A randomised controlled trial of coblation, diode laser and cold dissection in paediatric tonsillectomy.

OBJECTIVE: This study aimed to compare the efficacy of diode laser, coblation and cold dissection tonsillectomy in paediatric patients. METHODS: A total of 120 patients aged 10-15 years with recurrent tonsillitis were recruited. Participants were prospectively randomised to diode laser, coblation or cold dissection tonsillectomy. Operative time and blood loss were recorded. Pain was recorded on a Wong-Baker FACES(®) pain scale. RESULTS: The operative time (10 ± 0.99 minutes), blood loss (20 ± 0.85 ml) and pain were significantly lower with coblation tonsillectomy than with cold dissection tonsillectomy (20 ± 1.0 minutes and 30 ± 1.0 ml; p = 0.0001) and diode laser tonsillectomy (15 ± 0.83 minutes and 25 ± 0.83 ml; p = 0.0001). Diode laser tonsillectomy had a shorter operative time (p = 0.0001) and less blood loss (p = 0.001) compared with cold dissection tonsillectomy. However, at post-operative day seven, the diode laser tonsillectomy group had significantly higher pain scores compared with the cold dissection (p = 0.042) and coblation (p = 0.04) tonsillectomy groups. CONCLUSION: Both coblation and diode laser tonsillectomy are associated with significantly reduced blood loss and shorter operative times compared with cold dissection tonsillectomy. However, we advocate coblation tonsillectomy because of the lower post-operative pain scores compared with diode laser and cold dissection tonsillectomy.

Pilot comparison between potassium titanyl phosphate laser and bipolar radiofrequency in paediatric tonsillectomy.

OBJECTIVES: To compare the advantages and disadvantages of potassium titanyl phosphate laser with those of bipolar radiofrequency techniques, in paediatric tonsillectomy. STUDY DESIGN: Prospective, randomised, clinical study. PATIENTS AND METHODS: From July 2004 to April 2006, 80 patients aged between 10 and 15 years, with tonsillectomy planned for chronic tonsillitis, were included in the study. Children were prospectively randomised into two equal groups: potassium titanyl phosphate laser tonsillectomy and bipolar radiofrequency tonsillectomy. Operative time and intra-operative blood loss were recorded. Patients were scheduled for follow up during the first, second and fourth post-operative weeks. They were asked to record their pain and discomfort on a standardised visual analogue scale, from zero (no pain) to 10 (severe pain). Post-operative complications were also recorded and managed. RESULTS: The potassium titanyl phosphate laser group showed a slightly longer operative time (mean 12 minutes) than the bipolar radiofrequency group (mean 10 minutes). Intra-operative blood loss was significantly less in the potassium titanyl phosphate laser group (mean 21 cm3) than in the bipolar radiofrequency group (mean 30 cm3). In the first week, post-operative pain scores were less in the potassium titanyl phosphate laser group than in the bipolar radiofrequency group (means 7.5 and 8.5, respectively). However, in the second week pain scores increased more in the potassium titanyl phosphate laser group than in the bipolar radiofrequency group (means 8.5 and 6, respectively). In the fourth week, both groups showed equal and nearly normal pain scores. No case of reactionary post-tonsillectomy haemorrhage was recorded in either group. Only one case of secondary post-tonsillectomy haemorrhage was recorded, in the potassium titanyl phosphate laser group (2.5 per cent), managed conservatively. CONCLUSION: Both the potassium titanyl phosphate and the bipolar radiofrequency techniques were safe and easy to use for tonsillectomy, with reduced operative time, blood loss and complication rates and better post-operative general patient condition. Potassium titanyl phosphate laser resulted in reduced operative bleeding and immediate post-operative pain, compared with the bipolar radiofrequency technique. However, potassium titanyl phosphate laser required slightly more operative time and caused more late post-operative pain than the bipolar radiofrequency technique. The low rate of recorded complications showed that both techniques cause little damage to the tonsillar bed during dissection, thus minimising complications.

