Endoscopic Evaluation after Conventional Adenoid Curettage.

Introduction Adenoidectomy is one of the most common procedures performed by otolaryngologists. Traditional adenoid curettage is performed blindly, which can result in inadequate removal of the adenoid and injury to the surrounding structures. Objective To perform transnasal endoscopic examinations to assess the nasopharynx after conventional curettage adenoidectomy. Methods The present prospective study included 100 children with a mean age of 4.2 ± 3.07 years. It is composed of two steps: conventional curettage adenoidectomy by a resident trainee; and endoscopic evaluation of the nasopharynx through a 0° telescope to assess adenoidal remnants, injury to the surgical field or adjacent structures, and bleeding points. Results Adenoid remnants were observed in 42% of the cases after conventional adenoid curettage in multiple locations, such as the roof of the nasopharynx over the choana (24%), the tubal tonsil (12%), the posterior pharyngeal wall (4%), and the posterior end of the nasal septum (2%). Injury to the surgical field and adjacent structures was observed in 46% of the cases (posterior pharyngeal wall: 23%; lateral pharyngeal wall: 11%; Passavant ridge: 10%; and the Eustachian tube orifice: 2%). Endoscopic bleeding was observed in 29% of the cases; 13% of the cases were from adenoid remnants, 10%, from the mucosa, and 6%, from the pharyngeal muscles. Bleeding was mild in 19% of the cases, moderate in 9%, and severe in 1%. Conclusion Endoscopic evaluation of the nasopharynx following conventional adenoid curettage provides important data regarding adenoid remnants, injury to the surgical field or nearby structures, and bleeding points, which aids in the provision of optimal care and in the achievement of a better outcome.

Morphofunctional changes following adenotonsillectomy of obstructive sleep apnea children: a case series analysis.

OBJECTIVE: To perform a case series analysis of the changes in the pulmonary artery systolic pressure (PASP), nasal inspiratory flow (NIF), upper airway volume, obstructive apnea/hypopnea index (OAHI), and the maxillomandibular three-dimensional (3D) morphology after adenotonsillectomy (T&A) of obstructive sleep apnea children (OSA). MATERIALS AND METHODS: Retrospective assessment of files from 1002 children screened between 2012 and 2020 in a hospital-based mouth-breather referral center. From this universe, 15 obstructive sleep apnea children (7 females; 8 males), ages 4.1 to 8.9 years old (mean age of 5.4 years ± 1.3), who presented indications of tonsillectomy and/or adenoidectomy were selected. The complete baseline examination (T0) was carried out before T&A and a second complete examination (T1) was made 18.7-month follow-up after T&A (ranging from 12 to 30 months). Eleven patients were submitted to T&A, and four patients had indications but did not receive authorization for surgery from the public health system. According to the protocol of the outpatient clinic for OSA patients, Doppler echocardiography, polysomnography, rhinomanometry, and computed tomography imaging was performed at (T0) and (T1). RESULTS: PASP decreased 16.6% after T&A. NIF increased more in T&A children (40.3%) than in non-T&A children (16.8%). The upper airway volume increased in T&A and non-T&A children, but greater volumetric gain (45.6%) was found in the nasopharynx of T&A patients. OAHI did not change in six T&A children (55%) and three non-T&A children (75%). The maxilla displaced downward and backward relative to the cranial base in six T&A children (55%) and two untreated children (50%). Nine of the T&A children (85%) and three untreated children (75%) presented extensive condylar growth and increased mandibular length. The qualitative 3D assessment showed similar morphological 3D changes in T&A and non-T&A patients. CONCLUSION: Pulmonary artery systolic pressure decreased, nasal inspiratory flow increased, and nasopharynx volume increased following adenotonsillectomy, but obstructive apnea/hypopnea index and maxillomandibular morphology were similar in surgical and non-surgical patients.

Repercussão da adenotonsilectomia sobre o estado nutricional em crianças respiradoras orais / Repercussion of adenotonsillectomy on the nutritional status of mouth breathing children

