Tonsillar Resection Research Articles

Posterior fossa decompression and duraplasty with and without tonsillar resection for the treatment of adult Chiari malformation type I and syringomyelia

The current surgical management of adult Chiari malformation type I (CM-I) with associated syringomyelia remains controversial. The objective of this study was to explore posterior fossa decompression and duraplasty (PFDD) with and without tonsillar resection in adult patients with CM-I and syringomyelia. A total of 116 adult patients suffering from both CM-I and syringomyelia who were scheduled to undergo surgical decompression at our institution between 2012 and 2020 were randomly divided into 2 groups: the PFDD group (n = 64) underwent PFDD without tonsillar resection, while the PFDD-T group (n = 52) underwent PFDD with tonsillar resection. The primary outcome was improvement or resolution of the syrinx. The secondary outcome was an improvement in clinical outcome based on Chicago Chiari Outcome Scale (CCOS) scores. All participants were followed-up to 1-year postoperatively. The proportions of patients who had >20% improvement in syrinx size were 60.9% and 78.8% in the PFDD and PFDD-T groups, respectively (P = .038). The improvement in clinical outcome based on CCOS scores was significantly different in the 2 groups (P = .004). The functionality sub-score was significantly different between the 2 groups (P = .027), but there were no significant differences in the pain symptoms, non-pain symptoms, and complications sub-scores. The total CCOS scores were higher in the PFDD-T group than in the PFDD group (P = .037). This study determined the role of tonsillar resection in achieving obvious syrinx improvement following PFDD-T. PFDD with tonsillar resection seems to be a safe and effective surgical option to treat adult CM-I patients with syringomyelia.

Total or partial tonsillar resection (tonsillectomy or tonsillotomy) to change the quality of life for adults with recurrent or chronic tonsillitis: study protocol for a randomised controlled trial

BackgroundTonsillar surgery has been used for decades to treat recurrent and chronic tonsillitis in adults. Recurrent and chronic tonsillitis result in disturbing symptoms, treatment costs, sick leave, and impaired quality of life (QoL). Theoretically, removing all or part of the altered pathological palatal lymphoid tissue alleviates the symptoms and enhances the QoL. Whether this is true with total or partial tonsillar resection (tonsillectomy (TE) and tonsillotomy (TT), respectively) has not been reported in a randomised trial yet.MethodsWe conduct a multicentre, partly blinded, randomised, 6-month, parallel-group clinical study including 285 adult participants referred to surgical treatment for chronic or recurrent tonsillitis. The participants will either have TE, TT or watchful waiting (WW). The primary outcome will be the difference between the mean disease-specific Tonsillectomy Outcome Inventory-14 (QoL questionnaire) scores at 6 months. Comparison is made firstly between the combined TE+TT and WW groups (superiority analysis), and secondly between the TE and TT groups (non-inferiority analysis).DiscussionThis study will add significant new information to the effects and harms of TE and TT procedures in the treatment of adults with chronic or recurrent tonsillitis.Trial registrationClinicalTrials.gov: NCT04657549

Cover Image

The cover image is based on the Operative Techniques Transoral robotic submandibular gland transposition to reconstruct radical tonsillar resection defects by Allen Young et al., HYPERLINK “https://doi.org/10.1002/hed.26622”.

In Reply to “Do We Need To Perform Duroplasty and Tonsillar Resection in the Surgical Treatment for Patients with Chiari 1 Malformation?”

In Reply to “Do We Need To Perform Duroplasty and Tonsillar Resection in the Surgical Treatment for Patients with Chiari 1 Malformation?”

Do We Need to Perform Duroplasty and Tonsillar Resection in the Surgical Treatment for Patients with Chiari 1 Malformation?

Do We Need to Perform Duroplasty and Tonsillar Resection in the Surgical Treatment for Patients with Chiari 1 Malformation?

