Absceso periamigdalino bilateral. Reporte de un caso y revisión de las controversias en el diagnóstico y tratamiento / Bilateral peritonsillar abscess. A case report and review of controversies surrounding diagnosis and management

La presentación bilateral del absceso periamigdalino es poco frecuente. Su abordaje es controversial y se discute si realizar amigdalectomía en caliente versus diferida. Se presenta el caso de un paciente de sexo masculino, de 14 años, con odinofagia, trismo y fiebre. Presentaba hipertrofia amigdalina bilateral, pilares abombados y edema de paladar blando. Tomografía computada: hipertrofia amigdalina bilateral, con realce poscontraste, ambas con colección, edema con moderada estenosis faríngea. Se decidió internación para tratamiento endovenoso y amigdalectomía con drenaje bilateral. Resolución completa del cuadro con alta a las 48 horas. Ante la presencia de un absceso periamigdalino, debe considerarse la posibilidad de un absceso contralateral oculto. Debe ser diagnosticado y tratado adecuadamente para prevenir complicaciones. La amigdalectomía en caliente podría ser un tratamiento seguro y debería ser considerado en pacientes que serán sometidos a anestesia para drenaje. La decisión final debe ser determinada para cada caso en particular.

The bilateral presentation of peritonsillar abscess is uncommon. Its management is controversial and it has been argued whether a quinsy tonsillectomy or an interval tonsillectomy should be performed. Here we describe the case of a 14-year-old boy with sore throat, trismus, and fever. He had bilateral tonsillar hypertrophy, convex arches, and soft palate edema. Computed tomography: bilateral tonsillar hypertrophy, with post-contrast enhancement, both with collection, edema with moderate pharyngeal stenosis. The patient was hospitalized for intravenous therapy and tonsillectomy with bilateral drainage resulting in a complete resolution of his condition and discharge at 48 hours. In the presence of a peritonsillar abscess, an unsuspected contralateral abscess should be considered. It should be diagnosed and managed adequately to prevent complications. Quinsy tonsillectomy could be safe and should be considered in patients who will undergo anesthesia for abscess drainage. The final decision should be made for each patient on an individual basis.

Effect of tonsillotomy on the inflammation and immune function in children with chronic tonsillitis / 临床耳鼻咽喉头颈外科杂志

Objective:To investigate the changes of inflammation and immune function in children with chronic tonsillitis after tonsillotomy. Methods:Prospectively collected 60 children with obstructive sleep apnea （OSA） diagnosed as chronic tonsillitis with adenoids and tonsillar hypertrophy from January to June 2021. Two groups were divided, the experimental group （n=30） underwent bilateral partial tonsillectomy + adenoidectomy by hypothermia plasma ablation, and the control group （n=30） underwent adenoidectomy by using the same hypothermia plasma ablation method. The number of tonsillitis attacks before surgery and within one year after surgery was recorded, and the serum immunoglobulin IgM, IgG, IgA, complement C3 and complement C4 levels before operation, one month and three months after operation were measured. Results:The number of tonsillitis attacks in the experimental group and the control group at one year after surgery was lower than that before surgery（P<0.05）; The number of inflammatory attacks in the experimental group was （0.50±0.63） times/year, which was lower than that of （1.33±0.80） times/year in the control group. There was no significant difference in the five immunization results of the two groups at one month and three months after operation compared with before operation, and there was also no significant difference between the experimental and the control groups. Conclusion:Partial tonsillectomy can be applied to children with chronic tonsillitis, which can effectively reduce the number of tonsillitis attacks and has no effect on the immune function of children.

Manejo de hemorragia posamigdalectomía en Chile / Treatment of post tonsillectomy bleeding in Chile

Resumen Introducción: La amigdalectomía es una de las cirugías más frecuentes en la población pediátrica. Aunque se considera una cirugía sencilla y segura, no está exenta de riesgos, siendo el principal la hemorragia posoperatoria. Objetivo: Evaluar el manejo de la hemorragia posamigdalectomía en otorrinolaringólogos en Chile. Material y Método: Se realizó un estudio transversal descriptivo sobre la experiencia y manejo de hemorragias posamigdalectomía mediante una encuesta difundida a socios activos de la Sociedad Chilena de Otorrinolaringología, Medicina y Cirugía de Cabeza y Cuello (SOCHIORL). Resultados: Se recopilaron respuestas de 102 de los 348 socios. El 97% ha presentado esta complicación. La medida inicial ante una hemorragia tardía fuera de una unidad de otorrinolaringología es derivar al servicio de urgencias en el 88% de los casos. En urgencia, la indicación más frecuente es administrar ácido tranexámico endovenoso en un 80%. En el caso de hemorragia sin estigmas de sangrado actual, un 68% indica alta con control precoz. Si se evidencian coágulos en la fosa amigdalina, el 72% indica hospitalización para observación. Si se evidencia sangrado activo, el 94% indica hospitalización y revisión de hemostasia en pabellón. Conclusión: Los resultados a nivel nacional, según este estudio, son concordantes con la literatura mundial. El manejo en el servicio de urgencia se basa en la experiencia del tratante. Respecto a los distintos escenarios clínicos, se recomienda hospitalización en caso de evidenciar coágulos y manejo en pabellón en la presencia de sangrado activo. El manejo es variable en pacientes sin hallazgos al examen físico.