Introdução: a hiperplasia adenotonsilar (HAT) é uma das causas mais comuns da Síndrome do Respirador Oral (SRO) devido à obstrução de via aérea superior em crianças e adolescentes. Tal afecção pode causar alterações ortodônticas, miofuncionais orofaciais, posturais, cardiopulmonares, antropométricas e polissonográficas. O diagnóstico precoce e indicação de Adenotonsilectomia (A&T) é essencial para reversão dessas consequências deletérias da SRO e restauração do bem estar biopsicossocial da criança.Objetivo: avaliar o estado nutricional, patência nasal, distúrbios do sono e fator de crescimento semelhante à insulina tipo 1 (IGF-1) em crianças de dois a doze anos de idade com SRO devido HAT grave e comparar com a reavaliação após seis meses de pós-cirúrgico das crianças operadas e com as demais que permanecem com obstrução da via aérea e aguardam a cirurgia na fila de espera do Sistema Único de Saúde. Métodos: trinta pacientes com SRO por HAT grave e indicação de A&T foram submetidos à avaliação antropométrica, polissonográfica, dosagem do IGF-1, rinomanométrica, teste alérgico cutâneo, questionário de padrão alimentar e prática de atividade física antes da A&T. Dez pacientes repetiram essa avaliação seis meses após o procedimento cirúrgico (grupo intervenção). Vinte pacientes aguardam a cirurgia na fila de espera do SUS e tiveram seus dados antropométricos e de IGF-1 reavaliados após seis meses com obstrução da via aérea (grupo controle). Resultados: trinta crianças realizaram a fase pré-operatória do estudo. A idade média foi de 5,6 anos (±2,17). Dezessete (56,7%) eram do sexo masculino e treze (43,3%) do sexo feminino. O teste cutâneo foi positivo em dezesseis indivíduos (53,3%) As médias dos escores Z de estatura por idade foi de -0,95 (±1,09); peso por idade de 0,17 (±1,42); índice de massa corporal (IMC) por idade de 0,31 (±1,36). A média do fluxo nasal inspiratório total (FNIT) foi de 444,63 ml/s (±161,02) e da patência nasal de 72,9% (±24,76). A média do índice de Apneia e Hipopneia (IAH) do sono foi de 4,95 ev/h (±4,07); da saturação mínima de oxihemoglobina no sono (Nadir de O2) de 78,93% (±6,00); da percentagem de sono com saturação menor que 90% (T90) de 4,16% (±5,48); da porcentagem do sono com ondas lentas (sono N3) de 37,62% (±9,61). A média do escore Z de IGF-1 foi de 0,72 (±1,30). O grupo intervenção e grupo controle não apresentaram alterações dos dados antropométricos com significância estatística. Houve diminuição do IGF-1 após a cirurgia sendo a média do escore Z de IGF-1 pré-operatório de 1,33 (±1,74) e pós-cirúrgico de -0,07 (±0,85); p=0,03. No grupo controle a variação do IGF-1 não foi significativa. O grupo intervenção não apresentou alteração com significância estatística do FNIT e da patência nasal. Nas dez crianças operadas foi constatada uma melhora da média do IAH de 5,25 ev/h (±4,29) para 1,99 ev/h (±1,16) e do T90 de 6,27% (±7,46) para 0,64% (±0,55) com p<0,05. Já o sono N3 e o Nadir de O2 não apresentaram alterações significativas. Não houve mudança qualitativa no padrão alimentar e na prática de atividade física nos dois períodos avaliados na vigência da pandemia de COVID19. Conclusão: Após A&T houve diminuição do IGF-1; p=0,03, melhora do IAH; p=0,03 e do T90; p=0,04. A cirurgia não modificou o estado nutricional com significância estatística nas dez crianças após 6 meses de pós-operatório. No pós-cirúrgico, não houve diferença estatística do FNIT e da patência nasal, assim como nessa amostra também não ocorreram alterações significativas do sono N3 e do Nadir de O2. O padrão alimentar e a prática de atividade física foram semelhantes qualitativamente no pré e no pós-operatório. Vinte crianças no grupo controle não tiveram alterações significativas dos dados antropométricos e do IGF-1 com seis meses de espera pela cirurgia e permanência da obstrução da via aérea. Não houve diferença estatística dos dados antropométricos e do IGF-1 entre o grupo controle e o grupo intervenção.

Introduction: adenotonsillar hyperplasia (ATH) is one of the most common causes of Mouth Breathing Syndrome (MBS) due to upper airway obstruction in children and adolescents. This condition can cause orthodontic, orofacial myofunctional, postural, cardiopulmonary, anthropometric and polysomnographic changes. Early diagnosis and indication of Adenotonsillectomy (T&A) is essential to revert these deleterious consequences of MBS and restore the child's biopsychosocial well-being. Objective: to evaluate the nutritional status, nasal patency, sleep disorders and insulin-like growth factor 1 (IGF-1) in children aged two to twelve years old with MBS due to severe ATH and compare with reassessment after six months post-surgical care of operated children and others who remain with airway obstruction and are waiting for surgery on the Unified Health System (UHS) waiting list. Methods: Thirty patients with MBS due to severe ATH and indication for T&A were submitted to anthropometric, polysomnographic, IGF-1 dosage, rhinomanometric, allergic skin test, dietary pattern questionnaire and physical activity practice before T&A. Ten patients repeated this evaluation six months after the surgical procedure (intervention group). Twenty patients were waiting for surgery on the UHS waiting list and had their anthropometric and IGF-1 data reassessed after six months with airway obstruction (control group). Results: Thirty children underwent the preoperative phase of the study. The mean age was 5.6 years (±2.17). Seventeen (56.7%) were male and thirteen (43.3%) were female. The skin test was positive in sixteen individuals (53.3%) The average Z-scores for height for age were -0.95 (±1.09); weight for age 0.17 (±1.42); body mass index (BMI) for age of 0.31 (±1.36). The mean total inspiratory nasal flow (TINF) was 444.63 ml/s (±161.02) and nasal patency was 72.9% (±24.76). The average sleep apnea and hypopnea index (AHI) was 4.95 ev/h (±4.07); minimum oxyhemoglobin saturation during sleep (O2 Nadir) of 78.93% (±6.00); percentage of sleep with saturation lower than 90% (T90) of 4.16% (±5.48); percentage of sleep with slow waves (N3) of 37.62% (±9.61). The mean IGF-1 Z-score was 0.72 (±1.30). The intervention group and control group did not show statistically significant changes in anthropometric data. There was a decrease in IGF-1 after surgery, with a mean preoperative IGF-1 Z-score of 1.33 (±1.74) and postoperative value of -0.07 (±0.85); p=0.03. In the control group, the IGF-1 variation was not significant. The intervention group did not show statistically significant changes in TINF and nasal patency. In the ten operated children, an improvement in the mean AHI from 5.25 ev/h (±4.29) to 1.99 ev/h (±1.16) and T90 of 6.27% (±7. 46) to 0.64% (±0.55) with p<0.05. On the other hand, N3 sleep and O2 Nadir showed no significant changes. There was no qualitative change in dietary patterns and physical activity in the two periods evaluated during the COVID19 pandemic. Conclusion: After T&A there was a decrease in IGF-1; p=0.03, AHI improvement; p=0.03 and T90 too; p=0.04. The surgery did not change the nutritional status with statistical significance in the ten children after 6 months postoperatively. Post-surgery, there was no statistical difference in TINF and nasal patency, as well as in this sample there were no significant changes in N3 sleep and O2 Nadir either. The dietary pattern and the practice of physical activity were qualitatively similar before and after the operation. Twenty children in the control group did not have significant alterations in anthropometric data and IGF-1 after six months of waiting for the surgery and the remaining airway obstruction. There was no statistical difference in anthropometric and IGF-1 data between the control and intervention groups.

The Associations of Tonsillectomy with Adenoidectomy with Pneumonia and Appendicitis Based on National Sample Cohort Data from the Korean National Health Insurance Service.

