What lessons can be learned from the Austrian events?

INTRODUCTION: The death of 5 children in Austria below the age of 6 years due to posttonsillectomy haemorrhage in 2006 and 2007 led to an intensive discussion on the potential life-threatening risks of tonsil surgery. On this occasion, a consensus paper with clear recommendations for tonsil surgery was released by the Austrian Societies of Otorhinolaryngology, Head and Neck Surgery and Paediatrics followed by a nationwide multicentre study. METHODS: All consecutive tonsillectomies, tonsillotomies and adenoidectomies performed in public hospitals in Austria within 9 months were assessed. Data on all participating patients were collected via an online questionnaire requesting patient characteristics, surgery details and postoperative haemorrhage. A strict definition for postoperative bleeding episodes with 7 severity grades was applied. Every bleeding episode after extubation was counted as postoperative bleeding event. RESULTS: The study population - all younger than 18 years of age - consisted of 6,765 patients (tonsillectomy 2,080, 31%; tonsillotomy 1,292, 19%; adenoidectomy 3,393, 50%). Postoperative haemorrhage episodes were reported in 15% after tonsillectomy and in 2.3% after tonsillotomy, with the risk increasing parallel to age. Multiple bleeding episodes were recorded in one fourth of all tonsillectomy bleedings, but were rare after tonsillotomy. Surgical revision under general anaesthesia was necessary in 4.2% after tonsillectomy and in 0.9% after tonsillotomy. DISCUSSION: As the incidence of tonsillectomy in children younger than 6 years has declined following the recommendations of the consensus paper issued in 2007, tonsillotomy has become more frequent in this age group. Overnight hospital admission and observation is suggested for all patients experiencing postoperative haemorrhage, as the occurrence of one minor bleeding doubled the risk of a second severe bleeding.

Tissue penetration of bipolar electrosurgical currents: Joule overheating beyond the surface layer.

BACKGROUND: There is extensive evidence that electrosurgical current application increases hemorrhage when compared with "cold" dissection and hemostasis. The way that the "hot" technique is used may influence the outcome decisively. METHODS: Temperature-time functions were measured in distances of 3 to 12 mm underneath the surface at which bipolar electrosurgical current was applied. Measurements were made in human cadaver, excised pig tissues, and pig animal models. RESULTS: Bipolar current causes Joule heating in distances of several millimeters. A single maximum power pulse of 1 second increased the temperature in the muscle in 3 and 6 mm distance to 90° and 65°C, respectively; similar accumulated thermal effects were detected for a series of low- and medium-power pulses, too. CONCLUSION: Joule heating is primarily responsible for unintended thermal damages. Severe damages can easily occur even in several millimeters distance from the forceps tips. Utmost caution is also advised at low power setting when current is applied repetitively.

Preoperative coagulation screening prior to tonsillectomy in adults: current practice and recommendations.

The hypotheses of the study are: (1) a positive history of coagulopathy predicts a higher postoperative haemorrhage risk, (2) a positive laboratory screening for coagulopathy can forecast a higher haemorrhage risk and (3) the haemorrhage risk in patients with known bleeding disorder is elevated. In a multicentre study information on 3,041 tonsillectomies in adults over 9 months, from 1st October 2009 until 30th June 2010, was evaluated. The outcome variables were patient characteristics, postoperative haemorrhage, history of coagulopathy and laboratory screening for coagulopathy. A history of coagulopathy and laboratory screening for coagulopathy were performed in almost all patients (98.6 %, 2,998/3,041). The overall haemorrhage rate was 16 %, including all bleeding episodes after extubation, with 4.8 % returning to theatre. A positive history was reported in 2 % (55/3,041) and a positive laboratory screening in 3 % (94/3,041) of all patients. A positive history is significantly associated with a higher risk of postoperative haemorrhage (31 %, 17/55, p < 0.002) compared to patients with a negative history (16 %, 387/2,497). A positive laboratory for coagulopathy was not significantly associated with an increased haemorrhage risk (20 %, 19/94, p < 0.235) compared to patients with a negative laboratory (16 %, 390/2,249). The haemorrhage risk for adults with a bleeding disorder is twice as high (31 %, 17/55) as for adults without bleeding disorder (16 %, 476/2,973). In conclusion, an adult patient's history of coagulopathy should be taken prior to tonsillectomy as a positive history doubles the haemorrhage risk while a laboratory screening for coagulopathy has no significant power to predict an elevated haemorrhage risk. Bleeding disorders double the risk of postoperative haemorrhage.