Neurilemmomas of the paranasal sinuses.

Within the head and neck region, neurilemmomas are rarely found in the nasal cavity or paranasal sinuses. A 70-year-old man presented with complaints of left-sided epiphora, rhinorrhea, epistaxis, and transient diplopia. Nasal endoscopy showed a large necrotic mass filling the left middle meatus. A computed tomography scan showed a large left ethmoid mass, with erosion of the medial wall of the orbit and the anterior cranial base. Multiple biopsies were nondiagnostic. Complete excision of the tumor was performed with endoscopic techniques. Small dural defects were repaired with a middle turbinate mucosal flap. Postoperatively, the patient was treated with nasal packing and a lumbar spinal drain. Final pathology showed a benign neurilemmoma. There has been no evidence of recurrence or cerebrospinal fluid leakage in follow-up. A review of the literature shows a similar presentation of patients with neurilemmomas of the paranasal sinuses. Bony destruction and intracranial extension is viewed. Lack of encapsulation and locally destructive growth in an otherwise histologically typical neurilemmoma should not suggest malignant potential. Many benign tumors of the paranasal sinuses with bone destruction may be removed by using endoscopic techniques.

Transnasal endoscopic repair of cerebrospinal fluid rhinorrhea: a meta-analysis.

OBJECTIVES/HYPOTHESIS: Trauma and surgery are the most common causes of cerebrospinal fluid (CSF) rhinorrhea. Surgical repair is recommended for patients with CSF leaks that do not respond to conservative measures, traumatic CSF leaks that require transcranial surgery for associated brain injuries, and iatrogenic defects that are discovered intraoperatively. The purpose of our study was to ascertain the outcome after transnasal endoscopic repair of CSF leaks and to identify factors regarding the patient, CSF fistula, and treatment that may influence the results of the repair. METHODS: We performed a meta-analysis of all studies published in English between 1990 and 1999 that reported a minimum of five patients with CSF fistulae that were repaired using an endoscopic approach. We analyzed data that included type of graft and technique used during the repair, surgical complications, the use of packing, and the use of lumbar drains and antibiotics. The success rate was monitored and correlated with the other variables. The meta-analysis database was compared with and added to a database comprising our own patients. RESULTS: Fourteen studies comprising 289 CSF fistulae met the inclusion criteria. Endoscopic repair of CSF leaks was successful in 90% (259/289) of the cases after a first attempt. Seventeen of 30 persistent leaks (52%) were closed after a second attempt. Thus ultimately 97% (276/289) of the leaks were repaired using an endoscopic approach. The success rate of repairs using any of the reported techniques and materials was high and not statistically different. The incidence of major complications such a meningitis, subdural hematoma, and intracranial abscess was less than 1% for each complication. CONCLUSION: The endoscopic approach is highly effective and is associated with low morbidity. The literature supports the endoscopic approach using a variety of techniques and materials for the repair of CSF leaks.

Evaluation of toxicity of intravitreal ceftazidime, vancomycin, and ganciclovir in a silicone oil-filled eye.

PURPOSE: To evaluate the toxicity of intravitreal drugs in an eye filled with silicone oil for prolonged internal retinal tamponade. METHODS: Vitrectomy was performed in 21 rabbit eyes, and the vitreous was replaced with silicone oil. Different concentrations of various drugs (ceftazidime, vancomycin, and ganciclovir) were injected intravitreally. RESULTS: Silicone oil increased the toxicity of these drugs, which were injected in previously determined nontoxic doses, possibly because of a reduction of the preretinal space. Injecting one quarter of the known nontoxic dose failed to show any toxicity. CONCLUSIONS: Nontoxic concentrations of intravitreal drugs can cause toxicity in a silicone-filled eye.

Use of perfluorocarbon liquids, silicone oil, and 5-fluorouracil in the management of experimental PVR.