Introduction The association between tonsillectomy with adenoidectomy (T&A) with appendicitis is controversial, and the association of T&A with pneumonia has not been investigated. Objective To investigate the associations of T&A with pneumonia and appendicitis using data from the Korean National Health Insurance Service National Sample Cohort. Methods We selected patients between the ages of 3 and 10 years who had undergone T&A in 2005 and were monitored since the performance of the T&A until 2013. The control group was established to have similar propensities for demographic characteristics compared to the T&A group. For eight years after the T&A, the number of patients with a diagnosis of pneumonia, patients who were admitted due to pneumonia, and those who underwent appendectomy were analyzed. The risk factors for pneumonia and appendectomy were analyzed. Results The number of pneumonia diagnoses was significantly higher in the T&A group than in the control group ( p = 0.023), but there were no significant differences in the number of admissions due to pneumonia between the 2 groups ( p = 0.155). Younger age and T&A were significant risk factors for the development of pneumonia. There were no significant differences in the number of appendectomies between the T&A and the control groups ( p = 0.425), neither were there significant risk factors for appendectomy. Conclusion Tonsillectomy with adenoidectomy was associated with an increase in pneumonia diagnoses, but it was not associated with the number of appendectomies. The associations of T&A with pneumonia and appendicitis were analyzed in this population-based study.

Effectiveness and Adverse Effects of Tranexamic Acid in Bleeding during Adenotonsillectomy: A Randomized, Controlled, Double-blind Clinical Trial.

Introduction Intra and postoperative bleeding are the most frequent and feared complications in adenotonsillectomy (AT). Tranexamic acid (TXA), which is known for its antifibrinolytic effects, has a proven benefit in reducing bleeding in hemorrhagic trauma and cardiac surgery; however, the effectiveness and timing of its application in AT have not yet been established. Objectives We aimed to evaluate the efficacy of TXA in controlling bleeding during and after AT and assess its possible adverse effects in children. Methods The present randomized, controlled, double-blind clinical trial included 63 children aged 2 to 12 years. They were randomly assigned to receive either intravenous TXA (10 mg/kg) or placebo 10 minutes before surgery. The volume of intraoperative bleeding, presence of postoperative bleeding, and adverse effects during and 8 hours after the surgery were assessed. Results No difference in bleeding volume was noted between the 2 groups (mean, 122.7 ml in the TXA group versus 115.5 ml in the placebo group, p = 0.36). No intraoperative or postoperative adverse effects were noted because of TXA use. Furthermore, no primary or secondary postoperative bleeding was observed in any of the participants. Conclusion In our pediatric sample, TXA (10 mg/kg) administration before AT was safely used, without any adverse effects. It did not reduce the bleeding volume in children during this type of surgery. Future studies should assess the use of higher doses of TXA and its administration at other time points before or during surgery.

Pediatric emergence delirium is linked to increased early postoperative negative behavior within two weeks after adenoidectomy: an observational study.

BACKGROUND: The aim of this prospective multicenter observational study was to measure the incidence of postoperative pediatric emergence delirium and to investigate the occurrence of early postoperative negative behavior within two weeks after outpatient adenoidectomy in preschool children. METHODS: The study comprised 222 patients (1-7 years of age). All children received a multimodal anesthesia based on total intravenous anesthesia with propofol and remifentanil in combination with piritramid (0.1 mg.kg-1), ibuprofen (10 mg.kg-1), dexamethason (0.15 mg.kg-1), and ketanest S (0.1 mg.kg-1). We evaluated emergence delirium using the Pediatric Anesthesia Emergence Delirium Scale (PAED) at different predefined time points during the recovery period. Emergence delirium was defined as a PAED score ≥ 9 for the first three criteria. Additionally, we defined early postoperative negative behavior to be present when at least 5 of 27 criteria of the post hospitalization behavior questionnaire were positive. RESULTS: The incidence of emergence delirium following our anesthetic regime was 23%. The incidence of early postoperative negative behavior was significantly higher among patients with emergence delirium (24% vs. 11%, p = 0.04). The two categories, "sleep disturbance" and "separation anxiety", tested within the questionnaire for early postoperative negative behavior, were identified as the most common postoperative negative behavioral changes. CONCLUSION: Emergence delirium not only plays a role immediately after surgery but is also linked to early postoperative negative behavior within two weeks after outpatient adenoidectomy. Parents should be informed that early postoperative negative behavior may occur in 1 out of 4 patients if emergence delirium was present postoperatively. TRIAL REGISTRATION: DRKS - German Clinical Trial Register ID: DRKS00013121.

Long-term Impact of Adenotonsillectomy on the Quality of Life of Children with Sleep-disordered breathing.

Introduction Adenotonsillectomy is the first-line treatment for obstructive sleep apnea secondary to adenotonsillar hypertrophy in children. The physical benefits of this surgery are well known as well as its impact on the quality of life (QoL), mainly according to short-term evaluations. However, the long-term effects of this surgery are still unclear. Objective To evaluate the long-term impact of adenotonsillectomy on the QoL of children with sleep-disordered breathing (SDB). Method This was a prospective non-controlled study. Children between 3 and 13 years of age with symptoms of SDB for whom adenotonsillectomy had been indicated were included. Children with comorbities were excluded. Quality of life was evaluated using the obstructive sleep apnea questionnaire (OSA-18), which was completed prior to, 10 days, 6 months, 12 months and, at least, 18 months after the procedure. For statistical analysis, p -values lower than 0.05 were defined as statistically significant. Results A total of 31 patients were enrolled in the study. The average age was 5.2 years, and 16 patients were male. The OSA-18 scores improved after the procedure in all domains, and this result was maintained until the last evaluation, done 22 ± 3 months after the procedure. Improvement in each domain was not superior to achieved in other domains. No correlation was found between tonsil or adenoid size and OSA-18 scores. Conclusion This is the largest prospective study that evaluated the long-term effects of the surgery on the QoL of children with SDB using the OSA-18. Our results show adenotonsillectomy has a positive impact in children's QoL.