Functional Outcome for Chiari Malformation Using a Novel Scoring System

Abstract Background The authors report functional outcomes comparing various surgical techniques, using a Chiari-specific assessment tool. They also intend to externally validate the performance of the CCOS by comparing with gestalt outcome. Methods Total cohort comprised 73 surgically treated patients, and patients were divided into two groups: patients who were operated upon at the authors’ institute and those who were evaluated at their institute but underwent surgery elsewhere due to various reasons. Functional outcome was evaluated on the basis of the Chicago Chiari outcome scale (CCOS) and gestalt outcome scale. Mean duration of follow-up was 10.23 ± 5.8 months. Results In the authors’ cohort of 73 patients, 76.70% (n = 56) were improved, 23.30% (n = 17) were unchanged, and none of them deteriorated. The median CCOS was 14 ± 1.34 (range: 11–16). There was no statistical difference in outcome between the different operative groups (foramen magnum decompression, duraplasty, tonsillar resection “other”). The CCOS value of 14 has excellent sensitivity (0.95) and good specificity (0.746) for identifying patients with good gestalt outcome. Conclusion The authors found a clear correlation between higher CCOS score and gestalt outcome. There was no statistical difference in outcome between the different operative groups.

A case report on result of posterior fossa decompression on syringomyelia in a case of chiary type I malformation

Abstract The prime objective in the surgical treatment of Chiari malformation (CM) and/or syringomyelia (SM) is based on the restoration of the normal cerebrospinal fluid (CSF) dynamics at the craniovertebral junction through the creation of a large artificial cisterna magna. In this case a patient came to our hospital with type 1 chiary malformation having large syrinx which underwent posterior fossa decompression by midline sub occipital craniectomy with subpial cerebellar tonsillar resection which after one year of follow up we have found significant resolution of syrinx radiologically.

Local application of haemocoagulase for control of haemorrhages after tonsillectomy: a study in a teaching hospital

<p class="abstract"><strong><span lang="EN-US">Background: </span></strong>Post-tonsillectomy haemorrhage remains the most serious complication of tonsillectomy. Many topical agents have been used to control the post-operative bleeding by the surgeons. This study was undertaken to evaluate hemocoagulase as a local application in tonsillectomy for the control of primary, reactionary and secondary haemorrhages.</p><p class="abstract"><strong><span lang="EN-US">Methods: </span></strong>50 patients, between the ages 5-60 years, who came with chronic tonsillitis or adenoid hypertrophy, were included into the study. The surgery was performed under general anaesthesia by tonsillar resection or tonsilloadenoid resection. </p><p class="abstract"><strong><span lang="EN-US">Results: </span></strong>The most common age group to be affected was between 5 and 15 years, though in this age group the number of females and males were the same, accounting for 28% each of the total number of patients. Among the 50 patients, only 5 (10%) of them had reactionary haemorrhage, which was immediately contained. None of the patients had either primary or secondary haemorrhage.</p><p class="abstract"><strong><span lang="EN-US">Conclusions: </span></strong>The use of hemocoagulase has after tonsillectomy has definite advantage in controlling post-operative bleeding. It can be used as a routine application after tonsillectomy to control the bleeding.</p>

Minimally invasive subpial tonsillectomy for Chiari I decompression.

BackgroundA number of different surgical techniques have been used through the years to address Chiari I malformation (CMI).MethodsThis article describes how we surgically manage CMI at two high-volume centers. We call the technique the minimally invasive subpial tonsillectomy (MIST). The technique consists of a minimalistic dissection and craniectomy with a short, linear durotomy for the subpial tonsillar resection. The dura is closed without the use of a duraplasty.ConclusionsWe describe our current methods of surgery for CMI.Electronic supplementary materialThe online version of this article (doi:10.1007/s00701-016-2877-2) contains supplementary material, which is available to authorized users.

The use of the trendelenburg position in the surgical treatment of extreme cerebellar slump

Background. State-of-the-art treatment for Chiari Malformation I (CM-I) consists of decompression by posterior fossa craniectomy. A rare but severe complication that develops over months to years after this procedure is cerebellar slump. Treatment options for this condition are limited. We present a new and promising approach to treat this rare condition. Methods. The patients were placed in the Trendelenburg position to facilitate ascent of the cerebellum. After almost complete dissolution of neurologic symptoms, surgical reconstruction was performed by tonsillar resection and the creation of a new structural support using a bone graft. Results. Both patients experienced good clinical and morphological outcomes immediately after surgery, and for two years thereafter. Conclusions. Neurological symptoms related to cerebellar or brainstem slump can be adequately reversed by placing the patient in the Trendelenburg position. After uneventful gravitational reversal of the slump, safe surgical reconstruction of the cerebellar support can be performed to securely preserve the anatomical reversal.