Reflux symptom index and reflux finding score in otolaryngologic practice.

OBJECTIVES: To evaluate whether patients with abnormal Reflux Symptom Index (RSI) and Reflux Finding Score (RFS) benefit from proton pump inhibitor (PPI) therapy. STUDY DESIGN: Open, multicenter, prospective longitudinal cohort study. METHODS: Patients with suspected reflux-associated laryngologic symptoms were evaluated by 40 community practice otolaryngologists using RSI and RFS. Patients were treated with pantoprazole 40-80 mg/d for 8-12 weeks if RSI was greater than 9 and RFS greater than 7. Pre- and posttherapeutic RSI and RFS were compared using Wilcoxon signed rank test and additionally controlled with the symmetry test of Bowker. RESULTS: A total of 1044 patients were included over a period of 20 months. Median total score of RSI before therapy was 12 and decreased to 3 (P≪0.001). Median total score of RFS before therapy was 16 and decreased to 6 (P≪0.001). Assessment of the treatment effect by otolaryngologists and patients was judged as being excellent in at least 50%. In 2% of the patients, gastrointestinal side effects were documented. CONCLUSION: RSI and RSF are easy to administer in the routine care of patients suspected of having laryngopharyngeal reflux. Patients identified by positive results of these tests have a high likelihood of excellent improvement after 8-12 weeks of PPI treatment. By implementation of RFS and RSI in daily use, most patients may not need time-consuming and cost-intensive examinations in the first-line assessment of LPR. These examinations can be reserved for nonresponders, and uncontrolled prescription of PPIs can be restricted.

Significant post-tonsillectomy pain is associated with increased risk of hemorrhage.

OBJECTIVES: In this study, we set out to assess the association of postoperative pain types with the risk of hemorrhage after tonsillectomy. METHODS: The questionnaire-based study was conducted on 335 patients who had undergone tonsillectomy. Hemorrhage risk and postoperative pain were evaluated retrospectively with use of a visual analog scale for 5 time periods (day 1, days 2 to 3, days 4 to 7, days 7 to 14, and later). RESULTS: Five pain types were identified by a cluster analysis. The most frequent pain types, I (24.8%; 83 patients) and II (50.8%; 170 patients), show decreasing pain, with pain type II starting on a higher level than pain type I. Pain types III (10.7%; 36 patients) and IV (1.2%; 4 patients) start at a low level with increasing pain for the first few days. In type III, pain decreases after 1 week, whereas type IV consists of a high level of pain for more than 2 weeks. Pain type V (12.5%; 42 patients) involves a very high level of pain from the beginning, which decreases only gradually. Pain type I is associated with a low hemorrhage rate. Patients with increasing pain (types III and IV) and pain type V show a significantly higher hemorrhage risk. CONCLUSIONS: Patients who have severe or increasing pain in the first few days after tonsillectomy have a significantly higher risk of hemorrhage.

Intraoperative medialization of medial rectus muscle as a new endoscopic technique for approaching intraconal lesions.