Long-term Impact of Adenotonsillectomy on the Quality of Life of Children with Sleep-disordered breathing

Abstract Introduction Adenotonsillectomy is the first-line treatment for obstructive sleep apnea secondary to adenotonsillar hypertrophy in children. The physical benefits of this surgery are well known as well as its impact on the quality of life (QoL), mainly according to short-term evaluations. However, the long-term effects of this surgery are still unclear. Objective To evaluate the long-term impact of adenotonsillectomy on the QoL of children with sleep-disordered breathing (SDB). Method This was a prospective non-controlled study. Children between 3 and 13 years of age with symptoms of SDB for whom adenotonsillectomy had been indicated were included. Children with comorbities were excluded. Quality of life was evaluated using the obstructive sleep apnea questionnaire (OSA-18), which was completed prior to, 10 days, 6 months, 12 months and, at least, 18 months after the procedure. For statistical analysis, p-values lower than 0.05 were defined as statistically significant. Results A total of 31 patients were enrolled in the study. The average age was 5.2 years, and 16 patients were male. The OSA-18 scores improved after the procedure in all domains, and this result was maintained until the last evaluation, done 22 ± 3 months after the procedure. Improvement in each domain was not superior to achieved in other domains. No correlation was found between tonsil or adenoid size and OSA-18 scores. Conclusion This is the largest prospective study that evaluated the long-term effects of the surgery on the QoL of children with SDB using the OSA-18. Our results show adenotonsillectomy has a positive impact in children's QoL.

The microbiome of pediatric patients with chronic rhinosinusitis.

BACKGROUND: This study aimed to compare the microbiota of pediatric patients with chronic rhinosinusitis (CRS) who are undergoing adenoidectomy to treat their disease with that of healthy control patients. METHODS: Patients undergoing adenoidectomy-only for obstructive sleep apnea (n = 50) and CRS (n = 37) were recruited. Preoperative 22-item Sino-Nasal Outcome Test (SNOT-22) or Sinus and Nasal Quality of Life Survey (SN-5) were collected. Each patient had samples collected from their nasopharynx (adenoid bed) and nasal cavity (sinus) at the onset of surgery. 16S ribosomal ribonucleic acid (rRNA) gene sequencing was subsequently performed to obtain per sample taxonomic abundances. Statistical analyses included permutational multivariate analysis of variance (PERMANOVA), alpha (within sample) diversity measures, and changes in taxonomic abundance. RESULTS: Moraxella was the most abundant organism. Nasopharyngeal swabs demonstrated higher alpha diversity compared to the nasal cavity. The diversity was not different based on CRS vs obstructive history. There was an increase in diversity with increasing age, and eczema contributed to a greater difference in diversity between the nasopharynx and nasal cavity. Diversity was not affected by adenoid size; however, use of nasal steroids, inhaled steroids, and antihistamines influenced diversity in both the nasopharynx and nasal cavity. Nasopharyngeal samples were higher in relative abundance for Fusobacterium, Prevotella, Porphyromonas, and Campylobacter compared to the nasal cavity. CONCLUSION: The nasopharynx and nasal cavity differed in both microbiota composition and diversity. In contrast, no significant difference in composition or diversity were found in CRS vs control patients. Ecological changes in the nasopharyngeal and sinus site may contribute to the etiology for adenoid hypertrophy in both healthy controls and CRS patients.

Crescimento pôndero-estatural de crianças e adolescentes submetidos à adenoamigdalectomia / Weight and height growth of children and adolescents after adenoton sillectomy

Objetivo: documentar de forma sistemática o padrão de desenvolvimento pôndero-estatural de pacientes submetidos à adenoamigdalectomia. Métodos: coleta de dados secundários dos prontuários de pacientes atendidos no ambulatório de Otorrinolaringologia Pediátrica, antes e depois da cirurgia de adenoamigdalectomia. Resultados: de forma individual, os pacientes apresentaram elevação no escore Z e percentis das variáveis ao peso e a altura no período entre as análises. Especificamente em relação ao peso, a média antes do procedimento e quatro meses depois do procedimento foi, respectivamente, de 29,1 kg e 32,8 kg; no que diz respeito à altura, a média foi de 1,22 m e 1,25 m, respectivamente. Ao aplicar o Teste T de Student foi possível notar significância estatística para ambas as variáveis em estudo. Aspecto não percebido ao avaliar os indivíduos reunidos em grupos etários (pré-escolares, escolares e adolescentes). Conclusões: as crianças submetidas à adenoamigdalectomia apresentaram ganho pôndero-estatural após a cirurgia. A atuação cirúrgica diante do diagnóstico da hipertrofia e da hiperplasia das amígdalas e tonsila faríngea deve ser precoce, desde que haja indicação formal, a fim de evitar a manutenção do atraso no crescimento nesses pacientes.

Aims: to systematically document weight and height development in children after adenotonsillectomy. Methods: analysis of secondary data from the Pediatric Otorhinolaryngology clinic patient's medical records before and after adenotonsillectomy. Results: regarding weight, the average before the procedure and four months and the average after the procedure were, respectively, 29.1 kg and 32.8 kg; as regards height, the averages were 1.22 m and 1.25 m, respectively. By applying the Teste T de Student it was possible to notice statistical significance for both variables under study. Conclusions: children exhibited statistically significant weight and height gain after surgery. Surgical treatment should be performed early after the diagnosis of pharyngeal tonsil and tonsils hypertrophy and hyperplasia provided in case of a formal indication in order to avoid the maintenance growth retardation in these patients.