Operative Management of OSAS in a Complex Case of Proteus Syndrome.

Obstructive sleep apnea syndrome (OSAS) is a common disorder in childhood with high prevalence in syndromic subjects with craniofacial malformations. Proteus Syndrome (PS) is a rare hamartoneoplastic disorder associated with disproportionate and asymmetric overgrowth of body parts and hypertrophy or malformation of lymphatic tissues, such as palatine tonsils. We report a case of a 12-year-old boy diagnosed with Proteus Syndrome (PS) and suffering from OSAS due to asymmetric palatine tonsillar hypertrophy, treated with partial resection of left tonsil. To avoid the risk of a general anesthesia and remove only the obstructive portion of the palatine tonsil bipolar radiofrequency-induced thermotherapy (RFITT) under local anesthesia was performed. Recovery of the obstructive respiratory disease was obtained. To our knowledge, this is the first case reported in the literature of partial tonsillar resection performed in a patient with PS suffering from OSAS under local anesthesia.

Pediatric and adult Chiari malformation Type I surgical series 1965-2013: a review of demographics, operative treatment, and outcomes.

Chiari malformation Type I (CM-I) is a hindbrain disorder associated with elongation of the cerebellar tonsils, which descend below the foramen magnum into the spinal canal. It occurs in children and adults. Clinical symptoms mainly develop from alterations in CSF flow at the foramen magnum and the common subsequent development of syringomyelia. The authors reviewed English-language reports of pediatric, adult, and combined (adult and pediatric) surgical series of patients with CM-I published from 1965 through August 31, 2013, to investigate the following: 1) geographical distribution of reports; 2) demographics of patients; 3) follow-up lengths; 4) study durations; 5) spectrum and frequency of surgical techniques; 6) outcomes for neurological status, syrinx, and headache; 7) frequency and scope of complications; 8) mortality rates; and 9) differences between pediatric and adult populations. Research and inclusion criteria were defined, and all series that contained at least 4 cases and all publications with sufficient data for analysis were included. The authors identified 145 operative series of patients with CM-I, primarily from the United States and Europe, and divided patient ages into 1 of 3 categories: adult (>18 years of age; 27% of the cases), pediatric (≤18 years of age; 30%), or unknown (43%). Most series (76%) were published in the previous 21 years. The median number of patients in the series was 31. The mean duration of the studies was 10 years, and the mean follow-up time was 43 months. The peak ages of presentation in the pediatric studies were 8 years, followed by 9 years, and in the adult series, 41 years, followed by 46 years. The incidence of syringomyelia was 65%. Most of the studies (99%) reported the use of posterior fossa/foramen magnum decompression. In 92%, the dura was opened, and in 65% of these cases, the arachnoid was opened and dissected; tonsillar resection was performed in 27% of these patients. Postoperatively, syringomyelia improved or resolved in 78% of the patients. Most series (80%) reported postoperative neurological outcomes as follows: 75% improved, 17% showed no change, and 9% experienced worsening. Postoperative headaches improved or resolved in 81% of the patients, with a statistical difference in favor of the pediatric series. Postoperative complications were reported for 41% of the series, most commonly with CSF leak, pseudomeningocele, aseptic meningitis, wound infection, meningitis, and neurological deficit, with a mean complication rate of 4.5%. Complications were reported for 37% of pediatric, 20% of adult, and 43% of combined series. Mortality was reported for 11% of the series. No difference in mortality rates was seen between the pediatric and adult series. Before undergoing surgical treatment for CM-I, symptomatic patients and their families should be given clear information about the success of treatment and potential complications. Furthermore, surgeons may benefit from comparing published data with their own. In the future, operative CM-I reports should provide all details of each case for the purpose of comparison.