BACKGROUND: Intraconal tumors of the orbit are rare entities and surgical treatment is challenging. Endoscopic transnasal approaches to the orbit offer a new perspective for surgery, although only few reports exist in literature. This study displays the Graz experience with endoscopic approaches to intraorbital tumors between 2006 and 2010 introducing a novel endoscopic technique for temporary medialization of the medial rectus muscle facilitating access to the orbital cone. METHODS: A retrospective analysis of patients' charts was performed. RESULTS: For approaches to intraconal lesions a special endoscopic temporary medialization technique of the medial rectus muscle through applying transseptal sutures was developed. Six patients (four male and two female patients) have been included in this study presenting with intraconal/intraorbital tumors. Three patients underwent endoscopic surgery for two hemangiomas and one Schwannoma, respectively, and three patients were successfully biopsied endoscopically revealing one malignant melanoma, one malignant lymphoma, and one optic glioma each. Both hemangiomas were completely resected without any deterioration of vision. The Schwannoma was partially resected with postoperative imaging showing no tumor progression within 3 months. No intraoperative complications occurred. Five cases were performed with computer assisted surgery using CT/MR fusion navigation. CONCLUSION: Although technically challenging, the endoscopic approach to the orbit, even for intraconal lesions with medialization of the medial rectus muscle, can be safe and promising for well-selected cases. Good postoperative results and sufficient material acquisition for proper histological examination can be obtained. Advantages are good visualization of the surgical field and avoidance of external scars. Limitations to endoscopic techniques are tumors in the lateral superior and lateral inferior quadrant of the orbit.

Hemorrhage following tonsil surgery: a multicenter prospective study.

OBJECTIVES/HYPOTHESIS: Postoperative hemorrhage as a serious complication after tonsillectomy (TE), tonsillotomy (TO), or adenoidectomy (AE) is covered in many studies, using rather inconsistent measurement methods. We introduce a new classification for the severity of postoperative hemorrhage and investigate risk factors for the frequency and severity of bleeding episodes. STUDY DESIGN: Prospective, multicenter cohort study. METHODS: Our study is based on a prospective census recording all TEs, TOs, and AEs from October 1, 2009, to June 30, 2010, in Austria. Information concerning surgery indication, grade of surgeon, operation technique, and postoperative hemorrhage, classified as any bleeding episode after extubation according to severity, were collected. RESULTS: A total of 9,405 patients were included. Hemorrhage rate for TE ± AE was 15.0%, for TO ± AE was 2.3%, and for AE was 0.8%. Rate of return to the operating room for TE ± AE was 4.6%, for TO ± AE was 0.9%, and for AE was 0.3%. Minor bleeding episodes increased the risk of a subsequent severe bleeding episode (P < .001). Elevated hemorrhage rates were observed for adults (P < .001), TE ± AE (P < .001), and cold steel dissection combined with bipolar diathermy (P = .05). Multivariate logistic regression model for the frequency of post-TE hemorrhage showed significant odds ratios for males, children aged <6 years, children aged 6-15 years, abscess TE, and cold steel combined with bipolar diathermy. In addition, we found a significantly higher risk of severe bleeding episodes for children aged 6-15 years (P = .007), males (P = .02), and all bipolar operation techniques (P = .005). CONCLUSIONS: The occurrence of a postoperative minor bleeding episode increases the risk of a subsequent severe bleeding episode.

Tonsilar haemorrhage and re-admission: a questionnaire based study.

The aim of our study was to investigate the accuracy of haemorrhage rate in the community (i.e., actual rate versus hospital recorded rate) for tonsil operations. Bleeding episodes were investigated for 695 consecutive patients undergoing tonsillectomy, adenotonsillectomy and tonsillotomy at the Department of ORL, H&NS, MU of Graz, Austria, between January 1 2007 and June 30 2008 by questionnaire. Main purposes of our study were the evaluation of the incidence of postoperative haemorrhage, need for revision surgery, medical care of patients experiencing postoperative bleeding and multiple bleeding episodes. Haemorrhage was defined as any bleeding, be it minimal or significant, after extubation. The study group comprised 407 patients who answered the questionnaire: 61.7% adults, 22.1% school children between 6 and 15 years and 16.2% children aged less than 6 years. Exactly 100 patients (24.6% of 407) showed some kind of postoperative bleeding, but only 79 of them (19.4% of 407) were recorded at hospital. A return to theatre due to haemorrhage was required in 4.7% of all 407 cases. Combining hospital records and data from the questionnaire allowed us to estimate an overall haemorrhage rate of 21.4% for all 695 patients. Every fifth patient experiencing postoperative haemorrhage did not return to the hospital he or she was operated in. We would have missed 21.0% of all bleeding episodes by assessing re-admitting patients suffering postoperative bleeding only. We conclude that haemorrhage rate is considerably higher than assumed by investigating hospital records only and strongly related to the definition of postoperative bleeding and to the study design.