Cost and Value of Routine Histopathologic Analysis after Adenoidectomy and Tonsillectomy

Abstract Introduction Tonsillectomy and adenoidectomy are common procedures. Most surgeries in children and young adults are recommended due to recurring infections or obstructive constraints. However, occult malignant findings are reported in the literature. The clinical guidelines still refrain from recommending routine histopathologic analyses when discussing these procedures. Objective The present study aims to define the value of a routine histopathologic analysis after tonsillectomy, adenoidectomy and tonsillotomy. Methods We conducted a prospective survey including all German ear, nose and throat (ENT) departments, asking physicians about their current clinical practice and opinion. Furthermore, we reviewed all patients attending our department for tonsillectomy/adenoidectomy/tonsillotomy or a combination of these procedures between 2011 and 2016. In addition to this, a cost analysis was conducted to assess the financial burden of a routine histopathologic analysis. Results Most German ENT departments perform a routine histopathologic analysis after tonsillectomy/adenoidectomy/tonsillotomy. Despite this, only a minority deemed this approach necessary. Our retrospective review of the histopathologic analysis after tonsillectomy/adenoidectomy/tonsillotomy in our department rendered a cohort size of 2,157 patients. Within this group, there were no occult malignant findings. We found a yearly burden of 2,509,401€ for routine histopathologic analyses in patients under the age of 15 years in Germany in 2016. Conclusion We found a divergence between the physicians opinions and their current clinical practice concerning the question of whether to conduct routine histopathologic analyses. Even though there was no occult malignant finding in our cohort, unsuspected malignant findings are reported in the literature. Therefore, we call for a discussion on clinical practice guidelines.

Cost and Value of Routine Histopathologic Analysis after Adenoidectomy and Tonsillectomy.

Introduction Tonsillectomy and adenoidectomy are common procedures. Most surgeries in children and young adults are recommended due to recurring infections or obstructive constraints. However, occult malignant findings are reported in the literature. The clinical guidelines still refrain from recommending routine histopathologic analyses when discussing these procedures. Objective The present study aims to define the value of a routine histopathologic analysis after tonsillectomy, adenoidectomy and tonsillotomy. Methods We conducted a prospective survey including all German ear, nose and throat (ENT) departments, asking physicians about their current clinical practice and opinion. Furthermore, we reviewed all patients attending our department for tonsillectomy/adenoidectomy/tonsillotomy or a combination of these procedures between 2011 and 2016. In addition to this, a cost analysis was conducted to assess the financial burden of a routine histopathologic analysis. Results Most German ENT departments perform a routine histopathologic analysis after tonsillectomy/adenoidectomy/tonsillotomy. Despite this, only a minority deemed this approach necessary. Our retrospective review of the histopathologic analysis after tonsillectomy/adenoidectomy/tonsillotomy in our department rendered a cohort size of 2,157 patients. Within this group, there were no occult malignant findings. We found a yearly burden of 2,509,401€ for routine histopathologic analyses in patients under the age of 15 years in Germany in 2016. Conclusion We found a divergence between the physicians opinions and their current clinical practice concerning the question of whether to conduct routine histopathologic analyses. Even though there was no occult malignant finding in our cohort, unsuspected malignant findings are reported in the literature. Therefore, we call for a discussion on clinical practice guidelines.

Analgesia for adenotonsillectomy in children: a comparison between peritonsillar infiltration of tramadol, ketamine, and placebo.

INTRODUCTION: Post-tonsillectomy pain is mediated by nociceptive C-fibers located at peritonsillar space. Peritonsillar infiltration of medication could relieve post-operative pain blocking the afferent via. PURPOSE: To evaluate the effect of peritonsillar infiltration of tramadol, ketamine, and placebo on post-operative pain in cases of adenotonsillectomy. METHODS: This is a double-blind randomized placebo-controlled study. Children ASA I-II aged 3-13 years scheduled for adenotonsillectomy were included in the study. Patients were randomized to receive either 2 mg/kg of peritonsillar tramadol (Group T), 0.5 mg/kg of peritonsillar ketamine hydrochloride (Group K), and 3 mL of peritonsillar saline (Group P). Post-operative pain was recorded using the modified visual analogue scale at 2 h, 6 h, 12 h, and 24 h. Side effects, analgesia requirement, and first oral intake were also recorded. RESULTS: There were included 112 patients and five were excluded until final evaluation. We evaluated 36 children of Group T, 36 of Group K, and 35 of Group P. Groups were similar regarding to age, weight, height, gender, tonsil and adenoid size, hemodynamic parameters during the surgery, surgery, and anesthesia time. There were no differences between the groups in relation to pain scores, analgesia requirement, or first time of oral intake (p > 0.05). Group T presented a higher incidence of vomit between 2 and 6 h after surgery (p > 0.05). CONCLUSION: This study showed that peritonsillar infiltration of tramadol or ketamine were not superior to placebo in reducing post-operative pain in children undergone adenotonsillectomy. The use of tramadol increased the risk of nausea and vomit between 2 and 6 h after surgery.

Comparison between curettage adenoidectomy and endoscopic-assisted microdebrider adenoidectomy in terms of Eustachian tube dysfunction / Comparação entre adenoidectomia por curetagem e adenoidectomia por microdebridador assistida por endoscopia, em relação à disfunção tubária

Abstract Introduction Adenoidectomy can be performed with many ways, including curettage and microdebrider endoscopic-assisted adenoidectomy. Those two techniques have advantages and disadvantages. Objective The objective of this study is to research the effects of curettage adenoidectomy and endoscopic-assisted microdebrider adenoidectomy on the tympanum pressures in pediatric patients with adenoid hypertrophy without otitis media with effusion. Methods This prospective descriptive study was performed with 65 patients who had a normal tympanic membrane and normal tympanogram and then underwent adenoidectomy or adenotonsillectomy for adenoid and tonsil hypertrophy. The subjects were randomly divided into two groups: curettage adenoidectomy group and endoscopic microdebrider-assisted adenoidectomy group. They underwent tympanometry, and the preoperative as well as 1st and 7th day postoperative values of the tympanum pressures were compared within and among the groups. Results There were 32 patients in the curettage adenoidectomy group and 33 patients in the microdebrider adenoidectomy group. Statistically significant differences were observed in the median tympanum pressure on the preoperative and 1st and 7th postoperative days for both the left and right ears with curettage adenoidectomy (p < 0.001, p < 0.001). This difference occurred on the 1st postoperative day, and the value returned to normal on the 7th day. There was no significant difference in the median tympanum pressure on the preoperative and 1st and 7th postoperative days for both the left and right ears in the microdebrider adenoidectomy group (p = 0.376, p = 0.128). Conclusion Postoperative Eustachian tube dysfunction is seen less often with the endoscopic-assisted microdebrider adenoidectomy technique than with the conventional adenoidectomy technique.