PURPOSE: To evaluate the toxicity and efficacy of 5-fluorouracil (5-FU) in combination with perfluoroperhydrophenanthrene (Vitreon), silicone oil, or a combination of silicone oil and Vitreon in a ratio of 3:2 in the management of experimental proliferative vitreoretinopathy (PVR). METHODS: Toxicity study. Seventy rabbit eyes underwent vitrectomy followed by intravitreal injection of 5-FU in doses of 800, 400, or 200 microg: Group 1, 5-FU alone; Group 2, 5-FU plus 1 mL Vitreon; Group 3, 5-FU plus 1 mL silicone oil; Group 4, 5-FU plus 0.6 mL silicone oil and 0.4 mL Vitreon; Group 5, 0.6 mL silicone oil plus 0.4 mL Vitreon. Electroretinography was performed preoperatively and 8 weeks postoperatively before the animals were sacrificed. Efficacy study. Seventy-two rabbit eyes underwent vitrectomy and were injected intravitreally with 100,000-200,000 retinal pigment epithelial cells to induce PVR. Groups were injected with 200 microg 5-FU alone or with 1 mL silicone oil, 1 mL Vitreon, or a combination of 0.6 mL silicone oil and 0.4 mL Vitreon. Others were given only 1 mL Vitreon or 1 mL silicone oil. The animals were followed for 8-12 weeks; PVR was graded using Fastenberg's system. RESULTS: Toxicity study. Eyes given 200 microg 5-FU, silicone, and Vitreon showed mild inflammation and vitritis which resolved in 1 week; the dose was nontoxic by electroretinography and histopathology. Doses of 400 and 800 microg 5-FU were toxic. Efficacy study. Clinical severity of PVR was less in the groups which received 5-FU plus vitreous substitutes when compared to the control groups at all time points. The lowest incidences were in groups given 5-FU plus Vitreon or 5-FU plus Vitreon and silicone oil: 33.33% and 11.11%, respectively. CONCLUSIONS: A dose of 200 microg 5-FU with silicone oil and Vitreon combined was nontoxic to the rabbit retina. The combination of 5-FU, Vitreon, and silicone oil showed significant efficacy in the prevention of experimental PVR.

Prophylaxis of experimental Pseudomonas aeruginosa endophthalmitis after vitrectomy using ceftazidime in the irrigating solution.

PURPOSE: To test the efficacy of ceftazidime in irrigating solution during vitrectomy to prevent experimental Pseudomonas aeruginosa endophthalmitis. METHODS: Thirty-two rabbit eyes were divided into 6 groups. Vitrectomy using one of two different irrigating solutions was followed by intravitreal injection of P. aeruginosa: Group 1, balanced salt solution (BSS) followed by 100 colony-forming units (CFU) P. aeruginosa; Group 2, BSS fortified with ceftazidime 175 microg/mL (CBSS) followed by intravitreal injection of 100 CFU P. aeruginosa; Group 3, BSS followed by 500 CFU P. aeruginosa; Group 4, CBSS followed by 500 CFU P. aeruginosa; Group 5, BSS followed by 5000 CFU P. aeruginosa; and Group 6, CBSS followed by 5000 CFU P. aeruginosa. The eyes were examined clinically. Vitreous samples were cultured and histology was performed. RESULTS: Group 1: Three of 5 eyes showed mild to moderate vitreous opacities. Group 2: No vitreous opacities developed. Group 3: All eyes demonstrated endophthalmitis. Group 4: All 6 eyes had clear vitreous with visible fundus. Group 5: Severe endophthalmitis occurred in all 6 eyes. Group 6: Four eyes had clearly visible fundus, 2 eyes had hazy vitreous with red reflex of the fundus. Bacterial growth in groups 3, 4, 5, and 6 was seen in 4/4, 1/6, 6/6, and 0/6 eyes, respectively. CONCLUSION: When 100-5000 CFU P. aeruginosa were injected after vitrectomy, ceftazidime in the irrigating solution inhibited the signs of intraocular inflammation, and the rate of positive bacterial culture.