Abstract Introduction: Tonsillectomy is one of the most frequent surgeries in the pediatric population. Although it is considered a simple and safe surgery, it has associated risks, the main one being postoperative bleeding. Aim: Evaluate the management of post-tonsillectomy hemorrhage in otorhinolaryngologists practicing in Chile. Material and Method: A descriptive cross-sectional study was carried out on the experience and management of post-tonsillectomy hemorrhage through a survey distributed to active members of the Sociedad Chilena de Otorrinolaringología, Medicina y Cirugía de Cabeza y Cuello (SOCHIORL). Results: Responses were collected from 102 out of 348 active members, of which 97% have presented this complication. The initial measure in a late hemorrhage occurring outside of an otolaryngology unit is referral to the emergency department in 88% of cases. In the emergency room, the most frequent management is to administer intravenous tranexamic acid in 80%. In the case of hemorrhage without trace of current bleeding, 68% discharge with early control. If clots are evident in the tonsillar fossa, 72% admit for observation. If there is evidence of active bleeding, 94% admit and perform revision surgery. Conclusion: Results of this study are consistent with international literature. Management in the emergency department is based on the experience of the treating physician and different clinical scenarios. Hospitalization is recommended when clots are observed, revision surgery when evidence of active bleeding and, in patients with no findings at the moment of the evaluation, management is variable.

Impact of adenotonsillectomy on the quality of life of patients operated on at the Hospital de Clínicas, Paraguay / Impacto de la amigdalectomía en la calidad de vida de los pacientes operados en el Hospital de Clínicas, Paraguay

The objective of this study is to determine the impact of adenotonsillectomy on the quality of life of postoperative patients. The study is observational, cross-sectional, and retrospective. The files of all postoperative adenotonsillectomy patients in Otorhinolaryngology Service, Hospital de Clínicas, San Lorenzo Paraguay. The Obstructive sleep apnea ­ 18 questionnaire (OSA 18) was applied, asking patients about symptoms before and after surgery. An effective sample of 143 postoperative patients was obtained. The average age was 6.05 ± 2.08 years, 55.10% (81) were male and 44.89% (66) were female, 65.30% (96) were from urban areas and 34.69% (51) from the rural areas. The t test was performed for means of two paired samples, comparing the results of the Obstructive sleep apnea ­ 18 questionnaire surveys before and after surgery which presented a significant difference (p <0.05) with a tendency to improve the quality of life after surgery. It has been shown that there is a significant difference, a considerable improvement in the quality of life of patients after adenotonsillectomy

El objetivo de este estudio fue determinar el impacto de la adenoamigdalectomía en la calidad de vida de los pacientes postoperados. Se diseñó un estudio observacional, transversal y retrospectivo. Se revisaron los expedientes de todos los pacientes postoperados de adenoamigdalectomía en el servicio de otorrinolaringología del Hospital de Clínicas de san Lorenzo, Paraguay, se aplicó el cuestionario de apnea obstructiva del sueño ­ 18 (AOS 18), en el que se preguntaba a los pacientes sobre los síntomas antes y después de la cirugía. Se obtuvo una muestra efectiva de 143 pacientes postoperatorios. La edad media fue de 6,05 ± 2,08 años, el 55,10% (81) eran hombres y el 44,89% (66) eran mujeres, el 65,30% (96) eran de zonas urbanas y el 34,69% (51) de zonas rurales. Se realizó la prueba t para medias de dos muestras pareadas, comparando los resultados de la encuesta del cuestionario de apnea obstructiva del sueño - 18 antes y después de la cirugía que presentó una diferencia significativa (p <0,05) con tendencia a mejorar la calidad de vida después de la cirugía. El estudio muestra una mejora considerable en la calidad de vida de los pacientes tras la adenoamigdalectomía.

Preemptive nebulized ketamine for pain control after tonsillectomy in children: randomized controlled trial / Uso preventivo de cetamina nebulizada para controle da dor após amigdalectomia em crianças: estudo randômico e controlado

Abstract Objectives The administration of ketamine as nebulized inhalation is relatively new and studies on nebulized ketamine are scarce. We aimed to investigate the analgesic efficacy of nebulized ketamine (1 and 2 mg.kg-1) administered 30 min before general anesthesia in children undergoing elective tonsillectomy in comparison with intravenous ketamine (0.5 mg.kg-1) and saline placebo. Methods One hundred children aged (7-12) years were randomly allocated in four groups (n = 25) receive; Saline Placebo (Group C), Intravenous Ketamine 0.5 mg.kg-1 (Group K-IV), Nebulized Ketamine 1 mg.kg-1 (Group K-N1) or 2 mg.kg-1 (Group K-N2). The primary endpoint was the total consumption of rescue analgesics in the first 24 h postoperative. Results The mean time to first request for rescue analgesics was prolonged in K-N1 (400.9 ± 60.5 min, 95% CI 375.9-425.87) and K-N2 (455.5 ± 44.6 min, 95% CI 437.1-473.9) groups compared with Group K-IV (318.5 ± 86.1 min, 95% CI 282.9-354.1) and Group C (68.3 ± 21.9 min, 95% CI 59.5-77.1; p < 0.001), with a significant difference between K-N1 and K-N2 Groups (p < 0.001). The total consumption of IV paracetamol in the first 24 h postoperative was reduced in Group K-IV (672.6 ± 272.8 mg, 95% CI 559.9-785.2), Group K-N1 (715.6 ± 103.2 mg, 95% CI 590.4-840.8) and Group K-N2 (696.6 ± 133.3 mg, 95% CI 558.8-834.4) compared with Control Group (1153.8 ± 312.4 mg, 95% CI 1024.8-1282.8; p < 0.001). With no difference between intravenous and Nebulized Ketamine Groups (p = 0.312). Patients in intravenous and Nebulized Ketamine Groups showed lower postoperative VRS scores compared with Group C (p < 0.001), no differences between K-IV, K-N1 or K-N2 group and without significant adverse effects. Conclusion Preemptive nebulized ketamine was effective for post-tonsillectomy pain relief. It can be considered as an effective alternative route to IV ketamine.

