Pediatric Tonsillectomy Research Articles

Gabapentin Premedication to Reduce Postoperative Pain for Pediatric Tonsillectomy/Adenoidectomy: A Pilot Study

PurposeTo examine the effects of preoperative gabapentin administration on postoperative pain in pediatric patients undergoing tonsillectomy/adenoidectomy (T/A) in a single ambulatory surgery location within a pediatric healthcare organization. DesignThis randomized, controlled pilot study enrolled patients age 3–18 years with American Society of Anesthesiologists (ASA) scores of I-II undergoing T/A. MethodsBoth gabapentin and placebo groups were given study medication preoperatively and received standard opiate regimens intraoperatively and postoperative pain instructions. Outcome measurements included: time to first analgesic medication in the postanesthesia care unit (PACU), mean acetaminophen, ibuprofen, and opiate doses in mg/kg. Additionally, we examined pain scores, medication use, and side effects reported by daily pain diaries completed by patients/families for 3 days postoperatively. FindingsForty-nine patients were included in final analysis (gabapentin n = 26, placebo n = 23). Demographic and clinical characteristics of both groups were similar; the majority (46 of 49) were under the age of 13.Both groups received opiates in PACU. Some patients in both groups received hydrocodone/acetaminophen postoperatively. There were no reported differences in side effects between groups. Gabapentin group reported less use of opiates, acetaminophen, and ibuprofen post-discharge. We identified small effect sizes for opiates and acetaminophen, and medium effect size for ibuprofen (80.1% gabapentin versus 100% placebo, RR 0.81 [95% CI 0.67–0.97]).Median pain scores were 4 on a scale of 10 for both groups for all 3 days of follow-up. Overall median satisfaction score was 9, with a mean difference of 0.35 (95% CI -0.78 – 1.37). Analysis of variance revealed no difference in pain scores or satisfaction per pain diaries between the groups in general and no difference in score trajectory. ConclusionsWe were able to establish a rigorous process and feasibility to launch a larger, multi-center trial to examine this important issue. There remain few evidence-based options for acute pain relief in pediatric surgical populations besides opiates. Identifying opiate alternatives that are effective, cost efficient and safe are needed for pediatric tonsillectomy patients.

Efficacy of topical 0.5% bupivacaine in pain reduction in pediatric tonsillectomy patients

BACKGROUND & OBJECTIVE: Palatine tonsils are lymphoid organs in the oropharynx part of the waldeyer's ring and serve as host defence organs with maximum immunological activity from 3-10 years. Tonsillectomy is associated with considerable postoperative pain and requires significant consumption of analgesia. This study aimed to determine effect of topically suffused 0.5% bupivacaine on postoperative tonsillectomy pain.
 RESULTS One hundred & twenty (120) patients with 61 males and 60-patients in each group with age range of 5-15 years (Group-A=8.63±2.63 and Group-B=8.32±6.60 in). Mean BMI of Group-A and group-B was 15.18±1.60 and 14.96±1.34 respectively (p=0.417). Mean pain score in group-A and group-B was 2.63±0.938 and 6.07±0.800 respectively (p<0.001).
 CONCLUSION: nsillectomies performed using bupivacaine-soaked packs postoperatively are associated with lower postoperative pain compared with those packed with normal saline.

Analgesic efficacy of preoperative single dose intravenous dexamethasone in pediatric tonsillectomies by either sharp snare dissection technique or laser technique: A randomised controlled trial

This study was designed to evaluate the postoperative analgesic efficacy of intravenous dexamethasone, and also to determine the postoperative rescue analgesic consumption, morbidity with respect to surgical technique, quality of oral intake, incidence of postoperative nausea and vomiting (PONV), and discharge from hospital. After ethical committee clearance, a prospective randomized double blind study was planned for one year period on 100 pediatric patients, with5-12 years of age, American Society of Anesthesiologists physical class I and II, undergoing elective tonsillectomy with or without adenoidectomy under general anesthesia were included in the study. Patients were randomly allocated into 4 groups and received the study drug intravenously 10 minutes before induction of anesthesia. Group A undergoing sharp snare dissection tonsillectomy received 0.9% normal saline 50ml, group B sharp snare dissection tonsillectomy received dexamethasone 0.15mg/kg diluted in 0.9% normal saline, group C laser tonsillectomy received 0.9% normal saline 50 ml, group D laser tonsillectomy received dexamethasone 0.15mg/kg diluted in 0.9% normal saline.We observed statistically significant difference in mean pain scores (p<0.05) between dexamethasone group (group B and D) and control group (group A and C) measured by KruskalWallis analysis of Variance test with less pain in dexamethasone group.Single dose intravenous administration of dexamethasone (0.15mg/kg) resulted in reduction of post-operative pain, need for rescue analgesics, reduced incidence of PONV, early return to normal diet and discharge from the hospital.