Resumo Introdução A adenoidectomia pode ser realizada de várias maneiras, inclusive por curetagem e por microdebridador, assistida por endoscopia. Essas duas técnicas têm algumas vantagens e desvantagens. Objetivo O objetivo deste estudo foi investigar os efeitos da técnica de adenoidectomia por curetagem e da adenoidectomia por microdebridador assistida por endoscopia sobre a pressão timpânica em pacientes pediátricos com hipertrofia adenoideana sem otite média com efusão. Método Estudo descritivo prospectivo feito com 65 pacientes que apresentavam membrana timpânica e timpanograma normais, que foram então submetidos à adenoidectomia ou adenotonsilectomia por hipertrofia adenoamigdaliana. Os pacientes foram divididos aleatoriamente em dois grupos: grupo adenoidectomia por curetagem e grupo adenoidectomia por microdebridador assistida por endoscópio. Todos os pacientes fizeram timpanometria e os valores das pressões do tímpano pré-operatórios e pós-operatórios no 1º e 7º dias foram comparados intragrupos e entre os grupos. Resultados Foram incluídos 32 pacientes no grupo adenoidectomia por curetagem e 33 pacientes no grupo adenoidectomia com microdebridador. Diferenças estatisticamente significantes foram observadas na mediana da diferença entre a pressão timpânica no pré-operatório e no 1º e 7º dias de pós-operatório para ambas as orelhas, direita e esquerda, na adenoidectomia por curetagem (p < 0,001, p < 0,001). Essa diferença ocorreu no 1º dia do pós-operatório e o valor retornou ao normal no 7º dia. Não houve diferença significante na mediana entre pressão timpânica no pré-operatório e no 1º e 7º dias de pós-operatório para as orelhas direita e esquerda no grupo de adenoidectomia com microdebridador (p = 0,376, p = 0,128). Conclusão A disfunção tubária no pós-operatório é observada menos frequentemente com a técnica de adenoidectomia por microdebridador assistida por endoscopia quando comparada com a técnica convencional.

Comparison between curettage adenoidectomy and endoscopic-assisted microdebrider adenoidectomy in terms of Eustachian tube dysfunction.

INTRODUCTION: Adenoidectomy can be performed with many ways, including curettage and microdebrider endoscopic-assisted adenoidectomy. Those two techniques have advantages and disadvantages. OBJECTIVE: The objective of this study is to research the effects of curettage adenoidectomy and endoscopic-assisted microdebrider adenoidectomy on the tympanum pressures in pediatric patients with adenoid hypertrophy without otitis media with effusion. METHODS: This prospective descriptive study was performed with 65 patients who had a normal tympanic membrane and normal tympanogram and then underwent adenoidectomy or adenotonsillectomy for adenoid and tonsil hypertrophy. The subjects were randomly divided into two groups: curettage adenoidectomy group and endoscopic microdebrider-assisted adenoidectomy group. They underwent tympanometry, and the preoperative as well as 1st and 7th day postoperative values of the tympanum pressures were compared within and among the groups. RESULTS: There were 32 patients in the curettage adenoidectomy group and 33 patients in the microdebrider adenoidectomy group. Statistically significant differences were observed in the median tympanum pressure on the preoperative and 1st and 7th postoperative days for both the left and right ears with curettage adenoidectomy (p<0.001, p<0.001). This difference occurred on the 1st postoperative day, and the value returned to normal on the 7th day. There was no significant difference in the median tympanum pressure on the preoperative and 1st and 7th postoperative days for both the left and right ears in the microdebrider adenoidectomy group (p=0.376, p=0.128). CONCLUSION: Postoperative Eustachian tube dysfunction is seen less often with the endoscopic-assisted microdebrider adenoidectomy technique than with the conventional adenoidectomy technique.

Características do sono de crianças respiradoras orais encaminhadas para realização de adenoidectomia e/ou amigdalectomia / Sleep characteristics in oral breathers pre adenoidectomy and/or tonsillectomy / Características del sueño de los niños respiradores orales encaminados para la realización de adenoidectomía y/o amigdalectomía

Introdução: A respiração oral acarreta diversas modificações na vida das crianças sendo uma delas as alterações na qualidade do sono, podendo ter impacto no desenvolvimento infantil. Objetivo: Compreender as características do sono de crianças com diagnóstico de respiração oral encaminhadas para a realização de cirurgias de adenoidectomia e/ou amigdalectomia prescritas pelo médico otorrinolaringologista, a partir das informações da família e das próprias crianças. Método: Estudo observacional, analítico, transversal e quantitativo, realizado com 100 crianças de ambos os sexos, com faixa etária entre cinco e 12 anos, divididas em dois grupos, sendo 50 crianças com respiração oral (GP) e 50 crianças sem diagnóstico de alteração respiratória (GC). A avaliação foi baseada no protocolo MBGR, classificação de Mallampati. Após a coleta, os dados foram tabulados e analisados estatisticamente a partir das variáveis queixa, qualidade e características do sono e classificação de Mallampati. Resultados: Os pais e/ou responsáveis não referiram espontaneamente informações relacionadas ao sono. Quando indagados sobre a qualidade do sono houve predomínio de sintomas para o GP. As principais queixas relacionadas ao sono foram ronco, sialorreia, agitação, boca seca, boca aberta, sono fragmentado, com maior ocorrência para o GP. Quanto à classificação de Mallampati houve predomínio dos graus II e III para o GP e grau I para o GC. Conclusão: Crianças respiradoras orais apresentam maior número de queixas referidas por pais/responsáveis em relação à qualidade do sono quando comparadas às crianças respiradoras nasais.