The efficacy of intraoperative ultrasonography⁃assisted microinvasive cisterna magna reconstruction for Chiari malformation typeIwith syringomyelia

Objective To report the method and effect of intraoperative ultrasonography⁃assisted microinvasive cisterna magna reconstruction for Chiari malformation type Ⅰ with syringomyelia. Methods Ninty⁃three patients suffered from Chiari malformation typeⅠwith syringomyelia were treated by microinvasive cisterna magna reconstruction. The skin incision was 1.50-3.00 cm. The bone removal of foramen magnum was 1.50 cm × 2.00 cm with C1 reserved. Dura and arachnoid were incised and sutured linearly. All of the patients underwent cerebellar tonsillar resection and exploration of median aperture of fourth ventricle. Intraoperative ultrasonography was performed both before and after cerebellar tonsillar resection to judge the effect of cisterna magna reconstruction. According to Tator method, the curative effect was divided into 3 groups, improved, stable and worsen. MRI were reviewed at the same time, and the result was divided into syrinx disappeared, reduced, no change and expanded. Results The operation was successful in all patients. Postoperative complications included cerebellum hemorrhage (n = 1), cerebral infarction (n = 1), hydrocephalus (n = 1), subcutaneous dropsy (n = 2) and were recovered after specific treatment. All patients were followed up for 6 months to 12 months after operation. Thirty⁃six cases were improved, 55 cases were stable, and 2 cases got worse. The MRI showed that the syringomyelia shrinked or disappeared in 90 cases, no change in 3 cases and no expansion. Eighty cases were followed up for 30 months to 36 months after operation, 12 stable cases improved, 1 stable case got worse, while the others remained unchanged. The MRI showed no change was compared with previous follow ⁃ up imaging. Conclusion Microinvasive cisterna magna reconstruction is a surgical procedure with mininal injury, quick recovery, stable effect, fewer complications, and high security. Intraoperative ultrasonography provides reliable data and is easy to perform. DOI：10.3969/j.issn.1672⁃6731.2012.04.015

Accessing the Recesses of the Fourth Ventricle

To compare the effectiveness of the telovelar approach with tonsillar manipulation for approaching the recesses of the fourth ventricle. A telovelar approach was performed in 8 injected cadaveric heads. Areas of exposure were measured for the superolateral and lateral recesses. Horizontal angles were evaluated by targeting the cerebral aqueduct and medial margin of the lateral recess. Quantitative comparisons were made between the telovelar dissections and various tonsillar manipulations. Tonsillar retraction provided a comparable exposure of the superolateral recess with tonsillar resection (26.4 +/- 17.6 vs 25.2 +/- 12.5 mm2, respectively; P = .825). Tonsillar resection significantly increased exposure of the lateral recess compared with tonsillar retraction (31.1 +/- 13.3 vs 20.2 +/- 11.5 mm2, respectively; P = .002). Compared with tonsillar retraction, the horizontal angle to the lateral recess increased after either contralateral tonsillar retraction (22.7 +/- 4.8 vs 36.7 +/- 6.5 degrees) or tonsillar resection (22.7 +/- 4.8 vs 31.5 +/- 7.6 degrees; all adjusted P < .01). The horizontal angle to the cerebral aqueduct increased significantly with tonsillar resection compared with tonsillar retraction (17.6 +/- 2.3 vs 13.2 +/- 2.8 degrees; P < .001) Compared with tonsillar retraction, tonsillar resection provides a wider corridor to, and a larger area of exposure of, the cerebral aqueduct and lateral recess. Contralateral tonsillar retraction improves access to the lateral recess by widening the surgical view from the contralateral side.