The Effects of Different Doses of Alfentanil and Dexmedetomidine on Prevention of Emergence Agitation in Pediatric Tonsillectomy and Adenoidectomy Surgery.

Background: Emergence agitation (EA) is a common problem often observed in children after sevoflurane anesthesia, which can be prevented by dexmedetomidine and alfentanil. This study aims to compare the effectiveness of dexmedetomidine alone and with different doses of alfentanil in preventing EA in children under sevoflurane anesthesia. Materials and Methods: In a double-blind trial, 80 children (ASA I or II, 3–7 years old) undergoing tonsillectomy alone and adenotonsillectomy with sevoflurane anesthesia were randomly assigned into four groups: the control group, dexmedetomidine (DEX) group, dexmedetomidine plus 10 μg/kg alfentanil group (DEX + Alf1), and dexmedetomidine plus 20 μg/kg alfentanil group (DEX + ALf2). The incidence of EA was assessed with the Aono’s scale, and the severity of EA was evaluated with the Pediatric Anesthesia Emergence Delirium (PAED) scale. The time of tracheal extubation and time of wake were recorded. Postoperative pain and complications such as nausea and vomiting, cough, laryngospasm, and bradycardia were recorded. Results: The incidence of EA was 50% in the control group, 25% in the DEX group, and 5% in the DEX + Alf1 group, and it never happened in the DEX + Alf2 group. The Aono’s scale, the PAED scale, and the FLACC scale in the control group and the DEX group were significantly more than those in the DEX + Alf1 group and the DEX + Alf2 group after the tracheal extubation (p < 0.05). The time of tracheal extubation of the control group and the DEX group were significantly shorter than those in the DEX + Alf1 group and the DEX + Alf2 group (p < 0.05). The awakening time of the DEX + Alf2 group is significantly longer than those in other groups (p < 0.05). The case of postoperative nausea and vomiting in the DEX + Alf1 group was fewer than those in the other groups (p < 0.05). And, the cases of cough and laryngospasm and bronchospasm in the DEX + Alf1 group and the DEX + Alf2 group were significantly less than those in the control group and the DEX group after the tracheal extubation (p < 0.05). Conclusion: The combined administration of alfentanil and dexmedetomidine can reduce EA in children undergoing tonsillectomy alone and adenotonsillectomy with sevoflurane anesthesia. Dexmedetomidine plus 10 μg/kg alfentanil seems to be more appropriate than other dose combinations as it reduced EA and postoperative nausea and vomiting but did not prolong the time to awake.

Opioid prescribing practices for pediatric tonsillectomy before and after policy interventions

ObjectiveThis study's purpose was to investigate opioid prescribing practices after pediatric tonsillectomy in the year before and year after implementation of statewide policy interventions in Vermont.MethodsWe reviewed charts of consecutive patients less than 18 years old that underwent tonsillectomy or adenotonsillectomy at a single tertiary academic medical center 1 year before (July 2016–June 2017) and 1 year after (July 2017–June 2018) implementation of policy interventions targeted at opioid prescribing. Data collected included demographics, procedure performed, indication, complications, medical comorbidities, opioid prescribing practices (medication, dose, morphine milliequivalents, and postdischarge opioid prescriptions), and postoperative telephone calls and emergency department (ED) visits.ResultsTonsillectomy or adenotonsillectomy was performed in 360 consecutive patients (185 in the pre‐policy year and 175 in the post‐policy year). Those receiving an opioid prescription in the pre‐ compared to post‐policy year was 49.7% versus 15.4% (p < .001). Of patients 6 years and older, 95.8% in the pre‐policy year compared to 25.2% in the post‐policy year received a postoperative opioid (p < .001). There was no difference in pain‐related office phone calls, postdischarge opioid prescriptions or ED visits between the two groups. There was no difference in morphine milligram equivalent prescribed in the pre‐ and post‐groups.ConclusionImplementation of statewide policy interventions can have a substantial impact on opioid prescribing practices in the pediatric tonsillectomy population without an increase in office phone calls, postdischarge opioid prescriptions, and ED visits.Level of Evidence4

Perioperative Acetaminophen and Dexmedetomidine Eliminate Post-Operative Opioid Requirement following Pediatric Tonsillectomy.