Resumo Objetivos A administração de cetamina por via inalatória através de nebulizador é relativamente nova e os estudos sobre este assunto são escassos. Nosso objetivo foi investigar a eficácia analgésica da cetamina nebulizada (1 e 2 mg.kg-1) administrada 30 minutos antes da anestesia geral em crianças submetidas à amigdalectomia eletiva, em comparação com cetamina intravenosa (0,5 mg.kg-1) e placebo (soro fisiológico). Métodos Cem crianças entre 7-12 anos foram randomicamente alocadas em quatro grupos (n = 25) e receberam: soro fisiológico para controle (Grupo C); 0,5 mg.kg-1 de cetamina intravenosa (Grupo C-IV); 1 mg.kg-1 de cetamina nebulizada (Grupo C-N1); 2 mg.kg-1 de cetamina nebulizada (Grupo C-N2). O desfecho primário foi o consumo total de analgésicos de resgate nas primeiras 24 horas de pós-operatório. Resultados O tempo médio para a primeira solicitação de analgésicos de resgate foi prolongado nos grupos C-N1 (400,9 ± 60,5 min, IC 95% 375,9-425,87) e C-N2 (455,5 ± 44,6 min, IC 95% 437,1-473,9) em comparação com o Grupo C-IV (318,5 ± 86,1 min, IC 95% 282,9-354,1) e o Grupo C (68,3 ± 21,9 min, IC 95% 59,5-77,1; p < 0,001), com uma diferença significativa entre os grupos C-N1 e C-N2 (p < 0,001). O consumo total de paracetamol IV nas primeiras 24 horas de pós-operatório foi reduzido no Grupo C-IV (672,6 ± 272,8 mg, IC 95% 559,9-785,2), Grupo C-N1 (715,6 ± 103,2 mg, IC 95% 590,4-840,8) e Grupo C-N2 (696,6 ± 133,3 mg, IC 95% 558,8-834,4) em comparação com o Grupo C (1153,8 ± 312,4 mg, IC 95% 1024,8-1282,8; p < 0,001). Não houve diferença entre os grupos de cetamina intravenosa e nebulizada (p = 0,312). Os pacientes dos grupos de cetamina intravenosa e nebulizada apresentaram escores VRS pós-operatórios menores, em comparação com o Grupo C (p < 0,001), sem diferenças entre os grupos C-IV, C-N1 ou C-N2 e sem efeitos adversos significativos. Conclusão A administração preventiva de cetamina nebulizada foi eficaz no alívio da dor pós-amigdalectomia. Cetamina nebulizada pode ser considerada como uma via alternativa eficaz à cetamina IV.

Long-term follow-up of tonsillectomy efficacy in children with PFAPA syndrome / Acompanhamento em longo prazo da eficácia da tonsilectomia em crianças com síndrome de PFAPA

Abstract Introduction: The role of tonsillectomy in the periodic fever, aphthous stomatitis, pharyngitis, and adenitis syndrome, is controversial. Although some studies reported high success rates with tonsillectomy, further investigations are needed with larger numbers of patients. Objective: To seek the long-term outcomes of tonsillectomy in periodic fever, aphthous stomatitis, pharyngitis, and adenitis syndrome. Methods: Case series; multi-center study. The study comprised 23 patients with periodic fever, aphthous stomatitis, pharyngitis, and adenitis syndrome who underwent surgery (tonsillectomy with or without adenoidectomy) between January 2009 and November 2014. Results: 21 (91%) of 23 patients had complete resolution immediately after surgery. One patient had an attack 24 h after surgery, but has had no further attacks. One patient had three attacks with various intervals, and complete remission was observed after 3 months. Conclusions: Tonsillectomy is a good option for the treatment of periodic fever, aphthous stomatitis, pharyngitis, and adenitis syndrome.

Resumo Introdução: O papel da tonsilectomia na síndrome da febre periódica, estomatite aftosa, faringite e adenite é controverso. Embora alguns estudos tenham relatado altas taxas de sucesso com a tonsilectomia, são necessárias mais pesquisas com um número maior de pacientes. Objetivo: Avaliar os resultados em longo prazo da tonsilectomia na síndrome de febre periódica, estomatite aftosa, faringite e adenite. Método: Série de casos; estudo multicêntrico. O estudo avaliou 23 pacientes com síndrome de febre periódica, estomatite aftosa, faringite e adenite submetidos a cirurgia (tonsilectomia com ou sem adenoidectomia) entre janeiro de 2009 e novembro de 2014. Resultados: Dos 23 pacientes, 21 (91%) apresentaram resolução completa imediatamente após a cirurgia. Um paciente apresentou um episódio 24 horas após a cirurgia, mas sem recorrência posterior. Um paciente teve três episódios com vários intervalos e a remissão completa foi observada após 3 meses. Conclusões: A tonsilectomia é uma boa opção para o tratamento da síndrome de febre periódica, estomatite aftosa, faringite e adenite.

Staphylococcus aureus in tonsils of patients with recurrent tonsillitis: prevalence, susceptibility profile, and genotypic characterization

ABSTRACT Introduction: Bacterial tonsillitis is an upper respiratory tract infection that occurs primarily in children and adolescents. Staphylococcus aureus is one of the most frequent pathogens in the etiology of tonsillitis and its relevance is due to its antimicrobial resistance and persistence in the internal tissues of the tonsils. Tonsillectomy is indicated in cases of recurrent tonsillitis after several failures of antibiotic therapy. Material and methods: In this study we evaluated 123 surgically removed tonsils from patients who had history of recurrent tonsillitis. The tonsils were submitted to microbiological analysis for detection of S. aureus. The isolates were identified by PCR for femA gene. Antimicrobial susceptibility of the isolates was determined by disk diffusion tests. All isolates were submitted to PCR to detect mecA and Panton-Valentine leucocidin (PVL) genes. The genetic similarity among all isolates was determined by pulsed field gel electrophoresis. Results: Sixty-one S. aureus isolates were obtained from 50 patients (40.7%) with mean age of 11.7 years. The isolates showed high level resistance to penicillin (83.6%), 9.8% had inducible MLSb phenotype, and 18.0% were considered multidrug resistant (MDR). mecA gene was detected in two isolates and the gene coding for PVL was identified in one isolate. The genetic similarity analysis showed high diversity among the isolates. More than one genetically different isolate was identified from the same patient, and identical isolates were obtained from different patients. Conclusions: MDR isolates colonizing tonsils even without infection, demonstrate persistence of the bacterium and possibility of antimicrobial resistance dissemination and recurrence of infection. A specific clone in patients colonized by S. aureus was not demonstrated.

