Tesi sul tema "Tonsillectomy"

Background: Tonsillectomy is among the most common operations performed on children in the UK. Yet little was known about the socio-demographic profile of children who undergo the operation and how the recent decline in tonsillectomy rates has influenced the rates of severe acute throat infections (ATI). Many children with mild ATI disease also undergo tonsillectomy despite a lack of evidence of its benefit in this group, particularly in the longer-term. The aims of this thesis were to characterise the socio-demographic profile of children who undergo tonsillectomy and investigate the clinical impact of the operation on ATI in primary and secondary care settings. Methods: The clinical spectrum of ATI in relation to tonsillectomy was investigated using a combination of retrospective time-trend analyses and a retrospective cohort study. I analysed routine data from the Hospital Episodes Statistics and Clinical Practice Research Datalink databases to investigate secondary care and primary care settings, respectively. Results: There was a 76% increase in ATI hospital admission rates among children between 1999/2000 and 2009/10 from 107.3 to 188.4 admissions per 100,000 children, respectively. However, the majority of these children did not stay overnight and admission rates for peritonsillar abscess (PTA) remained stable. By contrast, tonsillectomy rates fluctuated over the first three years of the study period, but declined overall from 367 to 294 per 100,000 children during the same study years. In general practice, tonsillectomy only modestly reduced the frequency of subsequent ATI consultations among children with low baseline ATI consultation rates. Conclusions: There does not appear to be a relationship between trends in tonsillectomy operations and admissions for ATI or PTA at a population level, which suggests that clinicians should continue to restrict the operation to children who are more severely affected by ATI disease. Additionally, tonsillectomy does not appear to have a clinically significant benefit in reducing ATI consultations among children with mild ATI disease in the longer-term, which further supports reserving the operation for children with severe ATI disease.

Abstract The purpose of this study was to investigate the clinical implications of a combination of a peripheral opioid, paracetamol (APAP) and ketoprofen (KTP) on the intensity of acute postoperative pain by focusing on tonsillectomy (TE) and third molar extraction. A second focus in the study was to assess the utility of the surgical ultrasonically activated scalpel (HS) technique for TE. In Study I, TE was performed on one side using the HS and on the contralateral side using a “blunt dissection technique”. The first TE study (I) demonstrated that - based on NRS pain scores during the first 10 postoperative hours - intra-operative blood loss and need for haemostasis were greater on the blunt dissection side than on the HS side. Pain scores were higher on the HS side than on the cold dissection side during the second postoperative week. Study III assessed the analgesic effect of a peripheral dose of 4 mg morphine. The peritonsillar infiltration of morphine locally did not significantly decrease pain compared to the control side. Studies (II and IV) included patients who were scheduled for third molar extraction. In Study II, patients received 1000 mg APAP or 100 mg KTP or both or a placebo to evaluate pain relief after third molar extraction. This study demonstrated that the mean sum of pain intensity differences scores up to the 1.5 h mark and the mean time to onset of pain relief at rest and on swallowing were favoured in the combination group more than in the APAP, KTP, and placebo groups. In Study IV, patients were assigned for a submucosal injection of 2 mg morphine or NaCl into either the non-inflamed (Trial I) or the inflamed (Trial II) peridental tissue, while the active control group received the same drugs in reverse order intramuscular (IM). Postoperative pain intensity at rest and on swallowing was assessed in all studies using the numerical rating scale (NRS). Pain scores in the peripheral morphine group at rest (Trials I and II) and on swallowing (Trial I) were not associated with any further pain reduction. Pain scores on swallowing during the 2–6 hours postoperative period (Trial II) were greater in the IM morphine group. HS TE was associated with decreased pain in the early postoperative period, but there was increased pain and otalgia during the second postoperative week. Locally administered peripheral morphine was not associated with any benefit during the postoperative period after TE. The multimodal analgesia combination of a single dose of KTP and APAP demonstrated the same benefit during the early postoperative period without an increase in side effects. Locally administered peripheral morphine produced significant analgesia on swallowing during the early postoperative stage in inflamed tissue after third molar extraction
Tiivistelmä Hyvä leikkauksen jälkeinen kivunhoito on yksilöllisesti suunniteltua, turvallista, helppokäyttöistä ja taloudellista. Nykyään pyritään kivunlievityksessä hyödyn-tämään eri vaikutuspaikkoihin kohdistuvia hoitoja eli multimodaalista kivun¬hoitoa. Tämän työn tarkoituksena oli selvittää eri kivunlievitysmenetelmien tehoa ja turvallisuutta kahdessa eri toimenpiteessä: nielurisojen poistoleikkauksen (TE) tai viisaudenhampaan poistoleikkauksen jälkeen. Tutkimuskokonaisuus käsittelee leikkaustekniikan (Ultraääniveitsi), lääke-ainekombinaatioiden ja perifeerisesti annostellun morfiinin vaikutusta post-operatiiviseen kipuun. Tutkimusaineisto koostuu neljästä tutkimuksesta. Kaikki työt olivat satunnaistettuja ja kaksoissokkoutettuja. Kipu mitattiin numeerista asteikolla (Numerical Rating Scale, NRS) sekä levossa että nielemisen aikana enintään 2 viikon ajan. Ultraääniveitsen käytön vaikutusta postoperatiiviseen kipuun verrattiin perinteiseen leikkaustekniikkaan. Potilailta toinen nielurisa poistettiin ultraääni¬veistä käyttäen ja toinen tylpästi irrotellen kylmiä instrumentteja käyttäen. Kipu oli perinteisellä tekniikalla leikatulla puolella voimakkaampi kuin ultraääni¬veitsellä leikatulla puolella leikkauspäivänä. Toisen leikkauksen jälkeisen viikon aikana kipu oli kuitenkin voimakkaampaa ultraääniveitsillä leikatulla puolella. Parasetamolin (APAP), ketoprofeenin (KTP) tuottamaa kivunlievitystä ja näiden yhteisvaikutusta verrattiin viisaudenhampaan poistoleikkauksen jälkeen. KTP ja APAP kombinaatio antoi tehokkaamman kivunlievityksen ja nopeamman hoitovasteen kuin kumpikaan lääke yksin annettuna. Perifeerisesti infiltroidun morfiinin vaikutusta kipuun tutkittiin TE sekä viisaudenhampaan poistoleikkauksen jälkeen. TE jälkeen toiselle puolelle infiltroitiin nielurisan taakse 4 mg morfiinia ja toiselle puolelle fysiologista suolaliuosta. Viisaudenhampaan poistoleikkauksessa paikallisesti infiltroitua 2 mg morfiinia verrattiin lihakseen annettuun samaa lääkkeeseen kahdessa eri tilanteessa, joko tulehtuneeseen tai tulehtumattomaan kudokseen annosteltuna. Paikallisesti infiltroidulla morfiinilla ei todettu kipua lievittävää vaikutusta TE jälkeen. Tulehtuneeseen kudokseen infiltroitu morfiini lievensi leikkauksen jälkeistä nielemiskipua 2–6 tuntia leikkauksesta. Tulehtumattomaan kudokseen infiltroidulla morfiinilla ei saatu lisäetua. Yhteenvetona voidaan todeta, että TE ja viisaudenhampaanpoistoleikkauksen jälkeen kivunhoitoa voidaan optimoida multimodaalisin kivunhoidon keinoin. Tutkimustulokset auttavat potilaskohtaisen yksilöllisen kivunhoidon suunnittelussa