Administration of post-operative opioids following pediatric tonsillectomy can elicit respiratory events in this patient population that often arise as central and obstructive sleep apnea. The primary objective of this study was to determine whether a perioperative combination of dexmedetomidine and acetaminophen could eliminate post-operative (in recovery and at home) opioid requirements. Following IRB approval and a waiver for informed consent, the medical records of 681 patients who underwent tonsillectomy between 1 January 2013 and 31 December 2018 were evaluated. Between 1 January 2013 and 31 December 2015, all patients received a fentanyl-sevoflurane-based anesthetic, without acetaminophen or dexmedetomidine, and received opioids in recovery and for discharge home. On 1 January 2016, an institution-wide practice change replaced this protocol with a multimodal perioperative regimen of acetaminophen (intravenous or enteral) and dexmedetomidine and eliminated post-operative opioids. This is the first time that the effect of an acetaminophen and dexmedetomidine combination on the perioperative and home opioid requirement has been reported. Primarily, we compared the need for rescue opioids in the post-anesthesia care period and after discharge. The multi-modal protocol eliminated the need for post-tonsillectomy opioid administration. Dexmedetomidine in combination with acetaminophen eliminated the need for post-operative opioids in the recovery period.

Hospital revisits after paediatric tonsillectomy: a cohort study

BackgroundTonsillectomy, with or without adenoidectomy, is the leading reason for paediatric unplanned hospital readmission, some of which are potentially avoidable. Reducing unplanned hospital revisits would improve patient safety and decrease use of healthcare resources. This study aimed to describe the incidence, timing and risk factors for any surgery-related hospital revisits (both emergency presentation and readmission) following paediatric tonsillectomy and adenotonsillectomy in a large state-wide cohort.MethodsWe conducted a population-based cohort study using linked administrative datasets capturing all paediatric tonsillectomy and adenotonsillectomy surgeries performed between 2010 and 2015 in the state of Victoria, Australia. The primary outcome was presentation to the emergency department or hospital readmission within 30-day post-surgery.ResultsBetween 2010 and 2015, 46,583 patients underwent 47,054 surgeries. There was a total of 4758 emergency department presentations (10.11% total surgeries) and 2750 readmissions (5.84% total surgeries). Haemorrhage was the most common reason for both revisit types, associated with 33.02% of ED presentations (3.34% total surgeries) and 67.93% of readmissions (3.97% total surgeries). Day 5 post-surgery was the median revisit time for both ED presentations (IQR 3–7) and readmission (IQR 3–8). Predictors of revisit included older age, public and metropolitan hospitals and peri-operative complications during surgery.ConclusionsHaemorrhage was the most common reason for both emergency department presentation and hospital readmission. The higher risk of revisits associated with older children, surgeries performed in public and metropolitan hospitals, and in patients experiencing peri-operative complications, suggest the need for improved education of postoperative care for caregivers, and avoidance of inappropriate early discharge.Graphical

Routine evaluation of tonsillectomy specimens: a cross-sectional survey of Canadian Otolaryngology: Head and Neck Surgeons

BackgroundTonsillectomy is a commonly performed procedure in Canada. The rate of occult malignancy is rare in adult and pediatric populations. At present, no guidelines exist surrounding the need for routine histopathological evaluation of tonsil specimens when no malignancy is suspected.MethodsWe sent a confidential online survey to active members of the Canadian Society of Otolaryngology – Head and Neck Surgery (CSO-HNS) about their current tonsillectomy practice and beliefs surrounding the need for routine histopathological evaluation of tonsillectomy specimens when no malignancy is suspected. We used Opinio survey software for data collection and descriptive statistics.Results95 participants completed our survey (response rate 19.3%). Most participants reported performing both adult and pediatric tonsillectomies. When no malignancy is suspected, participant responses were split between whether they send tonsil specimens in pediatrics only (4.2%), in adults only (31.6%), or not sending specimens (29.5%). Half of the participants reported that routinely sending specimens to rule out occult malignancy is an institutional policy. Approximately 75% of participants were in favour of removing this practice in both the pediatric and adult populations.ConclusionEliminating the practice of automatically sending tonsil specimens for histopathological evaluation when no malignancy is suspected was supported by the majority of study participants. This is in keeping with Choosing Wisely, a campaign designed to facilitate conversations about unnecessary medical tests and procedures. Institutional change is likely required in order to alter this practice.Graphical