Bloqueo de la rama lingual del nervio glosofaríngeo en pacientes pediátricos sometidos a adenotonsilectomía: estudio prospectivo y de corte transversal / Lingual branch of glossopharyngeal nerve block in pediatric patients undergoing adenotonsillectomy: prospective and cross-sectional clinical trial

OBJECTIVE: To determine the efficacy of lingual branch of glossopharyngeal nerve block in postoperative management of pain in pediatric patients undergoing adenotonsillectomy. METHODS: Prospective and cross-sectional clinical trial. The sample was 105 patients between 3 and 8 years old scheduled for adenotonsillectomy, who performed lingual branch of glossopharyngeal nerve block by anterior intraoral approach with bupivacaine 0.5% + adrenaline 1:200,000. Postoperative pain using CHEOPS scale, complications, need for postoperative analgesics, recovery time using modified Aldrete scale and time for oral tolerance was assessed. RESULTS: We studied 101 patients classified into three groups according to the level of postoperative pain divided into mild (88.1%), moderate (7.9%) and severe (4%), with means and DS for discharged time of 50.13 ± 13.912 min, 63.75 ± 10.607 min and 86.25 ± 7.5 min; first oral intake 3.08 ± 0.829 h, 4 ± 0 h and 4 ± 0 h; and, first post-discharge pain reference of 18.3 ± 7.414 h, 5.75 ± 0.866 h and 4.5 ± 1 h respectively. Analgesic reinforcement was needed in 11.9% of the cases. There were not complications. CONCLUSIONS: Lingual branch of glossopharyngeal nerve block is a useful and effective tool in the management of pain and anesthetic recovery of pediatric patients undergoing adenotonsillectomy.

OBJETIVO: Determinar la eficacia del bloqueo de la rama lingual del nervio glosofaríngeo en el manejo postoperatorio del dolor en pacientes pediátricos para adenotonsilectomía. MÉTODOS: Estudio con diseño prospectivo y de corte transversal. La muestra consistió en 105 pacientes con edades comprendidas entre los 3 y 8 años de edad programados para adenotonsilectomía, a los que se realizó bloqueo de la rama lingual del nervio glosofaríngeo abordaje intraoral anterior con bupivacaína 0,5% + adrenalina 1:200.000. Se estudió el dolor postoperatorio mediante escala CHEOPS, complicaciones, necesidad de analgésicos postoperatorio, tiempo de recuperación mediante escala de Aldrete modificado y tiempo para tolerancia oral. RESULTADOS: Se estudiaron 101 pacientes en tres grupos según el grado de dolor postoperatorio divididos en leve (88,1%), moderado (7,9%) y severo (4%), con medias y DS para tiempo de alta de 50,13 ± 13,912 min, 63,75 ± 10,607 min y 86,25 ± 7,5 min; primera ingesta oral 3,08 ± 0,829 h, 4 ± 0 h y 4 ± 0 h; y, primera referencia de dolor posterior al alta de 18,3 ± 7,414 h, 5,75 ± 0,886 h y 4,5 ± 1 h respectivamente. Se ameritó refuerzo analgésico en el 11,9% de los casos. No se evidenciaron complicaciones. CONCLUSIONES: El bloqueo de la rama lingual del nervio glosofaríngeo es una herramienta útil y eficaz en el manejo del dolor y recuperación anestésica de pacientes pediátricos sometidos a adenotonsilectomía.

Características posoperatorias de la faringoplastia combinada con amigdalectomía en comparación con la amigdalectomía en niños con síndrome obstructivo de apnea del sueño / Postoperative characteristics of combined pharyngoplasty and tonsillectomy versus tonsillectomy in children with obstructive sleep apnea syndrome

Objetivo. Identificar las ventajas posoperatorias de la amigdalectomía en conjunto con la faringoplastia en comparación con la amigdalectomía sola en niños con apnea obstructiva del sueño. Métodos. En un estudio prospectivo observacional, los pacientes que cumplían con los criterios del estudio fueron asignados aleatoriamente a dos grupos: el grupo de amigdalectomía y faringoplastia, y el grupo de solo amigdalectomía. En ambos grupos, también se practicó adenoidectomía a los pacientes con vegetaciones. Se compararon los procesos de cicatrización en la herida faríngea y las proporciones hemorrágicas. Además, se evaluó la función velofaríngea posoperatoria. Resultados. La faringoplastia junto con la amigdalectomía se practicó en 328 niños con apnea obstructiva del sueño debido a hipertrofia amigdalina, y la amigdalectomía sola, en 275 niños. Estas cohortes no mostraban diferencias demográficas significativas. Por otro lado, se encontró que la pérdida de sangre fue significativamente menor en el grupo que recibió amigdalectomía y faringoplastia (p < 0,01), y el proceso de cicatrización fue notablemente más breve. La función velofaríngea posoperatoria no resultó afectada. Conclusiones. En comparación con la amigdalectomía, la amigdalectomía junto con la faringoplastia redujeron la duración del proceso de cicatrización y la pérdida de sangre; no obstante, las complicaciones posoperatorias no aumentaron. En nuestra opinión, la combinación de faringoplastia y amigdalectomía reúne un gran potencial en el tratamiento de los niños con apnea obstructiva del sueño.