Abstract Recurrent pharyngitis causes doctor visits, antibiotics use and absences from school or work and thus worsens patients’ quality of life (QOL). Even though tonsillectomy is often performed for recurrent pharyngitis, there is limited evidence of the tonsillectomy benefit concerning both researcher- and patient-recorded outcomes. The intent of this work was to find out if tonsillectomy reduces numbers of pharyngitis episodes or symptom days, if tonsillectomy improves patients’ QOL and if there are any clinical factors predicting QOL benefit after tonsillectomy. Seventy adult patients with recurrent streptococcal pharyngitis (2001–2005) and 86 patients with recurrent pharyngitis of any origin (2007–2010) were enrolled for two randomised controlled trials. Patients with recurrent pharyngitis of any origin were followed up either before (control group, n=40) or after (tonsillectomy group, n=46) tonsillectomy. At five months of follow-up, 17 (43%) patients in the control group and 2 (4%) patients in the tonsillectomy group consulted a physician for pharyngitis. Thirty-two (80%) patients in the control group and 18 (39%) patients in the tonsillectomy group experienced any kind of pharyngitis episode. Only one episode was considered severe. The numbers of days with throat pain and fever were significantly lower in the tonsillectomy group. QOL of 142 responders measured by Glasgow Benefit Inventory (GBI) six months after tonsillectomy showed improvement: median GBI total score was +27. However, GBI total scores varied considerably between the patients (range −19 to +69). Only one patient reported declined QOL. The number of prior pharyngitis episodes, frequent throat pain, untreated dental caries and chronically infected tonsils were the best clinical factors predicting QOL improvement. The precision of these predictions was still quite low. The results of this work suggest that tonsillectomy reduces numbers of acute pharyngitis episodes and symptoms. Although most of the episodes are not severe, tonsillectomy still generally improves patients’ QOL. The distribution of QOL benefit is broad, however. Throat-related morbidity before tonsillectomy is the only clinical factor that was associated with patient satisfaction
Tiivistelmä Toistuvat nielutulehdukset aiheuttavat paljon lääkärikäyntejä, antibioottihoitoja sekä poissaoloja töistä tai opinnoista ja huonontavat potilaiden elämänlaatua. Toistuvien nielutulehdusten vuoksi päädytään usein nielurisaleikkaukseen, vaikka tutkimusnäyttö leikkauksen hyödystä on vähäistä. Tämän väitöskirjatyön tavoitteena oli tutkia, vähentääkö nielurisaleikkaus nielutulehdusten määrää tai oireita sekä selvittää leikkauksenjälkeistä elämänlaatua ja siihen liittyviä ennustekijöitä. Tutkimusaineisto koostui kahta eri satunnaistettua kliinistä koetta varten rekrytoiduista potilaista: 70 potilasta, joiden toistuvien nielutulehdusten aiheuttaja oli A-ryhmän streptokokki (2001–2005) ja 86 potilasta, joiden toistuvien nielutulehdusten etiologialle ei asetettu vaatimuksia (2007–2010). Potilaat, joilla nielutulehdusten etiologia oli avoin, satunnaistettiin kahteen ryhmään: kontrolliryhmää (n=40) seurattiin ennen nielurisaleikkausta ja leikkausryhmää (n=46) sen jälkeen, molempia 5 kuukauden ajan. Seurannassa 17 (43 %) kontrolliryhmän potilasta ja 2 (4 %) leikkausryhmän potilasta hakeutui lääkäriin nielutulehduksen vuoksi. Kontrolliryhmän potilaista 32 (80 %) ja leikkausryhmän potilaista 18 (39 %) sairasti nielutulehduksen vähintään kerran. Vain yksi episodi luokiteltiin vaikeaksi. Nielukipu- ja kuumepäiviä oli merkittävästi vähemmän leikkausryhmässä. Nielurisaleikkauksen vaikutusta elämänlaatuun tutkittiin Glasgow Benefit Inventory (GBI) -kyselyllä kuusi kuukautta leikkauksen jälkeen. Yhteensä 142 potilasta vastasi kyselyyn. GBI:n mediaanitulos +27 osoitti leikkauksen parantavan elämänlaatua. GBI-tulokset kuitenkin vaihtelivat huomattavasti potilaiden välillä (−19 – +67), vaikkakin vain yksi potilas raportoi elämänlaatunsa heikentyneen. Aiempien nielutulehdusten määrä, usein toistuva nielukipu, hoitamaton karies ja kroonisesti tulehtuneet nielurisat ennustivat parhaiten potilastyytyväisyyttä leikkauksen jälkeen, mutta näidenkin tekijöiden ennustearvo oli melko heikko. Tulosten perusteella nielurisaleikkaus vähentää akuutteja nielutulehduksia sekä oirepäiviä. Vaikka sairastamisjaksot ovat harvoin vaikeaoireisia, leikkaus parantaa useimmiten elämänlaatua, mutta hyödyn määrä vaihtelee merkittävästi potilaiden välillä. Ainoastaan leikkausta edeltävä nielun oireilun määrä ennustaa leikkaushyötyä jossain määrin

Background. Adeno-/tonsillectomy is a commonly performed procedure with internationally standardised and recognised indications. Despite this, there exists considerable international (190 - 850/100 000 people ≤19 years of age) and regional variation in adeno-/tonsillectomy rates. This variation has been ascribed to differences in clinical practice and referral patterns, as well as social and family factors, rather than differences in clinical need or regional morbidity. Objectives. To describe the adeno-/tonsillectomy rate in the South African private healthcare sector, and regional variations thereof. To compare local rates with international rates and to assess current trends in adeno-/tonsillectomy clinical practice. Methods. Analysis of adeno-/tonsillectomy data from January 2012 to December 2013, provided by the largest South African private healthcare funder, accounting for 31% of the medical scheme market. Rates are expressed per 100 000 people ≤19 years of age. Results. The tonsillectomy rate in the South African private healthcare sector was 1888/100 000 people ≤19 years of age in 2012. In 2013, the rate dropped significantly (p-value <0.001) to 1755/100 000. Both are more than double the highest national tonsillectomy rate reported in the literature. There was also considerable regional variation in the adeno-/tonsillectomy rate within South Africa. Otorhinolaryngologists are responsible for approximately 80% of adeno- /tonsillectomies performed in the South African private healthcare sector. Discussion. The South African tonsillectomy rate is very high when compared to international trends and varies regionally within the country. The literature does not support an increased burden of disease as the reason behind this. Rather, it is differences in training and clinical practice of clinicians, as well as social and family factors that have been implicated. Conclusion. The adeno-/tonsillectomy rate in the South African private healthcare sector is substantially higher than international norms. The reasons for this discrepancy require further consideration and investigation.