Aggressive inverted papilloma with intracranial invasion and short malignization time.

Inverted papillomas (IP) are considered benign lesions with a prevalence up to 4% among all sinunasal tumors; however, invasive growth and varying tendency for malignization are reported in literature. We report the case of a 69-year-old woman suffering from a large, aggressively growing IP invading the orbit, skull base, and frontal lobe of the brain. Within only 3 months' time the papilloma showed transformation into an invasive carcinoma, leaving surgical therapy in vain due to explosive recurrence. Intracranial and intraorbital expansion by IP is possible despite histology not showing signs of malignancy initially. In "regular" IP close endoscopic follow-up is mandatory to not overlook recurrence harboring malignancy.

Released intranasal eosinophilic major basic protein as a diagnostic marker for polypoid chronic rhinosinusitis.

OBJECTIVE: To investigate the hypothesis that eosinophil major basic protein is released in high concentrations in the nasal mucus of patients with polypoid chronic rhinosinusitis. STUDY DESIGN: Single center, open, prospective trial. SETTING: Medical University of Graz, Austria. SUBJECTS AND METHODS: Patients with polypoid chronic rhinosinusitis (n = 23) were compared to three different control groups: patients with chronic rhinosinusitis-like symptoms but without general mucosal thickening, patients who underwent functional endoscopic sinus surgery for reasons other than chronic rhinosinusitis, and patients without sinus disease (total n = 21). Mucus was harvested from each patient using a standardized technique and analyzed for eosinophil major basic protein with an enzyme-linked immunosorbent assay. RESULTS: In the patient group with polypoid chronic rhinosinusitis, 20 of 23 (87%) were positive for eosinophil major basic protein. In contrast, only one control patient was positive, whereas the remainder had no detectable amount of eosinophil major basic protein in the mucus (P < 0.001 vs chronic rhinosinusitis). CONCLUSION: Toxic eosinophil major basic protein levels are elevated in polypoid chronic rhinosinusitis patients compared to control groups that have similar clinical presentations but upon closer examination turn out not to have chronic rhinosinusitis. In the future, the detection of eosinophil major basic protein in nasal mucus may become a sensitive and specific marker for chronic rhinosinusitis and a helpful diagnostic tool.

Pre and post functional endoscopic sinus surgery nasal cavity volume assessment by acoustic rhinometry.

UNLABELLED: Acoustic rhinometry is an objective method to determine nasal cavity geometry. The technique is based on sound wave reflexion analysis in the nasal cavity, and determines crossectional areas as a function of distance as well as volume. AIM: The purpose of this study is to analyse nasal cavity volume changes caused by functional endoscopic sinus surgery (FESS) in adults with chronic rhinosinusitis by acoustic rhinometry, and to correlate these changes with improvements in the sensation of nasal obstruction. MATERIAL AND METHOD: Forty patients aged from 18 to 73 years were prospectively evaluated between August and October 1999 at the Graz University Hospital, Austria. All patients were diagnosed with chronic rhinosinusitis, and undertook acoustic rhinometry before and after FESS. SCIENTIFIC DESIGN: A clinical prospective study. RESULTS: The nasal cavity total volume increased significantly after surgery. Nasal obstruction was improved in 88% of the patients, 20% with partial improvement and 68% with total improvement. There was no correlation between volume increase and improvement of the sensation of nasal obstruction. CONCLUSION: Total nasal cavity volume significantly increased after surgery; however, there was no correlation between volume increase and improvements of nasal obstruction. No significant pre or postoperative increase in total nasal cavity volume after decongestion were observed.