Anesthetic injections and analgesia use in pediatric post-tonsillectomy patients: A meta-analysis and systematic review

ObjectiveTo assess the effect of local anesthetic injection on post-operative analgesia and complications for pediatric tonsillectomies on post-operative day (POD) 0 and 1. MethodsA 2-researcher team following the PRISMA guidelines performed a systematic review and meta-analysis. The databases Pubmed.gov, Embase, Web of Science, and Scopus were used. Studies written with original data utilizing a saline injection control arm were selected. Corresponding authors were contacted for missing data, which was used when possible. The collated data was analyzed with Review Manager (RevMan) Version 5.4., The Cochrane Collaboration, 2020. Surgical technique subgroup analysis was performed. Results319 publications were identified and 8 articles with 12 total experimental arms (529 participants) were selected. Local anesthetic injection was compared to saline injection. The standard mean difference for time until first analgesic was 0.68 min [0.26, 1.09](P = 0.001) in favor of local anesthetic. The odds ratio (OR) for patients receiving one or more narcotic doses on POD 0 was 0.22 [0.06, 0.84](P = 0.03) in favor of local anesthetic. ConclusionsUse of an intraoperative anesthetic injection during pediatric tonsillectomy can help improve initial recovery as it delays the need for narcotic medication and may reduce postoperative narcotic usage on POD 0 and 1. In addition, a local anesthetic does not increase the risk of postoperative bleeding or dehydration.

Radiofrequency Versus Electrocautery in Pediatric Tonsillectomy: A Double-Blind, Randomized Controlled Trial.

To compare radiofrequency and electrocauterization in reducing the degree of postoperative pain in pediatric patients undergoing tonsillectomy. A double-blind, parallel-group, randomized controlled trial. Pediatric patients with indications for tonsillectomy were randomized to receive either tonsillectomy with radiofrequency or electrocautery. Also recorded were intraoperative blood loss, duration of the surgery, length of hospital stays, and complications from the surgery. Forty pediatric patients participated in the study; 20 were randomized to each group. The participants' ages ranged from 3 to 14years old, and 65% were male. The overall postoperative pain scale score during the early postoperative period was lower in the radiofrequency group compared to the electrocautery group (mean difference -1.37 (95%CI -1.72, -0.12); p < 0.001). Also, the mean pain scale scores at 6h, 1, and 2days were significantly lower in the radiofrequency group. Intraoperative blood loss and length of hospital stay in the radiofrequency group were also significantly lower than in the electrocautery group, whereas the duration of the surgery and complication rate were not different between the two groups. Pediatric tonsillectomy using radiofrequency ablation could reduce the severity of early postoperative pain, intraoperative blood loss, and length of hospital stay compared to tonsillectomy with electrocautery. Therefore, tonsillectomy with radiofrequency may be considered a safe and effective operative option. Trial registration Thai Clinical Trials Registry (TCTR-20210303007), 03-March-2021.

400 A Comparative Study of Intracapsular &amp; Extracapsular Coblation Paediatric Tonsillectomy in A Tertiary Centre

Abstract Background Intracapsular tonsillectomy has emerged as a novel alternative to traditional tonsillectomy where the tonsillar capsule is left intact with a small amount of overlying tonsillar tissue. There is growing evidence to suggest that intracapsular tonsillectomy is associated with reduced post-operative pain, haemorrhage and readmission rates. The aim of this study was to assess the reported benefits of intracapsular tonsillectomy within the ENT department at a tertiary paediatric hospital. Method Retrospective analysis comparing two cohorts of 72 consecutive paediatric patients undergoing coblation intracapsular and extracapsular tonsillectomy between March-2019 and November-2020. Patient age at procedure, removal of adenoids, indication, surgeon grade, and discharge time were recorded. Post-tonsillectomy bleeding and 30-day readmission rates were used as the main outcome measures. Results The median age in both groups was 5 years. The intracapsular cohort demonstrated a lower 30-day readmission rate (8.3% vs. 15.3%), lower primary (&amp;lt;24 hours) post-op bleed rate (0% vs. 2.78%) and lower secondary (&amp;gt;24hours) post-op bleed rate (4.2% vs. 12.5%) when compared to the extracapsular cohort. Eight cases were conducted as day cases in total, all Intracapsular, with none of these patients requiring readmission within 30 days. Discussion Coblation Intracapsular tonsillectomy is an effective and low-risk alternative to extracapsular techniques. It is hoped with the reduced associated risks and morbidity associated with the procedure, the department can move towards day case tonsillectomy procedures resulting in a reduction in overall healthcare costs and improved patient experience.