Thesis (M Med(Otorhinolaryngology)) -- University of Limpopo, 2011.
Background: Tonsillectomy is one of the commonest operations performed by ENT surgeons. Pain, haemorrhage, delayed feeding and resumption of normal activities are common morbidities. Different groups of analgesics are used to reduce these morbidities. Objective: We examined the effectiveness of the use of three analgesics, some in combinations in reducing these morbidities. The primary outcome measures were pain, resumption of normal diet, resumption of normal physical activities and secondary haemorrhage. The secondary outcome was comparison of pain profile of children and adults. Methods: A prospective randomized double blind controlled study. Subjects were recruited and randomized into three study groups; group A (Paracetamol & Ibuprofen), group B (Ibuprofen) and group C (Paracetamol, Ibuprofen & Tilidine). A diathermy dissection technique was used on all patients in removing tonsils. Pain was measured using a patient morbidity scoring form (PMS) as well as the Smiley scale. The care givers for children and adult patients recorded all other events. Results: Sixty five patients were recruited, 30 were in group A, 20 in group B and 15 in group C. There were 36 females and 29 males. The youngest patient was 4 years of age and the oldest was 38 years. The mean number of days prior to resuming normal daily activities for groups A, B and C was 9.27, 10.60 and 7.67 respectively. Group C patients started their daily activities earlier than those in group B (p≤0.05). The average number of days to stop analgesic use was 12.3, 13.3 and 10.6 for groups A, B and C respectively. Patients in group C stopped using analgesics earlier than group B patients (p≤0.05). There was no statistically significant difference in PMS scores, resumption of normal diet, post-tonsillectomy haemorrhage as well as pain profiles of adults and children. Conclusion: Paracetamol-ibuprofen-tilidine combination appears to be more effective than either paracetamol-ibuprofen combination or ibuprofen in the first two weeks in the treatment of post tonsillectomy pain (p>0.05), however, further studies will have to be carried out to confirm this. Patients treated with a paracetamol-ibuprofen-tilidine combination appear to stop medication and return to their normal daily activities much earlier (p ≤ 0.05). Minor haemorrhage from the use of ibuprofen following tonsillectomy was not a cause for concern.

Hitzschke, Maria: Der Einsatz von FloSeal® bei der Blutstillung im Rahmen der Tonsillektomie Universität Leipzig, Dissertation 76 S., 79 Lit., 14 Abb., 17 Tab. Referat: Die Tonsillektomie ist eine der häufigsten operativen Eingriffe in der HNO-Heilkunde in Deutschland. Trotz neuer Techniken der Präparation und Blutstillung kann es dabei zu teilweise lebensbedrohlichen Komplikationen kommen. Ziel der vorliegenden randomisierten, monozentrischen Einfachblindstudie, welche auf prospektiv erfassten Patientendaten beruht, war es zu prüfen, ob der Einsatz einer Gelatine-Thrombin-Matrix (FloSeal®) bei der Blutstillung im Rahmen der Tonsillektomie einen Einfluss auf die Operationsdauer, den postoperativen Schmerzverlauf, die Wundheilung oder auf die Nachblutungsrate im Vergleich zur konventionellen elektrischen Blutstillungstechnik aufweist. Im Ergebnis konnten die Operationszeiten, vor allem für erfahrene Operateure, durch FloSeal® nicht verkürzt werden. Die bessere Planbarkeit der Operationsdauer durch die vordefinierte Blutstillungszeit bei der FloSeal®-Anwendung ist aber vor allem für unerfahrene Operateure von Bedeutung. Die postoperativen Schmerzen ab dem 4. postoperativen Tag waren in der FloSeal®-Gruppe geringer, auch die Schmerzdauer konnte um knapp 3 Tage verkürzt werden. Dies ist am ehesten auf eine verbesserte Wundheilung bei den mittels FloSeal® behandelten Patienten zurückzuführen, die sich in den stets signifikant geringeren Wundbelägen widerspiegelte. Der verminderte Einsatz der bipolaren Koagulation durch die Anwendung von FloSeal® konnte jedoch nicht zu einer signifikanten Reduktion der Nachblutungsrate führen. Trotz ermittelter Vorteile des Einsatzes von FloSeal® im Rahmen der Tonsillektomie sollte FloSeal® aber aus unserer Sicht den Patienten mit diffusen flächigen Blutungen im Rahmen einer Tonsillektomie vorbehalten bleiben, bei denen eine großflächige bipolare Koagulation die postoperative Morbidität deutlich steigern würde.

Abstract Seventy-eight prepubertal children 3 to 10 years old (mean age 5,67 years, range 2.4 - 10.5 years), with symptoms suggestive of obstructive sleep apnea syndrome (OSAS) were studied. Based on overnight polysomnography (PSG) results, 32 children were classified as having OSAS, whereas 46 children were considered as primary snorers (PSs'), when an obstructive apnea-hypopnea index (AHIO) of over one was considered abnormal. Symptoms, signs and findings in these two groups were compared in a cross-sectional study. Fifty-eight of the children were retrieved for a follow-up visit, which was scheduled six months from the first visit. The children with an initial AHIO of 2 or over (n = 21) had been subjected to adenotonsillectomy swiftly after the first visit, whereas the others (n = 37) were observed without intervention. The changes in symptoms, signs and findings were analysed within and between these groups. Relative risk (RR) ratios were calculated in order to find clinical symptoms and signs predicting OSAS in snoring children. Observed apneas, restless sleep, constant snoring and tonsillar hypertrophy were significantly associated with an increased risk of OSAS. Dental arch measurements indicated that AHIO was significantly associated with the amount of overjet, suggesting that altered breathing may affect the dentofacial morphology. Nasalance measurements revealed no group differences between the OSAS children and PSs'. Adenotonsillectomy had no significant influence on the nasalence scores. Measurements of nasalance seem to contribute little to the diagnostics of OSAS in children. At the first visit the mean circulating concentrations of insulin-like growth factor-1 (IGF-1) were of the same magnitude in the OSAS children, the PSs' and the age-matched control group, but both the OSAS children and the PSs' had lower IGF-binding protein-3 (IGFBP-3) concentrations than the control subjects. At the second visit a significant increase of the peripheral concentrations of IGF-1 and IGFBP-3, along with increases in weight for height and BMI were observed in the surgically treated children, whose respiratory parameters and symptoms had improved highly significantly, as well. These results indicate that the growth of children with obstructed nighttime breathing is potentially affected through impaired growth hormone secretion. None of the primary snorers developed OSAS during the observation period, which finding suggests a favorable prognosis for primary snoring in children.