Avaliação do volume da cavidade nasal por rinometria acústica, pré e pós-cirurgia endoscópica funcional dos seios paranasais / Pre and post functional endoscopic sinus surgery nasal cavity volume assessment by acoustic rhinometry

A rinometria acústica é um método objetivo de determinar a geometria da cavidade nasal, pela análise da reflexão de ondas sonoras. Determina a área de secção transversal da cavidade em função da distância da narina e seu volume. OBJETIVO: Analisar a alteração do volume da cavidade nasal causada pela cirurgia endoscópica funcional dos seios paranasais, em adultos com rinossinusite crônica, e correlacionar esta alteração com a melhora da obstrução nasal. MATERIAL E MÉTODO: Foram avaliados 40 pacientes de 18 a 73 anos, entre agosto e outubro de 1999, na Universidade de Graz - Austria, com rinossinusite crônica, antes e depois de serem submetidos à CEFSP. FORMA DE ESTUDO: Clínico prospectivo. RESULTADOS: O volume total da cavidade nasal aumentou significativamente no pós-operatório. 88 por cento dos pacientes referiram melhora da obstrução nasal, 20 por cento de forma parcial e 68 por cento total. Nenhum paciente piorou deste sintoma. Não houve relação linear entre o aumento do volume da cavidade nasal e melhora subjetiva da obstrução nasal. CONCLUSÃO: O volume total da cavidade nasal aumentou no pós-operatório, mas não houve relação entre aumento do volume e melhora da obstrução nasal. Não houve aumento do volume da cavidade nasal após o uso do vasoconstritor, seja no pré ou no pós-operatório.

Acoustic rhinometry is an objective method to determine nasal cavity geometry. The technique is based on sound wave reflexion analysis in the nasal cavity, and determines crossectional areas as a function of distance as well as volume. AIM: The purpose of this study is to analyse nasal cavity volume changes caused by functional endoscopic sinus surgery (FESS) in adults with chronic rhinosinusitis by acoustic rhinometry, and to correlate these changes with improvements in the sensation of nasal obstruction. MATERIAL AND METHOD: Forty patients aged from 18 to 73 years were prospectively evaluated between August and October 1999 at the Graz University Hospital, Austria. All patients were diagnosed with chronic rhinosinusitis, and undertook acoustic rhinometry before and after FESS. SCIENTIFIC DESIGN: A clinical prospective study. RESULTS: The nasal cavity total volume increased significantly after surgery. Nasal obstruction was improved in 88 percent of the patients, 20 percent with partial improvement and 68 percent with total improvement. There was no correlation between volume increase and improvement of the sensation of nasal obstruction. CONCLUSION: Total nasal cavity volume significantly increased after surgery; however, there was no correlation between volume increase and improvements of nasal obstruction. No significant pre or postoperative increase in total nasal cavity volume after decongestion were observed.

Nasalance changes after functional endoscopic sinus surgery.

Forty adult patients diagnosed with chronic rhinosinusitis who underwent functional endoscopic sinus surgery (FESS), were analyzed with respect to postoperative resonatory voice changes. For evaluation the patients were asked about their subjective impression of voice changes using a questionnaire. An objective assessment was performed by determining the so-called nasalance using the Nasometer (Kay Elemetrics), preoperatively, on the immediate postoperative follow-up (2 days after surgery), and approximately 1 month after surgery. The mean nasalance values increased significantly one month after FESS whereas the immediate postoperative control (2 days after surgery) showed a decrease of nasalance. Although FESS is a minimally invasive procedure, it can change the acoustic characteristics of the vocal tract in the long term and produce a significant increase in nasality. The authors strongly recommend that clinicians inform all patients, in particular voice professionals, about the possible effects of endonasal sinus surgery on voice quality.