Purpose. The study aims to identify the postoperative advantages of tonsillectomy in conjunction with pharyngoplasty and tonsillectomy alone in children with obstructive sleep apneas. Methods. In a prospective observational study, patients who met the study criteria were randomly divided into two groups: tonsillectomy and pharyngoplasty group, and tonsillectomy alone group. In both groups, adenoidectomy was also performed in patients with adenoid hypertrophy. Differences in their healing processes in the pharyngeal wound and their hemorrhage proportions were compared. Furthermore, postoperative velopharyngeal function was also assessed. Results. Pharyngoplasty together with tonsillectomy was performed in 328 children with obstructive sleep apnea from tonsillar hypertrophy, and tonsillectomy was performed in 275 children. These cohorts did not reveal any significant demographic differences between groups. Furthermore, blood loss was found to be significantly decreased in the tonsillectomy and pharyngoplasty group (P <0.01), and the healing process was markedly shorter. Postoperative velopharyngeal function was not affected. Conclusions. Tonsillectomy in conjunction with pharyngoplasty reduced the duration of the healing process and blood loss, compared with tonsillectomy alone; however, postoperative complications did not increase. We consider pharyngoplasty in conjunction with tonsillectomy has great potential in the treatment of children with obstructive sleep apnea.

Puntos de aproximación de pilares en amigdalectomía pediátrica / Pillars´ approach suture points in pediatric tonsillectomy / Pontos de abordagem dos pilares na tonsilectomia pediátrica

INTRODUCCIÓN: A lo largo de los años, varias técnicas de amigdalectomía han sido desarrolladas y modificadas con el fin de reducir su morbimortalidad. Diversos estudios han comparado estas técnicas, no habiendo consenso en cuanto al método con mejores resultados. El objetivo de nuestro trabajo es describir la técnica personal de amigdalectomía y analizar la frecuencia de sangrado y el desarrollo de insuficiencia velopalatina post-quirúrgica en la cirugía con aproximación de pilares. MATERIAL Y MÉTODO: Estudio descriptivo, prospectivo. Se incluyeron pacientes operados de amigdalectomía con amigdalotomo de Daniels, de 3 a 15 años, en el período comprendido desde febrero de 2017 a febrero de 2018, en el sistema de salud Malvinas Argentinas. Se interrogó por sintomatología de sangrado e insuficiencia velopalatina mediante una encuesta de elaboración propia a la semana y al mes post-quirúrgico...

INTRODUCTION: Throughout the years, several tonsillectomy techniques have been developed and modified in order to reduce their morbidity and mortality. Several studies have compared these techniques, and there is no consensus regarding the method with better results. The objective of our study is to describe the personal technique of tonsillectomy and analyze the frequency of bleeding and development of post-surgical velopalatine insufficiency in surgery with abutment approach. MATERIAL AND METHOD: Descriptive, prospective study. We included patients undergoing tonsillectomy with Daniels, from between 3 and 15 years old, from February 2017 to February 2018, in the Malvinas Argentinas hospital. They were interrogated for symptomatology of bleeding and velopalatine insufficiency by through of a self-developed questionnaire one week and one month after surgery…

INTRODUÇÃO: Ao longo dos anos, várias técnicas de amigdalectomia foram desenvolvidas e modificadas para reduzir sua morbidade e mortalidade. Diversos estudos compararam essas técnicas, não havendo consenso em relação ao método com melhores resultados. O objetivo do nosso trabalho é descrever a técnica pessoal de amigdalectomia e analisar a frequência de sangramento e o desenvolvimento de insuficiência velopalatina pós-cirúrgica em cirurgia com abordagem de abutment. MATERIAL E MÉTODO: Estudo descritivo, prospectivo. Foram incluídos pacientes submetidos à tonsilotomia com tonsilectomia de Daniels, de 3 a 15 anos, no período de fevereiro de 2017 a fevereiro de 2018, no sistema de saúde Malvinas Argentinas. Foi interrogado por sintomatologia de hemorragia e insuficiência velopalatine por meio de um questionário autodevelado durante a semana e o mês pós-cirúrgico...

Is the difference in the volume of the pharyngeal space, as measured by acoustic pharyngometry, before and after tonsillectomy proportional to the volume of the excised tonsils?

OBJECTIVE: Adenotonsillectomy is recognized as an effective therapy for snoring and sleep disorders in children. It is important to understand whether adenotonsillectomy significantly increases the volume of the pharyngeal space. The goal of this study was to evaluate the change in oropharyngeal volume after adenotonsillectomy and the correlation of this change with the objective volume of the tonsils and body mass index. METHODS: We included 27 subjects (14 males) with snoring caused by tonsil and adenoid hypertrophy. The mean age of the subjects was 7.92 (±2.52) years. Children with craniofacial malformations or neuromuscular diseases or syndromes were excluded. The parents/caregivers answered an adapted questionnaire regarding sleep-disordered breathing. All patients were subjected to weight and height measurements and body mass index was calculated. The subjects underwent pharyngometry before and after adenotonsillectomy and the volume of both excised tonsils together was measured in cm3 in the operating room. RESULTS: Pharyngometric analysis showed that the mean pharyngeal volume was 28.63 (±5.57) cm3 before surgery and 31.23 (±6.76) cm3 after surgery; the volume of the oropharynx was significantly increased post-surgery (p=0.015, Wilcoxon test). No correlation was found between the objective tonsil volume and the post-surgical volume increase (p=0.6885). There was a fair correlation between the oropharyngeal volume and body mass index (p=0.0224). CONCLUSION: Adenotonsillectomy increases the volume of the pharyngeal space, but this increase does not correlate with the objective tonsil size. Furthermore, greater BMI was associated with a smaller increase in the pharyngeal volume. Oropharyngeal structures and craniofacial morphology may also play a role in the increase in oropharyngeal volume.

Síndrome de apnea obstructiva del sueño en niños (SAOS) / Obstructive sleep apnea syndrome in children (OSAS)

El síndrome de la apnea obstructiva del sueño (SAOS) es ocasionado por una obstrucción de las vías aéreas superiores, resultado de un desequilibrio entre la fuerza de succión respiratoria y la compensación de los músculos dilatadores faríngeos. El diagnóstico positivo es establecido por el registro polisomnográfico nocturno durante el sueño que define las características y la severidad de esta enfermedad. El objetivo del siguiente artículo es difundir los diversos aspectos clínicos y diagnósticos de una enfermedad recientemente descripta de alta prevalencia y que cruza las fronteras de múltiples especialistas (pediatras, neurólogos, neumólogos, otorrinolaringólogos, psiquiatras, psicólogos, odontoestomatólogos, ortodoncistas), así contribuiremos a su diagnóstico precoz a partir de los niños que roncan, evitando las importantes secuelas del SAOS infantil...