Thesis (M Med (Otorhinolaryngology))-- University of Limpopo, 2011.
Aims: The purpose of this study was to assess if the use of post-operative antibiotics have any beneficial effects in reducing morbidity following elective tonsillectomy in children with age range of 1-13 years. . Objectives: To assess the degree of post-tonsillectomy pain, determine the incidence of secondary haemorrhage, establish the time period to the resumption of a normal diet, document adverse effects of the use of antibiotics (e.g. skin rash, anaphylaxis, diarrhoea and vomiting), determine the bacteriology in tonsil removed and make recommendations on post-tonsillectomy treatment protocol at DGMH. Methods: This prospective study was conducted at DGMH on 81 children with an age range of l-13years (mean 5.7years). At total of 40 children received paracetamol l5mg/kg/day (Group A) in three divided doses for seven days, and 41 received amoxicillin 40 mg/kg/day and paracetamol (Group B) for the same duration. The post operative morbidity and bacteriology of the two treatment groups were compared. Primary outcomes measured included the incidence and severity of pain, use of analgesia, resumption of normal diet, incidence ofheamorrhage, fever, vomiting and adverse reactions.

Aim: The aim of the study was to evaluate the differences in postoperative pain, nausea and time of discharge in children 3-12 years old after undergoing Tonsillectomy (TE) or Tonsillotomy (TT) at the post anaesthetic care unit (PACU), children’s ward and at home.  Background: TE involves risk of bleeding, severe postoperative pain and nausea. TT is a less invasive method with lower risk of bleeding and postoperative pain and nausea according to performed studies. Method: A prospective, comparative follow-up study design. Eighty-seven children from December 2008 until April 2009 in the ages 3-12 undergoing TE or TT participated. Visual analogue scale (VAS) was used for children’s pain and nausea assessments. Result/Findings: Significantly fewer children operated on by the TT assessed postoperative pain ≥ 3 according to the VAS than children operated on by the TE in both the PACU and the children’s ward. A significant difference of postoperative nausea was only present during the care at the PACU and children’s ward with fewer TT children that assessed nausea VAS ≥ 3. The time of postoperative care was shorter among the TT children in both the PACU and the children’s ward. Postoperative pain and pain related difficulties in eating after discharge was significantly more present among the TE children compared to the TT children. Conclusion: The results of our study indicated that TT is a more favourable alternative than TE in children.

Tonsillektomi är en av de vanligast utförda operationerna på barn i världen och kan innebära en lång och smärtsam återhämtning. Syftet med denna studie var att belysa vilka upplevelser som framkom under återhämtningen efter tonsillektomi på barn. Metoden var en litteraturstudie där tolv vetenskapliga studier ingick. Resultatetvisade att halssmärta var den dominerande upplevelsen och varade i dagar till veckor. Att svälja gjorde smärtan värre. Analgetika gavs i för små eller för få doser för att ge tillräcklig smärtlindring. Smärtan påverkade barnens möjligheter att äta, dricka och sova. Barnen hade egna strategier att hantera smärtan. Utökadpreoperativ information gjorde föräldrar och barn tryggare och säkrare. Postoperativtuppföljningssamtal gav föräldrarna möjlighet att få upprepad information ochkänslomässigt stöd. Som slutsats är det viktigt med adekvat, anpassad och upprepadinformation till barn och föräldrar om återhämtningen. Detta för att skapa trygghet till barn och föräldrar samt göra barns återhämtning så lindrig och smärtfrisom möjligt.
Tonsillectomy is one of the most common paediatric surgery performed over theworld and the recovery can be long and painful. The aim of this study was to illustrate the experiences associated with recovery after tonsillectomy on children.The method was a literature review where twelve scientific studies were included.The results showed that throat pain was the most difficult experience which lasted for many days or weeks. When swallowing, the pain became more severe. The painkiller at home was given in to small or too rare doses to give enough pain release. The pain influenced the child’s possibility to eat, drink and sleep. Children had their own strategies to cope with the pain. Extended preoperative information made the parents and children feel secure and more comfortable. Postoperative telephone follow-up gave the parents a possibility to get repeated information and emotional support. As a conclusion it is important to give a more adequate, adaptive and repeated information about the recovery to the child and the parents. This will encourage the child and the parents and make the child´s recovery as comfortable and painless as possible.

Abstract Periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA) is a syndrome characterized by regular, high-fever episodes with healthy periods in between. In a classic phenotype of the syndrome, the fevers begin in childhood before the age of five, and fever flares are accompanied by aphthous stomatitis, pharyngitis, and/or cervical adenitis. The etiology of the syndrome is unknown, but tonsillectomy (TE) has been shown to be an effective treatment for the disease. The purposes of this study were as follows: (1) to assess the long-term outcome of PFAPA patients treated by TE with either the classic or incomplete phenotype (later onset of the disease and/or missing oropharyngeal symptoms), (2) to compare the health and growth of PFAPA patients with healthy controls, and (3) to compare the histological and microbiological findings of the tonsils of PFAPA patients with controls via conventional and modern sequencing technologies. In this approximately 9-year follow up, 97% (n = 56) of patients with the classic phenotype and all patients (n = 50) with the incomplete phenotype achieved a prompt and constant response after TE. There were no differences in either the length of fever episodes or flares between patients with both the classic and incomplete phenotypes. The health and growth of 119 PFAPA patients was compared to that of sex- and age-matched controls (n = 230), and no differences in prevalence of chronic diseases or growth were found between the groups. Infections, oral thrush, and pollen allergy were more common in the history of the PFAPA patients than in the controls. Microbiological and histological findings of the tonsils of PFAPA patients (n = 31) were compared with the findings of the controls (n = 24) who had undergone TE for other reasons. Biofilm formation and Candida albicans were more frequently found among PFAPA patients than the controls, but Staphylococcus aureus, varicella zoster, and herpes simplex viruses were more common in the controls. While comparing the bacterial microbiota between the groups, we found significant differences in the presence and relative abundance of many bacteria. For example, Cyanobacteria were more common and abundant in the case samples than in the controls. Because the long-term outcome after TE was excellent, both in classic and incomplete PFAPA patients; a new diagnostic criteria for the syndrome is proposed. The microbes of the tonsils in PFAPA patients differ from that of the controls, which may play an important role in triggering the inflammatory processes that lead to symptoms of PFAPA
Tiivistelmä Periodic fever, aphthous stomatitis, pharyngitis, adenitis (PFAPA) syndrooma, on oireyhtymä, jossa potilaat kärsivät hyvin säännöllisesti ilmaantuvista, toistuvista kuumejaksoista, joiden välillä potilaat ovat terveitä. Klassisessa tautimuodossa kuumeilut alkavat lapsuudessa ennen viiden vuoden ikää ja kuumevaiheeseen liittyy liitännäisoireita: suun limakalvojen rakkuloita, nielutulehdusta ja/tai kaulan imusolmukkeiden suurentumista. Oireyhtymän syytä ei tiedetä, mutta nielurisaleikkaus (TE) on osoittautunut tehokkaaksi hoidoksi. Tutkimuksen tarkoituksena oli (1) arvioida PFAPA potilaiden vointia pitkäaikaisseurannassa TE:n jälkeen ja vertailla taudinkuvaa niiden PFAPA potilaiden välillä, joilla oli klassinen PFAPA tai epätyypillinen PFAPA. (2) Lisäksi tutkimme myös TE:lla hoidettujen PFAPA potilaiden sairastuvuutta, yleistä terveydentilaa ja kasvua vertaamalla näitä sukupuoli- ja ikävakioituihin kontrolleihin ja (3) selvitimme mikrobiologisia ja histologisia löydöksiä PFAPA potilaiden nielurisoissa verrattuna muista syistä TE:ssa käyneiden lasten nielurisoihin. Tässä noin yhdeksän vuoden seurannassa TE:n jälkeen oli täysin parantunut 97% (n = 56) potilaista, joilla oli klassinen PFAPA, ja kaikki (n = 50) potilaat, joilla oli epätyypillinen PFAPA (tauti oli alkanut viiden ikävuoden jälkeen ja/tai klassiset liitännäisoireet puuttuivat). Kuumeprofiilit eivät muilta osin eronneet ennen nielurisaleikkausta näissä ryhmissä. PFAPA potilaiden (n = 119) kasvu ja yleinen terveydentila eivät eronneet väestökontrolleista (n = 230). Krooniset ja autoimmuunisairaudet olivat yhtä harvinaisia molemmissa ryhmissä. Potilaat raportoivat sairastaneensa enemmän infektioita ja sammasta lapsuudessa ja heillä oli enemmän siitepölyallergioita. PFAPA potilaiden (n = 31) ja muista syistä TE:ssa käyneiden lasten (n = 24) nielurisojen mikrobiologiaa ja histologiaa tutkittiin ja vertailtiin. Biofilmimuodostusta nielurisan pinnalla ja Candida albicansia löytyi enemmän tapauksilta kuin kontrolleilta, kun taas Staphylococcus aureusta, varicella zoster- ja herpes simplex -viruksia tavattiin enemmän kontrolleilla. Myös mikrobiomi erosi ryhmien välillä, esimerkiksi syanobakteerit olivat yleisempiä PFAPA risoissa kuin kontrolleilla. Klassisten ja epätyypillisten PFAPA potilaiden terveydentila TE:n jälkeen oli pitkäaikaisseurannassamme erinomainen ja siksi ehdotamme, että PFAPA –syndrooman diagnostisia kriteereitä tulisi muuttaa. Nielurisojen mikrobisto on erilainen kontrolleihin verrattuna ja tällä voi olla merkitystä PFAPA syndrooman inflammatorisessa prosessissa