Short-term therapeutic trial of proton pump inhibitors in suspected extraesophageal reflux.

Pharyngoesophageal gastric acid reflux is thought to initiate chronic posterior laryngitis. The gold standard for measuring gastric reflux is dual-channel 24-hour pH monitoring. This is a time-consuming, inconvenient, expensive method that is not available in all areas. New therapeutic regimes that make use of proton pump inhibitors (PPIs) have proven to be therapeutically efficient for control of acid reflux. Twenty-four consecutive patients with chronic voice disorders and signs of posterior laryngitis were selected for therapy. Twenty-four hour pH monitoring was performed independently before the therapy. The trial therapy consisted of all patients receiving pantoprazole, 40 mg once daily for 6 weeks. Immediately following the therapy a statistically significant (p < 0.05) improvement was observed in all patients. This improvement was analyzed retrospectively by comparison with the results of 24-hour pH monitoring. In 71% of the patients the 24-hour pH-monitoring gave a positive result showing a high number of patients with extraesophageal reflux in our study group. Patients with positive results of pH-monitoring responded in a statistically significant manner (p < 0.05) to the pantoprazole therapy, whereas those patients without detected reflux did not. A 3-month follow-up of the patients with a positive result of the pH-monitoring confirmed the improvement. No patients reported adverse effects. A 6-week treatment with pantoprazole can be clinically justified. It helps to save time and reduce costs, allows for selection of reflux-negative patients for alternative therapy, and may prevent inadequate treatment of patients with false-negative pH monitoring. Twenty-four hour pH monitoring is still recommended for patients unresponsive to this trial therapy.

Alterations in gap junction protein expression in human benign prostatic hyperplasia and prostate cancer.

PURPOSE: Gap junctions composed of connexin proteins have an essential role in intercellular communication and differentiation. Dysregulation of connexin expression is believed to have a role in carcinogenesis. The human prostate has been reported to express connexin 32 and 43. However, the expression pattern in prostate cancer is controversial, while to our knowledge connexin expression has not been reported in benign prostatic hyperplasia (BPH). To understand the potential involvement in prostate disease connexin 32 and 43 expression was evaluated in a series of normal prostate, BPH and prostate cancer specimens that were surgically removed due to bladder outlet obstruction. MATERIALS AND METHODS: Frozen sections of 23 normal, 43 BPH and 40 cancer involved prostates were evaluated for the presence, staining intensity and pattern of connexin 32 and 43 by immunocytochemical testing. RESULTS: In all specimens examined connexin 43 stain was punctate along the borders of the basal epithelial cells, whereas connexin 32 immunolocalized to luminal epithelial cells. In normal prostate connexin 43 and 32 were present in 87% and 65% of specimens, respectively, at low to moderate stain intensity. Importantly none of the normal samples were negative foreach connexin. In BPH specimens there was a marked increase in the incidence and intensity of connexin 43 and 32 immunostaining within epithelial cells. In addition, 23% of BPH samples showed strong connexin 43 expression in stromal cells. In contrast, connexin was decreased in prostate cancer specimens, of which 65% and 38% were negative for connexin 43 and 32, respectively, and 28% were negative for each type. In poorly differentiated tumors connexin 43 and 32 were present in only 10% and 40% of tumors, respectively, at low immunostaining intensity. CONCLUSIONS: In normal human prostate basal cells communicate via connexin 43 gap junctions, whereas luminal cells communicate via connexin 32 gap junctions. In BPH gap junctional intercellular communication is increased in epithelial and stromal cells, which may have a role in BPH pathogenesis. In prostate cancer gap junctional intercellular communication is decreased, is as indicated by decreased expression of connexin 43 and 32 with severe loss in poorly differentiated prostate cancer. These alterations in connexin expression may have a role in dedifferentiation and tumor progression.