Introduction: Oral breathing entails several changes in the life of children, one of them being changes in sleep quality, which may have an impact on child development. Objective: To understand the sleep characteristics of children diagnosed with oral breathing referred for adenoidectomy and/or tonsillectomy surgeries prescribed by the otorhinolaryngologist, based on information from the family and the children themselves. Method: An observational, analytical, cross-sectional and quantitative study was carried out on 100 children of both sexes, with age range 5 and 12 years, divided into two groups: 50 children with oral breathing (EG) and 50 children without respiratory disorder (CG). The evaluation was based on the MBGR protocol, Mallampati score. After collection, the data were tabulated and analyzed statistically from the variables complaint, sleep quality and characteristics and Mallampati classification. Results: Parents and/or caregivers did not spontaneously report sleep-related information. When asked about sleep quality there was a predominance of symptoms for the EG. The main complaints related to sleep were snoring, sialorrhea, agitation, dry mouth, open mouth, fragmented sleep, with higher occurrence for the EG. Regarding the classification of Mallampati, there was a predominance of classes II and III for the EG and class I for the CG. Conclusion: Oral breathing children have a higher number of complaints reported by parents / guardians regarding sleep quality compared to nasal breathing children.

Introducción: La respiración oral acarrea diversas modificaciones en la vida de los niños siendo una de ellas las alteraciones en la calidad del sueño pudiendo tener impacto en el desarrollo infantil. Objetivo: Comprender las características del sueño de niños con diagnóstico d respiración oral encaminadas para la realización de cirugías de adenoidectomía y/o amigdalectomía prescritas por el médico otorrinolaringólogo, a partir de las informaciones de la familia y de los propios niños. Método: estudio observacional, analítico, transversal y cuantitativo, realizado con 100 niños de ambos sexos, con rango de edad entre cinco y 12 años, divididos en dos grupos, siendo 50 niños con respiración oral (GE) y 50 niños sin diagnóstico de cambio respiratorio (GC). La evaluación se basó em el protocolo MBGR, la clasificación de Mallampati. Después de la recolección, los datos fueron tabulados y analizados estadísticamente de las variables queja, calidad y características del sueño y clasificación de Mallampati. Resultados: Los padres y/o tutores no mencionaron espontáneamente información relacionada con el sueño. Cuando se indagó sobre la calidad del sueño hubo predominio de síntomas para el GE. Las principales quejas relacionadas con el sueño fueron ronquidos, sialorrea, agitación, boca seca, boca abierta, sueño fragmentado, con mayor ocurrencia para el GE. En cuanto a la clasificación de Mallampati hubo predominio de las clases II y III para el GE y clase I para el GC. Conclusión: Los niños con respiración oral tienen un mayor número de quejas reportadas por los padres / tutores con respecto a la calidad del sueño en comparación con los niños con respiración nasal.

The effects of adenoidectomy on the smell perception of children.

BACKGROUND: In this study, we employed a novel children's olfactory test in order to more accurately assess the relationship between nasopharyngeal obstruction and odor identification ability. We quantified the impact of adenoidectomy on olfactory function, established whether the influences of the operation were related to the preoperative amount of nasopharyngeal obstruction, and determined whether sex influenced the olfactory measures. METHODS: Fifty-three boys and 23 girls were administered a standardized children's olfactory test, the Pediatric Smell Wheel™, before and 45 days after adenoidectomy. They ranged in age from 5 to 12 years and exhibited varying degrees of adenotonsillar hypertrophy and histories of recurrent adenotonsillitis. Radiographs of the nasopharynx were used to grade the degree of nasopharyngeal obstruction. RESULTS: Significant postoperative improvement in smell function occurred more frequently in children with >50% preoperative obstruction of the nasopharynx. In this group, average function improved 50.8% after surgery (95% confidence interval [CI], 39.1% to 64%). Improvement on 9 of the 11 odors was present, with significant differences occurring for the odors of bubble gum, baby powder, mint, and cinnamon. No sex differences were evident. CONCLUSION: Olfactory dysfunction occurs primarily in children whose nasopharyngeal obstruction is >50%. Removal of the hypertrophied adenoids returned smell function back to normal in these cases. This study suggests that smell loss may be of value in decisions regarding whether or not to perform adenoidectomy in children with nasopharyngeal obstruction.

Facial growth direction after surgical intervention to relieve mouth breathing: a systematic review and meta-analysis.

OBJECTIVES: A systematic review was performed to assess the prognosis for facial growth direction documented by mandibular plane inclination and anterior face height in growing subjects who had undergone surgical intervention to relieve mouth breathing (PROSPERO database, registration no. CRD 42013005707). METHODS: PubMed, Scopus, Web of Science, the Cochrane Library and LILACS were searched based on the guidelines of the PRISMA statement. Included were longitudinal studies with mouth-breathing patients who had undergone surgical interventions to relieve their respiratory pattern, with a minimum follow-up of one year. RESULTS: A total of 1555 studies were identified, whereby only three nonrandomized clinical trials comprising 155 participants met the inclusion criteria. Primary outcome was change between the initial and final measurements of the mandibular plane-SN angle (95% confidence interval [CI] -2.13° [-3.08, -1.18]). Secondary outcomes included changes in total anterior face height (AFH; 95% CI -0.76 mm [-1.91, 0.38]), upper AFH (95% CI 0.09 mm [-0.57, 0.74]), and lower AFH (95% CI 0.06 mm [-0.87, 0.99]). Risk of bias was low for most of bias domains and the quality of evidence across the studies was considered to be very low. The design, the small number of participants, and the absence of blinding generated imprecision. CONCLUSIONS: There is very low evidence that the mandibular growth direction became more horizontal during the first year after surgery to treat mouth breathing. The total anterior facial height decreased, although not always significantly.