Crianças com aumento do volume de tonsilas palatinas e faríngeas, freqüentemente apresentam anormalidades respiratórias tais como roncar, respiração oral e apnéia do sono, assim como atraso no crescimento, alterações físicas e emocionais. Sabe-se que a obstrução de vias aéreas superiores e conseqüentemente a respiração oral podem resultar em problemas pulmonares. A obstrução de vias aéreas superiores também pode conduzir a alterações na mecânica respiratória e evoluir para alterações no equilíbrio das forças musculares, causando disfunções faciais, torácicas e dos eixos posturais. As alterações na função pulmonar (Pressão Inspiratória Máxima, Pressão Expiratória Máxima e Volume Pulmonar) foram avaliadas em 32 crianças (6-13 anos, M: F) com aumento do volume de tonsilas que seriam submetidas a cirurgia de Adenoamigdalectomia na Divisão de Otorrinolaringologia da Universidade de São Paulo. Todas as crianças foram avaliadas no pré e pósoperatório (3 e 6 meses) de adenotonsilectomia. A pressão Inspiratória e expiratória máxima foram medidas com o uso de um manovacuômetro. O volume pulmonar foi medido através do uso de um Inspirômetro de Incentivo infantil. Os perímetros torácicos e abdominais foram obtidos através de uma fita métrica comum. No pré-operatório os seguintes valores foram obtidos: pressão inspiratória máxima média de 24,72 cm/H2O, pressão expiratória máxima média de 37,50 cm/H2O, volume pulmonar médio de 682,81ml, perímetro torácico com média de 69,25cm e o perímetro abdominal com média de 67,50 cm. Todos os valores analisados apresentaram-se maiores no pós-operatório, sendo os resultados mais significantes a pressão inspiratória máxima com o valor de 28,62 cm/H2O no pós-operatório de 3 meses e 32,52 cm/H2O em seis meses. O volume pulmonar também apresentou um ganho de 265,47 ml no pós-operatório de seis meses em relação ao valor obtido no pré-operatório. Concluímos que a pressão inspiratória máxima apresentou um aumento significativo em seus valores no pós-operatório de 3 e 6 meses o que denota um ganho na força da musculatura respiratória inspiratória o que propiciou o aumento no volume pulmonar. Verificamos um aumento gradativo em todos os parâmetros estudados nos resultados obtidos no pós-operatório de 3 meses para os 6 meses. Os resultados comparativos entre os tamanhos das tonsilas (grau 3 e 4) não demonstraram diferença significativa.
Children with enlarged tonsils and pharynx, often exhibit respiratory abnormalities such as snoring, mouth breathing and sleep apnea, as well as delay in growth, physical and emotional changes. It is known that the upper airway obstruction and consequent mouth breathing may lead to lung problems. The obstruction of upper airway can also lead to changes in respiratory mechanics and evolve to changes in the balance of forces muscle, causing facial disorders, thoracic and axes posture. The changes in lung function (maximal inspiratory pressure, maximal expiratory pressure and lung volume) were evaluated in 32 children (6-13 years old, M: F) with enlarged tonsils who would be subjected to surgery for adenotonsillectomy at Division of Otorhinolaryngology, University of São Paulo. All children were evaluated in the preoperative and postoperative (3 and 6 months) of adenotonsillectomy. The maximal inspiratory and expiratory pressures were measured using a manometer. The lung volume was measured by using a volumetric incentive spirometer. The thoracic and abdominal perimeters were obtained through a common tape. Preoperatively the following values were obtained: mean maximal inspiratory pressure of 24.72 cm/H2O, mean maximal expiratory pressure of 37.50 cm/H2O, mean pulmonar volume of 682.81 ml. Mean girth of 69.25 cm and mean Abdominal Perimeter of 67.50 cm. All figures analyzed were higher in the postoperative period, and the more significant result was maximal inspiratory pressure with a value of 28.62 cm/H2O the postoperative 3-month and 32.52 cm/H2O in six months. The lung volume also showed a gain of 265.47 ml in the postoperative period of six months from the value obtained preoperatively. We conclude that the maximal inspiratory pressure showed a significant increase in their values in the postoperative period of 3 and 6 months which indicates a gain in respiratory muscle strength which allowed the increase in lung volume. Noticed a gradual increase in all parameters studied the results in the postoperative period of 3 months to 6 months. The comparative results between the size of tonsils (grade 3 and 4) showed no significant difference.