O016 Exploring the drivers of geographic variation for paediatric tonsillectomy and adenoidectomy

Abstract Introduction Tonsillectomy and/or adenoidectomy (A/T) is first-line treatment for paediatric obstructive sleep apnoea. Provision of A/T is of critical interest to sleep medicine practitioners. Geographic variation of A/T has been described since the 1930s, but no studies have investigated the reasons behind it. This study aimed to describe the geographical distribution of paediatric A/T and investigate area-level factors associated with this variation. Methods Linked administrative datasets captured a complete state-wide population of paediatric A/T performed between 2010 and 2015. Surgery data were collapsed by patient residence to the level of Local Government Area. Regression models were used to investigate the association between likelihood of surgery and area-level factors. Results There was a 10.2-fold difference in A/T rates across the state, with higher rates more common in regional than metropolitan areas. Area-level factors associated with geographic variation that increased the likelihood of A/T were a higher proportion of children aged 5–9 years (IRR 1.07, 95%CI 1.01–1.14, P=0.03), while a higher proportion with low English-language proficiency (IRR 0.95, 95%CI 0.90–0.99, P=0.03) decreased the likelihood of A/T. In a sub-population of public sector surgeries, low maternal educational attainment increased the likelihood of A/T (IRR 1.09, 95%CI 1.02–1.16, P&amp;lt;0.001) and longer surgical waiting time reduced it (IRR 0.996, 95%CI 0.99273–0.99997, P=0.048). Discussion Significant variation in surgery rates exist by geographical area state-wide, with factors analysed having significant impacts. These findings suggest that improved surgical access and better community understanding of the indications for A/T could decrease geographic variation.

Tonsillectomy and hematologic malignancy: Should routine pediatric tonsillectomy specimens be sent to pathology?

ObjectivesRoutine pediatric tonsillectomy ± adenoidectomy (T ± A) is one of the most common procedures for children worldwide, accounting for approximately 2000 procedures per year at our institution. To determine the utility of pathologic analysis of routine, nonsuspicious pediatric tonsil specimens, we investigated the incidence of hematologic and lymphoid malignancy diagnosed at the time of or following T ± A. MethodsRetrospective review of patients 0–18 years undergoing T ± A between 2012 and 2020 with or without pathologic analysis. ResultsIncluded were 14,141 patients who underwent routine T ± A (mean age 11 ± 4.6 years, 48% female). Of these, tonsils of 2464 patients were sent to pathology, where zero were found to harbor malignancy. Seven patients (0.050%) developed malignancy after T ± A. Of these, 4 had unremarkable tonsils per pathology, and 3 did not have tonsils analyzed. There were 5 cases of Acute Lymphocytic Leukemia (ALL, 0.035%), 1 case of Acute Myeloid Leukemia (0.007%), and 1 case of Lymphoma (0.007%). The average length of time from T ± A to diagnosis was 2.4 ± 1.8 years. ConclusionNo cases of occult malignancy were identified in specimens from routine T ± A with pathologic analysis, even among patients who later developed malignancy. This study suggests that sending routine pediatric T ± A specimens for formal pathologic analysis is an inefficient use of resources without appreciably improving the quality and safety of patient care.

Price Transparency and Compliance With Federal Regulation for Pediatric Tonsillectomy.