Avaliação da recidiva de sintomas obstrutivos após adenoidectomia e adenoamigdalectomia / Evaluation of obstructive symptoms relapse after adenoidectomy and adenotonsillectomy

A Síndrome da Apneia Obstrutiva do Sono (SAOS) na criança é uma doença que leva a alterações nos padrões arquiteturais do sono e apresenta como principais consequências o ronco habitual, dificuldades respiratórias, sonolência diurna, alterações neurocognitivas e prejuízo no ganho de peso e altura. Sua principal causa é a hipertrofia adenotonsilar e o tratamento mais efetivo é a adenoamigdalectomia. Apesar disso, estima-se que 9 a 29% das crianças não melhoram com a cirurgia. Sendo assim, objetivo deste estudo é avaliar crianças submetidas a tonsilectomia que persistem com prejuízo na qualidade de vida devido a SAOS e estabelecer as possíveis causas para essa recidiva ou persistência dos sintomas. Trata-se de um estudo analítico transversal, que avaliou 99 crianças em um momento, dois anos após adenoidectomia/adenoamigdalectomia. Foram estudados: queixa do familiar relacionada a sintomas obstrutivos, rinite, asma, tabagismo passivo, enurese, características anatômicas desfavoráveis, hipertrofia de cornetos inferiores, desvio de septo nasal obstrutivo, palato mole redundante, hipertrofia amigdaliana, Mallampatti e hipertrofia adenoideana. Os pacientes foram separados em 2 grupos conforme o questionário OSA-18, sendo um com pontuação maior ou igual a 60 (grupo teste) e outro com pontuação menor que 60 (grupo controle). Realizada regressão logística binária, chegou-se à conclusão de que a queixa do familiar, a enurese e a hipertrofia de cornetos apresentam relação estatisticamente positiva com prejuízos na qualidade de vida relacionada à SAOS.

Obstructive Sleep Apnea Syndrome (OSAS) in children is a disease that leads to alterations in the architectural patterns of sleep and presents as main consequences habitual snoring, breathing difficulties, daytime sleepiness, neurocognitive alterations and impairment in weight gain and height. Its main cause is adenotonsillar hypertrophy and the most effective treatment is adenotonsillectomy. Despite this, it is estimated that 9 to 29% of children do not improve with surgery. Therefore, the objective of this study is to evaluate children submitted to tonsillectomy who persist with impaired quality of life due to OSAS and establish the possible causes for this relapse or persistence of symptoms. It is a cross-sectional analytical study that evaluated 99 children at one time two years after adenoidectomy / adenotonsillectomy. The following were studied: family complaint related to obstructive symptoms, rhinitis, asthma, passive smoking, enuresis, unfavorable anatomical characteristics, inferior turbinate hypertrophy, obstructive nasal septum deviation, redundant soft palate, tonsils hypertrophy, Mallampatti and adenoidean hypertrophy. Patients were separated into 2 groups according to the OSA-18 questionnaire, one with a score greater than or equal to 60 (test group) and another with a score lower than 60 (control group). A binary logistic regression was performed, and the family complaint, enuresis and turbinate hypertrophy were statistically positive with losses in OSAS-related quality of life.

Amigdalo adenoidectomía en pacientes con comobilidades / Adenotonsillectomy in patients with comorbidities

La adenoamigdalectomía es una de las cirugías más frecuentemente realizadas en los pacientes menores de 15 años. Es considerada una cirugía de mediana complejidad. No está exenta de riesgos y sus indicaciones deben ser muy bien evaluadas: la obstrucción de la vía aérea superior causada por hiperplasia y las infecciones bacterianas recurrentes son las indicaciones más frecuentes de amigdalectomía, y adenoidectomía. Objetivo: Describir las características clínico-epidemiológicas de la población a quien se le practica adeno-amigdalectomía portadores de hipertrofia amigdalina y vegetaciones adenoideas (HAVA) en el Hospital J.P Garrahan, sus complicaciones y el tiempo de estadía hospitalaria. Materiales y métodos: estudio descriptivo, observacional, retrospectivo y transversal, con revisión de Historias clínicas de los pacientes adeno-amigdalectomizados entre Enero 2015 a Marzo 2016. Resultados: Se realizó amigdalectomía y/o adenoidectomía en 68 pacientes. 36 masculinos, 32 femeninos. 93% (63/68) presentaban comorbilidades. El 7% (5/68) eran niños previamente sanos. Promedio de edad: 12,5 años (rango 1-16 años), mediana de edad 6 años. Tipos de comorbilidades: síndromes genéticos 18/63, antecedente de transplantes sólidos o alogénicos de médula ósea 12/63, obesidad 6/68, patología de base con compromiso muscular 4/63, patologías hematológicas 2/63, pacientes neurológicos 12/63, otros 9/63. Presentó sangrado en el postoperatorio inmediato 1/68. El tiempo de internación promedio fue de 3 días (AU)

Adenotonsillectomy is one of the most frequently performed surgeries in patients under 15 years of age. It is considered an intermediate surgery that is not devoid of risks and its indications should be well evaluated. Upper airway obstruction caused by hyperplasia and recurrent bacterial infections are the most common indications for tonsillectomy and adenoidectomy. Objective: To describe the clinical and epidemiological features of a series of patients who underwent adenotonsillectomy at Hospital J. P. Garrahan because of tonsillar hypertrophy and adenoid vegetation (THAV) assessing complications and the time of hospital stay. Material and methods: A descriptive, observational, retrospective and cross-sectional study was conducted consisting of a review of the clinical charts of patients who underwent adenotonsillectomy between January 2015 and March 2016. Results: Tonsillectomy and/or adenoidectomy was performed in 68 patients. 36 male, 32 female. Overall, 93% (63/68) presented with comorbidities; 7% (5/68) were previously healthy children. Mean age: 12.5 years (range, 1-16 years), median age: 6 years. Type of comorbidity: genetic syndromes 18/63, history of solid organ or allogeneic bone marrow transplantation 12/63, obesity 6/68, underlying muscular disorder 4/63, hematological disorders 2/63, neurological disorders 12/63, others 9/63. One patient had a hemorrhage in the immediate postoperative period 1/68. Mean hospital stay was 3 days (AU)