Indicaciones no tradicionales de amigdalectomía. Actualización / Non-traditional indications of tonsillectomy. Upgrade

Tonsillectomy is the most common surgical procedure in ENT surgery. Indications are well known in the field. Upper airway obstruction caused by tonsilar hyperplasia and recurrent bacterial infections are the most frecuent indications of tonsillectomy, however there are many other pathologies where tonsillectomy is considered part of the treatment. Non traditional indications, include IgA nephropathy, pediatric autoinmune neuropsychiatric disorders associated with Streptococcus, periodic fever with aphtous stomatitis, pharyngitis and adenitis, some dermatologic entities, among others. In this review we compile recent scientific evidence supporting the non tradicional indications of tonsillectomy, in order to allow an informed decision when prescribing this surgical procedure for the treatment of entities which are not of high prevalence in the daily practice. Evidence supports tonsillectomy as part of the treatment of some deseases, such as IgA nephropathy, however further evidence is required to support this treatment for the other pathologies. (AU)

Análisis crítico de un artículo: adenoamigdalectomía en niños con apnea del sueño / Adenotonsillectomy for childhood sleep apnea: CAT

Introducción: el síndrome de apnea/hipopnea del sueño infantil se asocia a numerosos resultados adversos a nivel cognitivo y conductual. El factor de riesgo más comúnmente identificado para presentar síndrome de apnea/hipopnea del sueño es la hipertrofia adenoamigdaliana, para el cual el tratamiento primario es la adenoamigdalectomía. Objetivo: evaluar la eficacia de la adenoamigdalectomía temprana versus la conducta expectante, en lo que respecta a factores cognitivos, conductuales, calidad de vida y sueño, en niños con síndrome de apnea/hipopnea del sueño. Pacientes y método: se analiza críticamente el artículo de Marcus (2013), estudio multicéntrico, enmascarado simple, aleatorizado, controlado, en siete centros de estudio del sueño. Resultados: en un seguimiento a siete meses, la proporción de remisión espontánea en el grupo control de parámetros polisomnográficos sugiere que 46 por ciento de los niños revierten espontáneamente las alteraciones, efecto que se observó en 79 por ciento de los niños en el grupo intervenido. Conclusión de los revisores: la cirugía adenoamigdaliana para el tratamiento de la apnea obstructiva del sueño en escolares no mejora significativamente la atención o la función ejecutiva, pero sí mejora algunos desenlaces de comportamiento, calidad de vida y variables polisomnográficas. Sin embargo, esta mejoría se aprecia en una alta proporción de niños que no recibieron el tratamiento, mejoría principalmente evidenciada en las variables polisomnográficas. Por lo tanto, no sería un requisito indispensable el realizar esta cirugía para revertir dicho cuadro clínico.

Introduction. Obstructive sleep apnea hypopnea syndrome (OSAHS) in children is associated with numerous adverse cognitive and behavioral consequences. The most common risk factor identified for OSAHS is tonsillar enlargement, and primary treatment is adenotonsillectomy. Aim. To compare the efficacy of early adenotonsillectomy versus watchful waiting, on cognitive, behavioral, quality of life and sleep outcomes in children with OSAHS. Patients and Methods. We critically appraised the Marcus (2013) article, a multicenter, single masked, randomized, controlled study in seven sleep centers. Results. After a seven month follow-up, the rate of spontaneous remission in polysomnographic parameters control group shows that 46 percent of children spontaneously revert untoward outcomes, compared to 79 percent of children in the intervention group. Reviewer’s conclusion. Adenotonsillar surgery for the treatment of obstructive sleep apnea in school-age children does not significantly improve attention or executive function, but it does improve some behavioral outcomes, quality of life, and polysomnographic variables. However, this improvement was also observed in a high proportion of children who received no treatment, mainly regarding polysomnographic variables. Thus surgery does not appear to be necessary to reduce symptoms.

Paracetamol e dipirona por via endovenosa aplicados à analgesia pós-operatória de pacientes pediátricos submetidos à amigdelectomia em hospital-dia: um estudo prospectivo, randomizado, duplo-cego, placebo controlado / Intravenous paracetamol and dipyrone for postoperative analgesia after day-case tonsillectomy in children: a prospective, randomized, double blind, placebo controlled study

O manejo da dor pós-amigdelectomia pode ser feito com uma série de medicamentos. OBJETIVO: O presente estudo duplo-cego placebo controlado pretendeu avaliar a eficácia de paracetamol e dipirona administrados por via endovenosa na analgesia de pacientes pediátricos pós-amigdelectomia. MÉTODO: Cento e vinte crianças com idades entre três e seis anos submetidas à amigdelectomia com ou sem adenoidectomia e/ou entubação foram randomizadas para receber infusões de paracetamol (15 mg/kg), dipirona (15 mg/kg) ou placebo (0,9% NaCl) durante a cirurgia. As avaliações foram executadas com 0,25, 0,50, 1, 2, 4, 6h de pós-operatório. Petidina 0,25 mg/kg foi utilizada como analgésico de resgate. Dose acumulada de petidina foi o desfecho primário. Medições de intensidade da dor, alívio da dor, nível de sedação, náusea e vômitos, hemorragia no pós-operatório e outros efeitos adversos foram anotados. RESULTADOS: Nenhuma diferença significativa foi encontrada na dose acumulada de petidina entre os grupos paracetamol e dipirona. A dose acumulada de petidina foi significativamente menor nos grupos paracetamol e dipirona em comparação ao grupo placebo. Nenhuma diferença significativa foi observada entre os escores de dor no pós-operatório dos grupos durante o estudo. CONCLUSÃO: Paracetamol endovenoso tem eficácia analgésica semelhante à da dipirona endovenosa; ambos ajudam a reduzir a necessidade de opioides na analgesia pós-operatória de pacientes pediátricos submetidos à amigdelectomia em hospital-dia.