To improve hospital price transparency, the Centers for Medicare & Medicaid Services (CMS) requires, as of January 2021, that all hospitals reveal charges for specific items and services. This analysis investigates whether otolaryngology residency-affiliated hospitals have complied with this new regulation, and it evaluates the variability in hospital-reported charges for pediatric tonsillectomy. Cross-sectional analysis. Subset of hospitals affiliated with otolaryngology residency programs. Hospital websites were searched to determine compliance rates with CMS guidelines by posting a price transparency tool and specific charges for Current Procedural Terminology code 42820 (tonsillectomy and adenoidectomy, <12 years old). Various charges were collected: gross charge, discounted cash price, deidentified minimum and maximum negotiated charges, hospital fees, and physician fees. Overall 104 unique hospitals were analyzed: 81 (78%) provided pricing data, but only 28 (27%) complied with CMS guidelines. The median reported total gross charge was $13,239 (range, $600-$41,957); deidentified minimum negotiated charge, $9222 (range, $337-$25,164); and deidentified maximum negotiated charge, $17,355 (range, $1002-$54,987). Hospital fees (median, $11,900; range, $2304-$38,831) were consistently higher than physician fees (median, $1827; range, $420-$5063). All estimates included a disclaimer stating that values likely underrepresent true prices. Hospital compliance with the new regulation remains low, which limits efforts toward improved price transparency. There is wide variability in reported charges for pediatric tonsillectomy and adenoidectomy.

Safety of day-case paediatric tonsillectomy in England: an analysis of administrative data for the Getting It Right First Time programme.

We used the Hospital Episodes Statistics database to investigate unwarranted variation in the rates Trusts discharged children the same day after scheduled tonsillectomy and associations with adverse postoperative outcomes. We included children aged 2-18 years who underwent tonsillectomy between 1 April 2014 and 31 March 2019. We stratified analyses by category of Trust, non-specialist or specialist, defined as without or with paediatric critical care facilities, respectively. We adjusted analyses for age, sex, year of surgery and aspects of presentation and procedure type. Of 101,180 children who underwent tonsillectomy at non-specialist Trusts, 62,926 (62%) were discharged the same day, compared with 24,138/48,755 (50%) at specialist Trusts. The adjusted proportion of children discharged the same day as tonsillectomy ranged from 5% to 100% at non-specialist Trusts and 9% to 88% at specialist Trusts. Same-day discharge was not independently associated with an increased rate of 30-day emergency re-admission at non-specialist Trusts but was associated with a modest rate increase at specialist Trusts; adjusted probability 8.0% vs 7.7%, odds ratio (95%CI) 1.14 (1.05-1.24). Rates of adverse postoperative outcomes were similar for Trusts that discharged >70% children the same day as tonsillectomy compared with Trusts that discharged <50% children the same day, for both non-specialist and specialist Trust categories. We found no consistent evidence that day-case tonsillectomy is associated with poorer outcomes. All Trusts, but particularly specialist centres, should explore reasons for low day-case rates and should aim for rates >70%.

Socioeconomic factors associated with readmission following pediatric tonsillectomy

ObjectivesWe aim to analyze factors associated with readmission after tonsillectomy to understand socioeconomic factors associated with readmission. MethodsSingle institution retrospective study of pediatric patients undergoing tonsillectomy over an 8 year study period, comparing patients who required readmission for bleeding concerns or pain/dehydration to those who did not require readmission. ResultsOf the 14,152 tonsillectomy patients, 508 (3.6%) were readmitted with 423 (83.3%) for bleeding concerns and 85 (16.7%) for pain or dehydration. Overall readmission was more likely in age >6 years (OR: 1.61, 95% CI: 1.34–1.92, P < 0.001), while poverty level below 10% (OR: 0.79, 95% CI: 0.66–0.94, P = 0.008) and parental college education above 25% (OR: 0.79, 95% CI: 0.65–0.96, P = 0.016) were associated with lower incidence of overall readmission. For patients readmitted for bleeding concerns, age >6 years (OR 1.66, 95% CI: 1.37–2.02, P < 0.001) was associated with readmission on multivariate analysis. Within the pain/dehydration group, African American race was associated with increased readmission rates, while poverty level below 10% and parental college education above 25% were associated with decreased readmission rates. ConclusionSocioeconomic factors and age play a role in readmission rates following pediatric tonsillectomy.