Kyoto University (京都大学)
0048
新制・課程博士
博士(社会健康医学)
甲第14908号
社医博第25号
新制||社医||6(附属図書館)
27346
UT51-2009-M822
京都大学大学院医学研究科社会健康医学系専攻
(主査)教授 中山 健夫, 教授 小川 修, 教授 三森 経世
学位規則第4条第1項該当

Introduction Rates of surgery vary considerably across the UK. Many assume that this on the one hand exposes residents of certain UK regions to unnecessary surgical risks, and on the other hand prevents those of neighbouring regions from receiving important surgical care. Nowhere is this more apparent than for tonsillectomy – an operation that involves removing the tonsils in patients suffering with severe recurring sore throats. With 40,000 tonsillectomies per year, it is one of the most common operations in the NHS, but remarkably, tonsillectomies are done seven times more frequently in some UK regions than in others. Despite national efforts to reduce these differences (e.g. re-education programmes for ENT surgeons, creation of national guidance on how to manage recurring sore throat, and financial penalties locally imposed to restrict high numbers of surgeries) this disparity has only got worse over the past 17 years. I undertook my research to examine the causes of these differences in more detail, to guide future policies. Aims The aim of my thesis was to develop a better understanding of the drivers of regional tonsillectomy rate variation by quantifying regional variation of tonsillectomy rates in relation to regional demands, and by exploring the role of professional uncertainty and treatment preference on the treatment chosen. Objectives The objectives were to establish the: A. Rate and regional variation of self-reported sore throat and help seeking behaviour in the community; B. Rate and regional variation of recurring sore throat in primary care; C. Rate and regional variation of tonsillectomy in secondary care, after adjusting for local rates of recurring sore throat; D. Constructs of clinical decision making and thereby ascertain which concepts were most likely to be related to surgical rate variation; E. Role of surgeon and patient decisional uncertainty on the treatment chosen for recurring tonsillitis; F. Role of surgeon and patient treatment preference on the treatment chosen for recurring tonsillitis; Methods By using the largest UK population based study of upper respiratory symptoms and primary-secondary care linked medical record databases, I was able to investigate regional surgical rate variations across the entire patient-disease pathway: from sore throat in the community (used as a surrogate marker for tonsillitis), through recurrent sore throat consultations in primary care and finally tonsillectomy in hospitals. Following systematic review and thematic analysis of patient focus groups, I designed an instrument to elicit patient and surgeon preference. By undertaking the largest observational study of decision-making in adults with recurring tonsillitis, I was able to investigate the role of both patient and surgeon treatment preference and decisional uncertainty on treatment choice. Results My results suggest: A. There is considerable variation in the incidence of self-reported severe sore throat between regions. However, once patient risk factors are accounted for there is no statistical evidence for disparity between regions. In those who self-report a severe sore throat there is also a degree of regional variation in the rate of relevant consultations for sore throat symptoms, however, once disease characteristics were accounted for, this regional disparity disappears. B. There is regional disparity in recurring sore throat consultations in primary care, however, once patient characteristics are accounted for, this regional variation reduces considerably. C. Similarly, there is regional disparity in tonsillectomy rates; this variation reduces considerably once patient characteristics are accounted for. D. In the literature concepts related to shared-decision-making are strongly inter-related and often poorly defined. Decisional uncertainty and treatment preference are amongst the best described, most measurable, and most appropriate constructs to investigate in a study of surgical rate variation. E. Decisional uncertainty, either patient’s or surgeon’s, was found to have no role to play in the treatment chosen during a consultation for recurring sore throat. F. Patients’ treatment preferences did not influence their treatment chosen, but surgeons’ treatment preferences did. Discussion There are three key findings of my thesis. Firstly, regional rate of consultation for sore throat – which was used as a proxy for the underlying tonsillitis rate in the population throughout – was mirrored in the regional rate of tonsillectomy. This implies the regional tonsillectomy rate variations reflect regional variations in the ‘need’ of the population. Secondly, regional tonsillectomy rate variations are greater for children than adults. Finally, treatment decisions for adults with recurring tonsillitis are more influenced by surgeon’s treatment preferences than patient preferences or severity. There is a strong culture within the NHS of addressing variations of all kinds as a means of increasing healthcare quality and decreasing cost. There are currently metrics of variation across almost every aspect of care, however few of these account for patient characteristics to the extent that this thesis has, meaning that the initiatives may be a waste of effort at best and harmful at worst. The work presented in my thesis uses a unique set of mixed methods to demonstrate the complexity of regional tonsillectomy rate variation, which too frequently has been investigated using poorly controlled cross-sectional studies and reduced to soundbites like the “Surgical Signature”. Whilst my study shows “surgical signature” is important, it fails to describe the true complexity of the variation observed. My study sheds more light on the complexity of this variation and provides a plausible reason as to why the policies to reduce tonsillectomy rate variations may have failed. This mixed methods approach could be used more broadly to inform discussions under regional surgical rate variations. Most importantly, the findings in this thesis also demonstrate where future policy could be targeted to reduce unwarranted regional tonsillectomy rate variation.

