Secondary Postoperative Hemorrhage in the Pediatric Tonsillectomy Patient- is there a correlation between hemorrhage and tonsilloliths?

INTRODUCTION: Tonsillectomy with or without adenoidectomy is one of the most common ambulatory procedures performed in children under 15. One rare yet serious complication of tonsillectomy is postoperative hemorrhage. Chronic tonsillitis, which is an indication for tonsillectomy, has been shown to have an increased risk for postoperative hemorrhage. Tonsilloliths or tonsil stones have been associated with cryptic tonsillitis. This 2020-2021 study examined whether tonsilloliths were a risk factor for post-tonsillectomy hemorrhage in a convenience sample of 187 pediatric patients. METHODS: This was a cross-institutional 12-month retrospective cohort study investigating pediatric patients who had undergone tonsillectomy. Exclusion criteria included patients who had received prior airway surgeries (e.g., supraglottoplasty), patients with significant comorbidities such as chromosomal abnormalities or congenital disorders, and patients with pre-existing bleeding disorders. Demographic, clinical, and operative data was extracted from each chart. Postoperative adverse events and bleeding were also recorded. These factors were then compared between the tonsillolith and no tonsillolith patient groups. RESULTS: A total of 187 pediatric patients met the inclusion criteria. Seventy-three (39%) of the patients had tonsilloliths and 114 (61%) did not have tonsilloliths at the time of surgery. The tonsillolith subgroup had a higher median age (10 vs 3, P < 0.001) when compared to the no tonsillolith subgroup. The most common indication for tonsillectomy was obstructive sleep apnea/sleep disordered breathing (N= 148, 79.1%). There was no statistical difference found between presence of tonsillolith and indication for surgery (P = 0.06). Only five (2.7%) of sample patients experienced postoperative bleeding and there was no association found between postoperative bleeding and presence of tonsilloliths (P = 0.38). CONCLUSION: In the current study there was no association found between the presence of tonsilloliths (indicating low grade chronic inflammation) and hemorrhage after tonsillectomy. Continued larger sample evaluations of possible risk factors for post-tonsillectomy hemorrhage patterns are encouraged.

Failure factors in pediatric deep neck space abscess surgical management.

INTRODUCTION: Deep neck space infections (DNSI) in pediatric otolaryngology are a common occurrence in the inpatient setting. A subset of DNSI patients will fail medical and surgical management. It is difficult to predict which patients will fail. There are no studies that effectively evaluate variables associated with readmission and reoperation for DNSI abscesses. The purpose of this study was to evaluate the specific perioperative decisions that may lead to combined therapy failure and necessitate reoperation. METHODS: A case-control study was performed at a single center academic tertiary care hospital. Patients <18 years old treated from January 2015 to April 2020 with a surgically treated DNSI were reviewed. The single incision and drainage group (SOp) and reoperation group (ReOp) were evaluated with reoperation performed within a 30-day period. Intravenous antibiotic administration timing, drain management and type (gauze or latex), diagnostic, and postoperative factors were evaluated. RESULTS: The SOp group consisted of 275 patients and the ReOp group of 21 patients. The average preoperative intravenous antibiotic time showed no statistical difference (p = 0.884) and no increased risk for reoperation (p = 0.470; OR = 0.993). Timing of drain removal showed a significant difference (p < 0.005; 41.1 SOp vs 46.5 h ReOp). Abscess location (p = 0.855) and complications rate did not vary (p = 0.450). Gauze drains were used in 131 (44.3%), latex in 80 (27%), and no drain in 84 (28.4%) with no difference regarding reoperation (p = 0.124). Length of stay was longer in the ReOp group (8 vs 4 days; p < 0.001). The average measured dimension for each group did not significantly vary (p = 0.633). CONCLUSIONS: The duration of antibiotics in the preoperative period showed no statistical role in the need for reoperation in DNSI abscess patients. Drain type and duration also had a potentially clinically relevant association with the need for reoperation. Extensive unknown abscess pockets or inadequate technique may be the main contributors to the need for reoperation.

Risk Factors and Management for Epistaxis in a Hospitalized Adult Sample.