Comparison of Two Techniques in Pediatric Tonsillectomy: Erbe Unipolar Electrocautery and Thermal Welding System

Comparison of Two Techniques in Pediatric Tonsillectomy: Erbe Unipolar Electrocautery and Thermal Welding System

Sociodemographic associations of geographic variation in paediatric tonsillectomy and adenoidectomy

Geographic variation of paediatric tonsillectomy, with or without adenoidectomy, (A/T) has been described since the 1930s until today but no studies have investigated the factors associated with this variation. This study described the geographical distribution of paediatric A/T across the state of Victoria, Australia, and investigated area-level factors associated with this variation. We used linked administrative datasets capturing all paediatric A/T performed between 2010 and 2015 in Victoria. Surgery data were collapsed by patient residence to the level of Local Government Area. Regression models were used to investigate the association between likelihood of surgery and area-level factors. We found a 10.2-fold difference in A/T rates across the state, with areas of higher rates more in regional than metropolitan areas. Area-level factors associated with geographic variation of A/T were percentage of children aged 5–9 years (IRR 1.07, 95%CI 1.01–1.14, P = 0.03) and low English language proficiency (IRR 0.95, 95% CI 0.90–0.99, P = 0.03). In a sub-population analysis of surgeries in the public sector, these factors were low maternal educational attainment (IRR 1.09, 95% CI 1.02–1.16, P < 0.001) and surgical waiting time (IRR 0.99635 95% CI 0.99273–0.99997, P = 0.048). Identifying areas of focus for improvement and factors associated with geographic variation will assist in improving equitable provision of paediatric A/T and decrease variability within regions.

Post-tonsillectomy hemorrhage control with nebulized tranexamic acid: A retrospective cohort study

ObjectiveEvaluate nebulized tranexamic acid (TXA) as a treatment to reduce the need for an operation to control a post-tonsillectomy hemorrhage (PTH). MethodsBased on a successful case report of a child treated with nebulized TXA for PTH in 2018, our institution began to treat PTH patients with three doses of nebulized TXA. To evaluate the outcomes of this non-invasive management, we conducted a three-year retrospective cohort study of children presenting with PTH from 2016 to 2019. Demographics, insurance, and laboratory information were collected from all pediatric tonsillectomies with and without adenoidectomy performed during the study period. Tonsillar fossae observations of bleeding and clot were documented before and after receiving TXA. ResultsThe incidence of pediatric PTH at our institution during the study period was 5.4%. Fourteen out of 58 PTH patients received nebulized TXA. Receiving nebulized TXA had no adverse events and over 60% showed resolution of bleeding on exam. Receiving nebulized TXA compared to routine care decreased the need for an operation to restore hemostasis by 44%, p < 0.005. There was no significant difference in age, gender, body mass index, hemoglobin, platelet count, trainee presence, or Medicaid status between the children that received TXA and those that did not. ConclusionTreatment of PTH with nebulized TXA may be a safe first-line therapy to decrease the need for operative control of bleeding. This data suggests that a large clinical trial is needed to determine the efficacy of nebulized TXA to mitigate this common and potentially fatal post-operative complication. Level of evidence4.

Effects of High and Normal Dose Fluid Therapy on Nausea and Vomiting after Pediatric Tonsillectomy: A Comparative Study

Background: Nausea, vomiting, and postoperative pain are common and undesirable complications after anesthesia and tonsillectomy surgery especially in children. This study was designed to evaluate the effects of high and normal dose lactated Ringer infusion on nausea, vomiting, and pain intensity after pediatric tonsillectomy.&#x0D; Methods: A total number of 100 tonsillectomy surgery candidates at the age range of 1-12 years were selected for this randomized clinical trial. The subjects were randomly assigned to the intervention or control group after signing of their informed consent. The intervention group received high-dose fluid therapy (lactated Ringer 30cc/kg) and the control group received the normal dose (lactated Ringer 10cc/kg) during the perioperative period. The amounts of consumed adjuvant antiemetic drugs, incidence of nausea and vomiting, and pain severity were evaluated in both groups in the recovery room, at 12 and 24 hours after tonsillectomy.&#x0D; Results: The incidence of nausea and vomiting and the use of rescue antiemetic drugs in the intervention group compared to the control group, were always lower in the recovery room, 12 and 24 hours after surgery; but only the difference in incidence of nausea and vomiting at 24 hours after surgery was statistically significant (P = 0.027).&#x0D; Conclusion: High-dose fluid therapy significantly reduces the late incidence (24 hours after surgery) of post- tonsillectomy nausea and vomiting in children.