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This dissertation was carried out in the form of two articles. The first one had the objective conduct a systematic reviewof about intravenous and intraoperative administration of morphine for the analgesia of children submitted to palatine tonsillectomy. These surgeries may have significant perioperative morbidity, with the possibility of nausea, vomiting and respiratory events such as hypoxia, especially in pediatric patients, in addition to postoperative pain, which is considered intense and can be difficult to evaluate and treat. Morphine is an opioid drug that can be used as an analgesic in these patients, but it also has the potential to lead to some of these adverse events, which makes its use infrequent in these procedures. Thus, a bibliographic review was performed in the electronic databases Pubmed, Cochrane, Lilacs, Scielo and ClinicalKey, searching for studies written in English, Portuguese or Spanish, published until June 2017. The selected uniterms were "morphine", "opioid", "analgesia", "tonsillectomy" and "tonsillectomies" and the keyword "tonsillectomy", separated by the AND and OR interlocutors. Randomized, prospective clinical trials with patients up to the age of 18 years who underwent tonsillectomy and who used intravenous morphine administered intravenously with postoperative pain evaluation were included. The research was complemented by a review of the bibliographic references of each relevant article found. In the results found, the total number of children evaluated was 1076, with physical status ASA I to III, and the postoperative pain intensity evaluation was variable, being performed through numerical pain scales (NRS), behavioral (FLACC, Hannallah, CHEOPS and modified CHEOPS), by nursing assessment in the recovery room or by simple patient complaint. Only one of the studies was placebocontrolled and eight were double-blind. Pre-anesthetic medication was administered in 6 studies and the main one was paracetamol (acetaminophen). Morphine was used as the main analgesic, with pain reduction, as well as analgesia recovery, and there were adverse effects in the postoperative period, with variable incidence of nausea, vomiting, Abstract xxi pruritus, sedation and oxygen desaturation, but without reports of gravity. The conclusion was that intravenous morphine can be successfully used to treat pain in children after tonsillectomy, despite the need for rigorous postoperative monitoring, mainly breathing, and addition of prevention of nausea and vomiting. The second article was a prospective randomized clinical trial aimed at evaluating the use of intravenous morphine for postoperative analgesia in children submitted to tonsillectomy. It includes fifty-seven children 5 to 12 years old, ASA I, submitted to elective tonsillectomy, with or without adenoidectomy, under standardized general anesthesia and distributed in two groups to receive intraoperative analgesia. One group received 0.1mg / kg morphine intravenously shortly after intubation and another group did not. Postoperative pain was assessed independently by parents / guardians and children through the Face Pain Scale at 30, 60, 120, 180 and 240 minutes. In addition, the time of awakening of the anesthesia, the need for rescue analgesics and the possible adverse effects were observed. The results showed that the group that used morphine had a lower level of pain both in the evaluation by the children, at the moment of 30 min after awakening, and by the parents / guardians, in the moments of 30, 60 and 180 minutes in relation to the other group, without increase the awakening time of anesthesia and without significant adverse effects. There was a greater need for rescue analgesics in the group that did not use morphine. The conclusion was that administration of intravenous morphine during surgery reduced the intensity of pain in the immediate postoperative period, both in the reports of the children and the parents / guardians, without increasing the time of awakening from general anesthesia or adverse effects.
Esta dissertação foi realizada sob a forma de dois artigos. O primeiro teve como objetivo realizar uma revisão sistemática sobre administração via endovenosa e intra-operatória de morfina para a analgesia de crianças submetidas à tonsilectomia palatina. Estas cirurgias podem ter significativa morbidade peri-operatória, com possibilidade de náuseas, vômitos e eventos respiratórios como hipóxia, especialmente em pacientes pediátricos, além da dor pós-operatória, considerada intensa e que pode ser de difícil avaliação e tratamento. A morfina é uma droga opioide que pode ser utilizada como analgésico nestes pacientes, mas também tem o potencial de levar a alguns destes eventos adversos, o que torna seu uso pouco frequente nestes procedimentos. Assim, foi realizada revisão bibliográfica nas bases de dados eletrônicas Pubmed, Cochrane, Lilacs, Scielo e ClinicalKey, com busca de estudos escritos em inglês, português ou espanhol, publicados até junho de 2017. Os unitermos selecionados foram “morphine”, “opioid”, “analgesia”, “tonsillectomy” e “tonsillectomies” e a palavra-chave “amigdalectomia”, separados pelos interlocutores AND e OR. Foram incluídos ensaios clínicos randomizados, prospectivos, com pacientes até 18 anos de idade, submetidos a tonsilectomia com utilização no intra-operatório de morfina administrada via endovenosa e com avaliação da dor pós-operatória. A pesquisa foi complementada pela revisão das referências bibliográficas de cada artigo relevante encontrado. Nos resultados encontrados, o total de crianças selecionadas foi de 1076, com estado físico ASA I a III, e a avaliação da intensidade da dor pós-operatório foi variável, sendo realizada através de escalas numérica de dor (NRS), comportamentais (FLACC, Hannallah, CHEOPS e CHEOPS modificada), por avaliação da enfermagem na sala de recuperação ou ainda pela simples queixa dolorosa do paciente. Apenas um dos estudos foi controlado com placebo e oito foram duplocegos. Medicação pré-anestésica foi administrada em 6 estudos, sendo a principal o paracetamol (acetaminofeno). A morfina foi utilizada como analgésico principal, com redução da dor, e também para resgate da analgesia, e houve presença de efeitos adversos no pós-operatório, com Resumo xix incidências variáveis de náuseas, vômitos, prurido, sedação e dessaturação do oxigênio, mas sem relatos de gravidade. A conclusão foi que a morfina via endovenosa administrada no intraoperatório pode ser utilizada com sucesso para tratamento de dor em crianças após tonsilectomia, apesar da necessidade de monitorização pós-operatória rigorosa, principalmente da respiração, além também da prevenção de náuseas e vômitos. Já o segundo artigo trata-se de um ensaio clínico randomizado prospectivo, com o objetivo de avaliar o uso de morfina endovenosa para analgesia pós-operatória de crianças submetidas à tonsilectomia. Ele inclui cinquenta e sete crianças de 5 a 12 anos, ASA I, submetidas à cirurgia eletiva de tonsilectomia, com ou sem adenoidectomia, sob anestesia geral padronizada e distribuídas em dois grupos para receberem analgesia intraoperatória. Um grupo recebeu morfina 0,1mg/kg via endovenosa logo após a intubação e outro grupo não. A dor pós-operatória foi avaliada de forma independente por pais/responsáveis e pelas crianças através da Escala de Dor pela Face nos momentos de 30, 60, 120, 180 e 240 minutos. Além disto, observou-se o tempo de despertar da anestesia, a necessidade de analgésicos de resgate e os possíveis efeitos adversos. Os resultados demostraram que o grupo que utilizou morfina apresentou menor nível de dor tanto na avaliação pelas crianças, no momento de 30 min após despertar, quanto pelos pais/responsáveis, nos momentos de 30, 60 e 180 minutos em relação ao outro grupo, sem aumentar o tempo de despertar da anestesia e sem efeitos adversos significativos. Houve maior necessidade de analgésico de resgate no grupo que não utilizou morfina. A conclusão foi que a administração de morfina via endovenosa durante a cirurgia reduziu a intensidade da dor no pós-operatório imediato, tanto no relato das crianças quanto no dos pais/responsáveis, sem aumentar o tempo de despertar da anestesia geral ou os efeitos adversos.

Tonsillectomy, adenoidectomy and myringotomy are the most common surgical procedures undergone by children. Medical opinion regarding the appropriateness of these procedures remains contentious, and considerable resources have been expended in the formulation and distribution of relevant practice guidelines. The impact of this surgery on the child, community and private and public health resources is considerable, yet there has been little examination of surgery rates and trends, or of the characteristics of children who undergo surgery. This thesis addressed five major questions regarding this surgery in New South Wales, Australia. The first three related to population rates: the level of surgery among NSW children, comparability with international rates, trends over time and the effect of guidelines. Comprehensive hospital data between 1981 and 1999 were analysed. Major findings were a higher myringotomy rate in NSW than reported internationally, the short-term effect of guidelines, and a major shift towards children having surgery at a younger age. The remaining questions asked whether children who had surgery differed from other children in their use of health services prior to surgery, and if so, whether their utilization reverted to the norm following surgery. Matched records of a population cohort of 6239 NSW children, born during January 1990, were extracted from Health Insurance Commission data, and their claims for medical services followed retrospectively from birth to 8 years. Children who had privately funded surgery were found to use more medical services than other children, and, most unexpectedly, this did not change following surgery. The results suggest potential non-clinical factors influencing this excess utilization. This is the first population study to examine health service utilisation by these children and it has identified an important new risk factor for surgery.