INTRODUCTION: Epistaxis is a common otolaryngologic problem that affects most of the general population. Common risk factors for epistaxis include nasal irritants, nasal/facial oxygen use, certain systemic conditions (e.g., hypertension and coagulopathies) and medication use (e.g., anticoagulants and intranasal medications). This study examined risk factors for and management of epistaxis in patients admitted for other medical conditions who developed an episode of epistaxis during their hospital admission. METHODS: Patients were included in the study if they were older than 18, admitted for medical illnesses other than epistaxis and developed an episode of epistaxis during their admission during calendar year 2020 at the authors' institution's hospitals. Electronic health record data regarding sociodemographic characteristics, common risk factors (e.g. oxygen use, anticoagulant use, history of hypertension) and treatment for epistaxis (e.g. holding anticoagulation therapy, administration of oxymetazoline, nasal cautery, nasal packing) were extracted from each chart. Patients were split into otolaryngologic treatment versus no treatment groups and risk factors were compared between sample subgroups. RESULTS: A total of 143 sample patients were included, with most common reason for admission being cardiovascular related, 48 (33.6%). Most patients, 104 (72.7%), did not have a previous diagnosis of epistaxis, were positive for anticoagulant use, 106 (74.1%) and were positive for hypertension, 95 (66.4%). Oxygen use showed a significantly decreased risk for intervention (OR 0.45, 95% CI: 0.23-0.894; p = 0.028). Most patients required changes in medical management (e.g., holding anticoagulation or starting nasal saline sprays/emollients). CONCLUSION: These results demonstrate the common risk factors for epistaxis in patients admitted for other clinical diseases. Identifying at-risk patients for epistaxis at hospital admission can help to initiate measures to prevent epistaxis episodes. Future studies are needed to study epistaxis risk factors and identify effective preventative measures for epistaxis among hospital populations.

Rapidly Progressive Orbital Apex Syndrome Due to Scedosporium apiospermum Following Endoscopic Sinus Surgery.

Scedosporium apiospermum is a ubiquitous, highly resistant opportunistic fungus found in sewage and polluted waters and may infect the paranasal sinuses. Orbital Apex Syndrome may occur following trauma, surgery, or infection. An 80-year-old male with diabetes mellitus and mild dementia underwent uncomplicated, bilateral functional endoscopic sinus surgery for chronic sinusitis with polyposis. Initial pathology was reported as non-invasive bacterial and fungal species. On postoperative day 4, he had sudden right vision loss and abducens nerve palsy. Imaging noted violation of the lamina papyracea and inflammation of the optic nerve without compression. Medical therapy was begun and the patient developed sudden vision loss of the left eye. The patient then underwent emergent surgical decompression of both optic nerves. A final culture from the original surgery of S. apiospermum was made on postoperative day 10. Aggressive medical therapy was continued and the patient ultimately expired from complications of medical therapy and other underlying conditions. Trauma to the delicate bony walls of the orbit during sinus surgery in an immunocompromised patient who is unknowingly colonized with S. apiospermum can lead to the rapid spread of this highly neurotoxic organism.

Zygomatic air cells in connection with Luc's abscess.

INTRODUCTION: An uncommon complication of Acute Otitis Media (AOM) is a subperiosteal temporal infection known as Luc's abscess. Zygomatic air cells (ZACs) are an uncommon anatomic variant. CASE SERIES: Two otherwise healthy male patients, aged six- and thirteen years-old presented with unilateral otalgia, swelling, trismus, and fever. Imaging revealed Luc's abscess near ZACs. Antibiotics, drainage and myringotomy tubes resulted in a full recovery. CONCLUSION: In addition to the spread of soft tissue infection through the Notch of Rivinus, the presence of ZACs may provide a pathway for suppurative effusion and development into Luc's abscess.

Ureteroscopy Without Fluoroscopy: A Feasibility Study and Comparison with Conventional Ureteroscopy.