Tonsillectomy in Children: Explanation in the Text Would Have Been Desirable

The authors do not distinguish sufficiently precisely between the terms, and indications for, tonsillectomy and tonsillotomy. Basically, tonsillectomy can be subdivided into the traditional extracapsular from and the intracapsular form (tonsillotomy, partial tonsillar resection). In tonsillotomy, the tonsils are incompletely resected. The difference is explained only later in the text. The authors say that an indication for tonsillectomy or tonsillotomy exists among others in selected types of inflammation of the tonsils or the peritonsillar area. The indication for tonsillotomy, however, is only symptomatic, not inflammatory, obstructive hyperplasia of the tonsils in childhood without any signs of recurring tonsillitis. Tonsillotomy was long seen as an obsolete intervention because after the operation, increased scarring of the remaining tonsillar tissue would develop, with subsequent chronic inflammation or abscesses. These complications were not due so much to the method as to the incorrect indication. A substantial perceived advantage of tonsillotomy compared with tonsillectomy is the low postoperative risk of hemorrhage. Also, pain is reduced because the palatine arches are spared. These advantages result in a shorter hospitalization period for children. In box 2, the authors list complications after tonsillectomy., but they do not rate these. The text only says that, compared with postoperative hemorrhage, other postoperative complications are rare and therefore not as important. However, some extremely rare and unusual complications were listed (emphysema, pneumomediastinum or thorax, damage to the recurrent laryngeal nerve, meningitis), which in the literature are reported only in case studies. A more detailed explanation in the text would have been desirable.

Toward a Simpler Surgical Management of Chiari I Malformation in a Pediatric Population

A wide variety of surgical adjuvants to the standard bony decompression have been advocated in the treatment of the Chiari I malformation, especially when the tonsillar herniation is associated with hydrosyringomyelia. These include various shunting procedures, duroplasty, obex plugging, and resection of the cerebellar tonsils. Our practice has been to avoid these adjuvants and to perform a simple limited occipital craniectomy, C₁ laminectomy, and dural opening. The dura mater is left open and overlain with oxidized cellulose. To evaluate the efficacy of this more limited procedure, a retrospective review was performed of the medical records of 31 consecutive patients treated over a 6-year period. Twenty-six (84%) of these patients had an associated spinal cord syrinx; all underwent the same procedure. The follow-up period ranged from 15 to 93 months, with all patients having at least one postoperative magnetic resonance imaging at 6 months. Twenty-three of the 26 patients (88%) who presented with a syrinx had significant resolution of the syrinx on follow-up scans with concomitant improvement of presenting signs and symptoms. Of the remaining 3 patients, 1 had progressive hydrocephalus and received a ventriculoperitoneal shunt, with symptom resolution. In the other 2 patients the syrinx did not diminish; both received syringopleural shunts. Postoperative morbidity includes a 26% incidence of headaches, of which half resolved within 5 days, and only 1 persisted beyond 2 weeks. Nausea and vomiting occurred in 16%. Neither of these figures significantly exceeds those of other large surgical series in which the dura mater was closed with a patch graft. Three patients (10%) did have a postoperative cerebrospinal fluid leak; all responded to bedside suturing without further sequelae. This study indicates that a simple bone removal and open dural decompression of the cervicomedullary junction is a safe, effective operative treatment for Chiari I malformation in children. Shunts, duroplasty, obex plugging, and tonsillar resection offer no benefit regarding the outcome when our series is compared to others in which such adjuvants were used.

Brain resection for exposure of deep extracerebral and paraventricular lesions

In exposing deep extracerebral or paraventricular lesions, it sometimes may be preferable to resect a small amount of noneloquent brain tissue rather than retract the brain. This may be the case in carefully selected instances when, in the surgeon's estimate, brain retraction may result in significant parenchymal damage, in aneurysmal rupture, or in damage to important bridging veins. Some surgical approaches involving brain resection have been well described. This technical note discusses the following approaches that, though undoubtedly used by many surgeons sporadically, have received less formal attention: (1) anterior-inferior temporal resection for basilar aneurysms, (2) posterior-inferior temporal resection to approach the posterior incisura and avoid damage to the vein of Labbé, (3) parahippocampal resection to expose the posterior cerebral artery in the ambient cistern, (4) paramedial posterior parietal incision to approach the trigone of the lateral ventricle, (5) parasagittal resection to expose the interhemispheric fissure and avoid damage to bridging veins, (6) cingulate resection for pericallosal aneurysms, and (7) tonsillar resection for aneurysms of the peripheral portion of the posterior-inferior cerebellar arteries.