Tonsillectomy is associated with severe postoperative pain for which, several drugs are employed for management. OBJECTIVE: In this double-blind, placebo-controlled study we aimed to evaluate the efficacy of intravenous paracetamol and dipyrone when used for post-tonsillectomy analgesia in children. METHOD: 120 children aged 3-6 yr, undergoing tonsillectomy with or without adenoidectomy and/or ventilation tube insertion were randomized to receive intraoperative infusions of paracetamol (15 mg/kg), dipyrone (15 mg/kg) or placebo (0.9% NaCl). Evaluation was carried out at 0.25, 0.50, 1, 2, 4, 6h postoperatively. Pethidine 0.25 mg/kg was utilized as rescue analgesic. Cumulative pethidine requirement was the primary outcome. Pain intensity measurement, pain relief, sedation level, nausea and vomiting, postoperative bleeding and any other adverse effects were noted. RESULTS: No significant difference was found in pethidine requirement between paracetamol and dipyrone groups. Cumulative pethidine requirement was significantly less in paracetamol and dipyrone groups vs. placebo. No significant difference was observed between groups in postoperative pain intensity scores throughout the study. CONCLUSION: Intravenous paracetamol is found to have a similar analgesic efficacy as intravenous dipyrone and they both help to reduce the opioid requirement for postoperative analgesia in pediatric day-case tonsillectomy.

Adenotonsillectomy in facial growing patients: spontaneous dental effects / Adenotonsilectomia em pacientes na fase de crescimento facial: efeitos dentários espontâneos

Children with hypertrophic tonsils and adenoids may have adverse effects on dental occlusion, which tend to worsen during the growth period. Diagnosis and early treatment is essential. AIM: Prospective clinical study to compare the cephalometric measurements before and after adenotonsillectomy in mouth breathing patients. MATERIAL AND METHOD: We had 38 patients of both genders, aged between 7 and 11 years in our sample, broken down into: oral group, 18 patients with obstructive hypertrophy of pharyngeal tonsil and/or palate grade 3 or 4; control group, 20 patients with normal breathing. Angular and linear dental measurements were compared between the groups in a 14 months interval. We used the "t" Student and Wilcoxon tests for unpaired samples, at 5 percent significance, for statistical purposes. RESULTS: The sagittal position and axial angle of the lower incisors increased significantly in the group with oral breathing, the sagittal position of the upper incisors increased significantly in the oral group, which still had a significant increase in overbite. CONCLUSION: Adenotonsillectomy was very effective in improving some dental measurements, with benefits to growing patients preventing malocclusions from becoming difficult to treat or permanent.

Crianças com tonsilas e adenoides hipertróficas podem apresentar efeitos desfavoráveis na oclusão dentária, que tendem a agravar no período de crescimento, tornando imprescindível seu diagnóstico e tratamento precoce. OBJETIVO: Este estudo clínico prospectivo comparou medidas cefalométricas dos incisivos antes e após a adenotonsilectomia, em respiradores orais. MATERIAL E MÉTODO: A amostra foi de 38 pacientes de ambos os gêneros, entre 7 e 11 anos, dividida em: grupo oral, com 18 pacientes com hipertrofia obstrutiva da tonsila faríngea e/ou palatinas grau 3 ou 4; grupo controle, com 20 pacientes com respiração nasal. Medidas dentárias angulares e lineares foram comparadas entre os grupos, antes e após adenotonsilectomia, em um intervalo de 14 meses. A análise estatística utilizou os testes t-Student e Wilcoxon para amostras não pareadas, ao nível de significância de 5 por cento. RESULTADOS: A inclinação axial e a posição sagital dos incisivos inferiores aumentaram significativamente no grupo com respiração oral; o posicionamento sagital dos incisivos superiores aumentou significativamente no grupo oral, que ainda obteve aumento significativo de sobremordida. CONCLUSÃO: A adenoamigdalectomia se mostrou bastante eficaz na melhora de algumas medidas dentárias, com benefícios aos pacientes em crescimento, prevenindo que más oclusões dentárias tenham difícil tratamento ou se tornem definitivas.

Posterior fossa decompression with tonsillectomy in 104 cases of basilar impression, Chiari malformation and/or syringomyelia / Descompressão da fossa posterior com tonsilectomia em 104 casos de impressão basilar, malformação de Chiari e/ou siringomielia

The prime objective in the surgical treatment of basilar impression (BI), 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. A small suboccipital craniectomy has been emphasized to avoid caudal migration of the hindbrain structures into the vertebral canal. Nevertheless, the results showed downward migration of the hindbrain related to that type of craniectomy. The authors present, otherwise, the results of 104 cases of BI, CM and/or SM, whose surgical treatment was characterized by a large craniectomy with the patient in the sitting position, tonsillectomy, large opening of the fourth ventricle and duraplasty with creation of a large artificial cisterna magna. A significant upward migration of the posterior fossa structures was detected by postoperative magnetic resonance imaging.

O principal objetivo no tratamento cirúrgico da impressão basilar, malformação de Chiari e/ou siringomielia fundamenta-se na restauração dinâmica do líquido cefalorraqueano ao nível da transição craniovertebral e criação de ampla cisterna magna. Uma craniectomia suboccipital de pequenas dimensões foi proposta para evitar a migração caudal de estruturas rombencefálicas no canal vertebral. Entretanto, os resultados evidenciaram migração caudal do rombencéfalo. Os autores apresentam, por outro lado, os resultados de 104 casos de malformação de Chiari e/ou siringomielia, nos quais o tratamento cirúrgico se baseou em ampla craniectomia com o paciente em posição sentada, tonsilectomia, abertura ampla do quarto ventrículo e enxerto dural com consequente criação de ampla cisterna magna. Uma significante migração cranial das estruturas da fossa posterior foi detectada pelo emprego pós-operatório da ressonância magnética.