INTRODUCTION AND OBJECTIVES: Patients with urolithiasis are exposed to significant amounts of radiation during their initial work-up, surgical treatment, and follow-up. The purpose of this study was to determine the feasibility of performing ureteroscopy without fluoroscopy. In addition, we compared patients treated using a completely fluoroless ureteroscopic technique with a cohort of conventional ureteroscopies performed using fluoroscopy. MATERIALS AND METHODS: A retrospective review of 50 consecutive patients undergoing fluoroless ureteroscopy was performed. These procedures were performed by inserting guidewires and instruments using tactile feedback, direct visualization, and external visual cues to substitute for fluoroscopy. In addition, this cohort was compared with 50 conventional, fluoroscopy-guided ureteroscopies performed in the same time period. RESULTS: Fifty ureteroscopies were performed without image guidance. For this cohort, the mean operative time was 59.2 minutes, overall stone burden was 91.53 mm(2), complication rate was 4%, and repeat procedure rate was 8%. Compared with conventional ureteroscopy the fluoroless ureteroscopy patients had a larger stone burden (p=0.042; 91.53 vs 56.58 mm(2)), but similar age, gender, American Society of Anesthesiologists (ASA) score, body-mass index, operative time, complication rate, and repeat procedure rate. CONCLUSIONS: This study demonstrates the feasibility and efficacy of the completely fluoroless ureteroscopic treatment of calculi throughout the entire upper urinary tract while completely removing radiation exposure to the patients and staff. Although this fluoroless technique may be most applicable in patients at highest risk for radiation exposure, such as pregnant women, children, and recurrent stone formers, it offers an alternative for reduction of radiation in all patients.

Detection of uric acid stones in the ureter using low- and conventional-dose computed tomography.

OBJECTIVE: To determine the ability of low- and conventional-dose computed tomography (CT) in identification of uric acid stones, which are of lower density than calcium oxalate stones. MATERIALS AND METHODS: Uric acid stones (3, 5, and 7 mm) were randomly placed in human cadaveric ureters and scanned using conventional 140-mAs and low-dose 70-, 50-, 30-, 15-, 7.5-, and 5-mAs settings. A single-blinded radiologist reviewed a total of 523 scanned stone images. Sensitivity and specificity were compared among different settings and stone sizes. RESULTS: Imaging using 140-, 70-, 50-, 30-, 15-, 7.5-, and 5-mAs settings resulted in 97%, 97%, 96%, 93%, 83%, 83%, and 69% sensitivity and 92%, 92%, 91%, 89%, 88%, 91%, and 94% specificity, respectively. There was a significant difference in sensitivity between 140 mAs and 15, 7.5, and 5 mAs (P = .011, P = .011, and P <.001, respectively). Sensitivity for 3-, 5-, and 7-mm stones was 83%, 90%, and 93%, respectively. At ≤ 15 mAs, 3-mm stones had a higher rate of false negatives (P <.001). CONCLUSION: Both low- and conventional-dose CTs demonstrate excellent sensitivity and specificity for the detection of ureteral uric acid stones. However, low-dose CT at ≤ 15 mAs resulted in reduced detection of uric acid stones.

Analgesic use and complications following upper pole access for percutaneous nephrolithotomy.

INTRODUCTION AND OBJECTIVES: Upper pole access (UPA) to the kidney optimizes working angles during percutaneous nephrolithotomy (PCNL). However, many surgeons are hesitant to employ UPA due to concerns for increased postoperative pain and complications. In this study, we compare perioperative pain and outcomes for PCNL performed through UPA with middle and lower pole access (LPA). METHODS: A retrospective review of PCNLs performed at a single academic institution between 2002 and 2012 was performed. Patient demographics, stone burden, operative characteristics, length of hospital stay, and perioperative complications were recorded. Narcotics administered on postoperative days (POD) 1 and 2 were converted to intravenous morphine equivalents. The Mann-Whitney U, Fisher's exact test, and logistic regression analyses were used for statistical comparison. RESULTS: Of 350 PCNLs performed on 269 patients, 125 patients underwent primary PCNL through single tract UPA, while primary LPA was utilized in 138 patients. Patients with multiple access tracts (n=6) were excluded. Baseline characteristics between groups were similar except for age; patients with UPA were older (52.6 vs. 46.2 years; p=0.003). Stone burden, operative time, and initial stone-free rate were comparable between groups. Additionally, analgesic requirements were similar on POD 1 (p=0.54) and 2 (p=0.62). There was no difference in the overall complications (p=0.23) or thoracic complications (p=0.43). Although both groups had equivalent stone-free rates after initial PCNL (p=0.78), those with residual stones had a superior stone-free rate after second-look PCNL through UPA (73.3% vs. 44.3%, p=0.035) and a superior overall stone-free rate (94.4% vs. 86.2%, p=0.037). CONCLUSIONS: Patients undergoing PCNL through UPA had a higher ultimate stone-free rate compared with LPA, while postoperative analgesic requirements and overall complication rates were similar between access sites. A trend toward higher thoracic complication rates was observed in the UPA group, although this did not reach statistical significance. Surgeons should not hesitate to utilize UPA when indicated for patients with large or complex stones.

