0.001). Tonsil asymmetry and cervical lymphadenopathy were more common in patients with recurrent tonsillitis (P < 0.001). Anterior pillar hyperaemia was also more frequent in recurrent tonsillitis (P < 0.01). In addition to the frequency and severity of tonsillitis it is suggested that the size and symmetry of the tonsils, plus cervical lymphadenopathy and anterior pillar hyperaemia should be taken into account when deciding which patients would benefit from tonsillectomy.

Immunohistochemistry for the detection of swine hepatitis E virus in the liver.

Swine hepatitis E virus (HEV) antigen was detected immunohistochemically in formalin-fixed, paraffin-embedded hepatic tissue from 30 naturally infected pigs. Thirty pigs from 30 different herds were selected on the basis of positive results for reverse transcription-polymerase chain reaction. Positive cells typically exhibited a red reaction product in the cytoplasm without any observable background staining. Swine HEV antigen was consistently detected in liver from all 30 pigs tested. A strong immunohistochemical signal was seen within a variable number of hepatocytes in multifocal lobules. The signal involved the majority of hepatocytes diffusely or was confined to foci of liver cells. Positive immunohistochemical signals were also detected in small and large intestine, lymph node, tonsil, spleen, and kidney. The immunohistochemistry technique developed in this study proved useful for the detection of swine HEV in formalin-fixed, paraffin-embedded tissues taken from naturally infected pigs and may be a valuable tool in studying the pathogenesis of swine HEV infection.