Dolor en amigdalectomía: técnica fría versus electrobisturí monopolar: estudio prospectivo randomizado / Postoperative tonsillectomy pain: cold versus monopolar electrocautery technique: prospective randomized trial

Introducción: Existen diferentes técnicas para realizarla amigdalectomía. Dentro de las más frecuentes está la técnica fría (bisturí frío, tijera y asa), y la técnica con electrobistrurí monopolar. No hay consenso que alguna de estas técnicas sea claramente superior a la otra respecto al dolor posoperatorio. Objetivo: Evaluar si la técnica quirúrgica (técnica fría-electrobisturí monopolar) repercute sobre la percepción de dolor posoperatorio. Material y método: Ensayo clínico prospectivo, ciego y randomizado. Se incluyeron 17 pacientes (34 amígdalas), mayores de 5 años sin antecedentes de riesgo, con indicación de amigdalectomía. A cada paciente, previo consentimiento informado y randomización, se le extrajo una amígdala con técnica fría y la contralateral con técnica electrobisturí monopolar. La percepción del dolor se midió con escala visual análoga (EVA) durante los primeros siete días posquirúrgicos. Paciente y familiares fueron enmascarados respecto a la técnica usada a cada lado. Resultados: Se encontraron diferencias en la percepción del dolor entre los días 3 a 7 (p <0,05) y al evaluarse la evolución del dolor en función del tiempo, ésta fue mayor con la técnica de electrobisturí (sin diferencias significativas en los 2 primeros días). Conclusión: En los casos evaluados en este estudio, la amigdalectomía con técnica fría se asocia a menor dolor a contar del tercer día posquirúrgico.

Introduction: There are different techniques for carrying out tonsillectomy. Among the mostcommon ones are the "cold technique" (scalpel, scissors and handle), and the monopolar electrocautery technique. No consensus is available to define which technique is less painful. Aim: To assess the effect of the surgical technique ("cold" vs monopolar electrocautery) on post-operative pain perception. Material ana method: Prospective blind randomized clinical trial. 17 patients with tonsillectomy indication (34 tonsils) over 5 years old, without major surgical risk, and after randomization and obtaining an informed consent, received a tonsillectomy using cold technique and the contra lateral side was removed using monopolar electrocautery technique. Pain perception was measured with visual analogue scale (VAS) during the firstseven days after surgery. Patients and relatives were unaware ofthe technique used on each side. Results: There were differences in pain perception between day 3 and 7 (p <0.05). Assessing evolution across time, pain was higher with the electrocautery technique (no significant difference was found in the first 2 days). Conclusion: Based on our results tonsillectomy using cold technique appears to be associated with less post-operative pain, starting on the third post-surgery day.

Surgical treatment of snoring & obstructive sleep apnoea.

Obstructive sleep apnoea (OSA) syndrome is a potentially serious disorder affecting millions of people around the world. Many of these individuals are undiagnosed while those who are diagnosed, often exhibit poor compliance with nightly use of continuous positive airway pressure (CPAP), a very effective nonsurgical treatment. Various surgical procedures have been proposed to manage and, in some cases, treat OSA. In this article we review methods used to assess the sites of obstruction and a number of surgical procedures designed to address OSA. Effective surgical management of OSA depends upon developing a complete database and determining different levels of obstruction, which may include nasal, nasopharyngeal, oropharyngeal, and hypopharyngeal/retrolingual, or a combination of these sites. A systematic approach to clinical evaluation, treatment planning and surgical management is recommended and is likely to result in more predictable outcomes. Surgical treatment may involve various procedures that are performed in different stages depending on the patient’s sites of obstruction. The most commonly performed procedures include nasal reconstruction, uvulopalatopharyngoplasty (UPPP), advancement genioplasty, mandibular osteotomy with genioglossus advancement, and hyoid myotomy and suspension. In more severe cases, maxillomandibular advancement (MMA) with advancement genioplasty may be indicated. Even after appropriate surgical treatment, some patients may demonstrate continued obstruction with associated symptoms. Published indications for surgical treatment include an elevated respiratory disturbance index (RDI) with excessive daytime somnolence (EDS), oxygen desaturations below 90 per cent, medical co-morbidities including hypertension and arrhythmias, anatomic abnormalities of the upper airway and failure of medical treatment. The success of surgery in OSA is generally measured by achieving a (RDI) of less than 5, improvement of oxygen nadir to 90 per cent or more with no desaturations below 90 per cent and quality of life improvements with elimination or significant reduction of OSA symptoms. From a practical point of view, achieving these goals may be extremely difficult without patients’ cooperation, most notably in the realm of weight loss and maintenance of a healthy lifestyle.

Prevalence of post-tonsillectomy bleeding as day-case surgery with combination method; cold dissection tonsillectomy and bipolar diathermy hemostasis

Post-tonsillectomy hemorrhage remains an important factor in determining the safety of performing tonsillectomy as a day case procedure. The aim of this study was to determine the safety of day case tonsillectomy by using combination method, cold dissection tonsillectomy and bipolar diathermy hemostasis. A prospective randomized clinical study conducted on the patients who had undergone day case tonsillectomy [DCT]. There were two groups [DCT and control group] each group consisting of 150 cases. Tonsillectomy was performed by using combination method; cold dissection and hemostasis was achieved by ligation of vessels with bipolar electerocautery. We found 3 cases of post-tonsillectomy bleeding in DCT group and 4 cases in the control group. There was no statistically significant difference in the rate of post-operative hemorrhage between the two groups. The findings suggest the safety of the combination of cold dissection tonsillectomy and bipolar diathermy hemostasis as day case tonsillectomy