Reduced fluoroscopy protocol for percutaneous nephrostolithotomy: feasibility, outcomes and effects on fluoroscopy time.

PURPOSE: Radiation exposure from fluoroscopy during percutaneous nephrostolithotomy contributes to patient overall exposure, which may be significant. We compared fluoroscopy times and treatment outcomes before and after implementing a reduced fluoroscopy protocol during percutaneous nephrostolithotomy. MATERIALS AND METHODS: We retrospectively reviewed the charts of patients treated with percutaneous nephrostolithotomy at a single academic institution by a single surgeon. We compared 40 patients treated before implementation of a reduced fluoroscopy protocol to 40 post-protocol patients. The reduced protocol included visual and tactile cues, fixed lowered mAs and kVp, a laser guided C-arm and designated fluoroscopy technician, and single pulse per second fluoroscopy. Preoperative characteristics, fluoroscopy and operative time, complications and treatment success were examined using univariate and multivariate analysis. RESULTS: There was no significant difference in body mass index, stone size, success rate, operative time or complications between the groups. After protocol implementation fluoroscopy time decreased from 175.6 to 33.7 seconds (p<0.001). A longer average hospital stay was seen in the pre-protocol group (3.9 vs 3.6 days, p=0.027). Stays greater than 2 days were associated with a body mass index of greater than 30 kg/m2 on multivariate analysis. No complication in either group was attributable to fluoroscopic technique. CONCLUSIONS: Implementing a decreased fluoroscopy protocol during percutaneous nephrostolithotomy resulted in an 80.9% reduction in fluoroscopy time while maintaining success rates, operative times and complications similar to those of the conventional technique. Adopting this reduced fluoroscopy protocol safely decreased radiation exposure to patients, surgeons and operating room staff during percutaneous nephrostolithotomy.

A prospective analysis of robotic tip cover accessory failure.

BACKGROUND AND PURPOSE: The robotic monopolar scissors tip cover accessory (TCA) is an insulation device that prevents current leak from surfaces on the instrument other than the scissors tip. Reports of insulation failure and patient injury have been made but not systematically studied. We investigate the incidence of TCA failure and potential mechanisms that lead to malfunction. MATERIALS AND METHODS: Eighty TCAs (40 first and 40 second generation) were collected after a single urologic or gynecologic surgery at a single academic institution. Each TCA was inspected for damage under a microscope. Current leak was measured in an electrolysis solution, and electrical arcing was tested in a porcine kidney model. Log-rank and Friedman two-way analysis of variance by ranks compared failure at different angulations and power settings. Chi-square analysis compared failure between first and second generation TCAs (f-TCAs and s-TCAs). RESULTS: Visible insulation defects were detected in 39% of f-TCAs (size range <0.5-2.75 mm). Electrical arcing was observed in 33% of f-TCAs. Arcing increased with greater wrist angulation (P=0.014) and higher power settings (P=0.048). Minor damage was observed in 25% of s-TCAs. No electrical arcing was observed in any of the s-TCAs despite angulation and power strain. s-TCAs demonstrated significantly less failure than f-TCAs (P<0.001). CONCLUSION: In this study, 33% of f-TCAs demonstrated insulation failure after a single surgical use. f-TCA failure increased with greater wrist angulation and electrical power. The improved design of s-TCAs demonstrated no current leak or arcing on ex-vivo testing and appears to have significantly decreased failure potential. Centers still using the f-TCA should transition to the s-TCA and be vigilant in reporting device failures to prevent unnecessary patient morbidity.