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The pharynx is an organ that participates in the respiratory and digestive systems. Its peculiar tubular anatomy may be mechanically obstructed, especially due to adenotonsillar hyperplasia. This hyperplasia, when chronic, results in changes in craniofacial growth and development. The present study aimed to perform the threedimensional evaluation, using cone beam computed tomography (CBCT), of 4- to 9- year-old children, with and without indication for adenotonsillectomy (AT) and with maxillary atresia, comparing the measurements and the location of the minimum area of the pharynx, as well as the total pharyngeal volume and the volume of the subregions of the palatine tonsils and adenoids and, additionally, locating the position of the hyoid bone (H) and correlating it with the total pharynx volume and the volume of the subregions of the palatine tonsils and adenoids. For the selection of the nonprobabilistic consecutive sampling, 487 children were screened at the Otorhinolaryngology Outpatient Clinic of the Hospital das Clínicas, School of Medicine of the Universidade Federal de Goiás, from March to December 2017. Inclusion criteria were: age group between 4 and 9 years, presence of maxillary atresia, and balanced face (evaluated by the S line) using facial analysis. Exclusion criteria were: obesity, extensive caries, previous AT, presence of craniofacial syndromes or congenital anomalies, history of traumas or surgeries in the region of head, neck, or face, previous orthopedic/orthodontic treatment, early tooth loss, and dental Class II or III. The diagnosis of maxillary atresia and the other oral conditions were performed by two orthodontists. After selection, the patients were evaluated by an otorhinolaryngologist, who conducted anamnesis, physical examination and flexible nasal endoscopy to diagnose the obstruction due to adenotonsillar hyperplasia. The sample size calculation, considering the minimum area of the pharynx as the primary variable, defined 30 patients in each of the two study groups, the surgical and the non-surgical groups, who underwent the Prick test. Posteriorly, they underwent CBCT exams to evaluate the airflow and position of H. CBCTs were analyzed using the Invivo Dental software to obtain the three-dimensional and two-dimensional measurements of the pharyngeal airway space and the position of H. The age did not show statistical difference between groups (p = 0.111). The surgical group had a higher frequency of male participants. The measurements of total pharyngeal volume (p = 0.038), volume of the adenoid region (p = 0.001), and minimum area of the pharynx (p = 0.011) showed significant statistical differences between the grupos. In the surgical group, the highest frequency of the minimum area of the pharynx was in the adenoid region (60.0%), while in the non-surgical group the highest frequency was in the palatine tonsil region (73.3%). The correlation coefficient between H-Tweed mandibular plane (MP) and the volume of the palatine tonsil region was moderate in the surgical group (r = 0.408; p = 0.025). In conclusion, in this study: the pharyngeal volumes and the volume in the adenoid region were signifcantly reduced in the patients of the surgical group compared to the non-surgical group; the volume corresponding to the palatine tonsil region was similar in both groups; the narrowest pharynx area was located at a higher frequency in the region near the adenoid hyperplasia in the surgical group, whereas in the non-surgical group it was located at a higher frequency in the palatine tonsil region; no significant statistical difference was found for the position of H between the groups, and the correlation between its position and the sagital and vertical cephalometric patterns was weak.
A faringe é um órgão que participa dos sistemas respiratório e digestório. Sua peculiar anatomia tubular pode sofrer obstrução mecânica, em especial por hiperplasia adenotonsilar. Quando de caráter crônico, essa hiperplasia resulta em alterações no crescimento e no desenvolvimento craniofacial. O presente estudo teve como objetivo realizar a avaliação tridimensional, por meio de tomografia computadorizada de feixe cônico (TCFC), de crianças de 4 a 9 anos, com e sem indicação de adenotonsilectomia (AT) e com atresia de maxila, comparando as medidas e a localização da área mínima da faringe, assim como o volume total da faringe e das sub-regiões das tonsilas palatinas e adenoides e, adicionalmente, localizando a posição do osso hioide (H) e correlacionando-a com o volume total da faringe e das sub-regiões das tonsilas palatinas e adenoides. Para a seleção da amostra não probabilística consecutiva, foram triadas 487 crianças atendidas no Ambulatório de Otorrinolaringologia do Hospital das Clínicas da Faculdade de Medicina da Universidade Federal de Goiás entre março e dezembro de 2017. Os critérios de inclusão compreenderam faixa etária entre 4 e 9 anos, presença de atresia maxilar e face balanceada (avaliada pela linha S) por análise facial. Os critérios de exclusão foram: obesidade, cáries extensas, AT prévia, presença de síndromes craniofaciais ou anomalias congênitas, histórico de traumas ou cirurgias na região da cabeça, pescoço ou face, tratamento ortopédico/ortodôntico prévio, perda precoce de dentes e Classe II ou III dentária. O diagnóstico de atresia maxilar e das demais condições bucais foi feito por duas ortodontistas. Após a seleção, os pacientes foram avaliados por otorrinolaringologista, que procedeu a anamnese, exame físico e endoscopia nasal flexível para diagnóstico de obstrução por hiperplasia adenotonsilar. Pelo cálculo amostral, considerando como variável de desfecho primário a área mínima da faringe, definiu-se o número de 30 sujeitos em cada um dos dois grupos de estudo, o cirúrgico e o não cirúrgico, os quais foram submetidos ao Prick test. Posteriormente, passaram por exame de TCFC para avaliação da via aerífera e da posição do H. As TCFCs foram analisadas usando o software Invivo Dental para obtenção das medidas tridimensionais e bidimensionais do espaço aéreo faríngeo (EAF) e do posicionamento do H. A idade não apresentou diferença estatística entre os grupos (p = 0,111). O grupo cirúrgico apresentou maior frequência de indivíduos do sexo masculino. As medidas de volume total (p = 0,038), volume da região das adenoides (p = 0,001) e área mínima da faringe (p = 0,011) apresentaram diferenças estatisticamente significativas entre os grupos. No grupo cirúrgico, houve maior frequência de área mínima na região das adenoides (60,0%) enquanto no grupo não cirúrgico houve maior frequência na região das tonsilas palatinas (73,3%). O coeficiente de correlação entre H-plano mandibular de Tweed (MP) e o volume da região das tonsilas palatinas foi moderado no grupo cirúrgico (r = 0,408; p = 0,025). Conclui-se que, neste estudo: os volumes aéreos faríngeos e da região das adenoides foram significativamente reduzidos nos pacientes do grupo cirúrgico em comparação com os do grupo não cirúrgico; o volume correspondente à região das tonsilas palatinas se apresentou semelhante para os dois grupos; a área de maior estreitamento faríngeo se localizou com maior frequência na região próxima à hiperplasia das adenoides no grupo cirúrgico, enquanto no não cirúrgico se localizou com mais frequência na região próxima às tonsilas palatinas; não houve diferença estatisticamente significativa na posição do H entre os grupos, e a correlação entre a sua posição e os padrões cefalométricos sagital e vertical foi fraca.

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Objetivo: Identificar preditores de risco para complicações respiratórias após adenotonsilectomia (AT) em crianças menores que 12 anos com AOS que aguardam cirurgia, bem como a prevalência e gravidade da AOS. Métodos: Estudo prospectivo em hospital escola da Faculdade de Medicina de Botucatu. Foram incluídas crianças de ambos os gêneros, 2 a 12 anos de idade, com AOS e indicação de AT. Todos realizaram polissonografia de noite inteira no pré- e pós-operatório. Foram utilizados o teste t independente, teste t dependente, Mann-Whitney, Kruskal-Wallis e Qui-quadrado para identificação de fatores de risco para morbidade respiratória após AT e estratificação da AOS. Resultados: As 82 crianças que realizaram AT foram divididas em 2 grupos de acordo com presença ou ausência de complicações respiratórias. Dezesseis crianças (20%), com idade média de 8,2 + 2,4 anos, apresentaram complicações respiratórias, sendo 9 gênero masculino. Foram observadas complicações respiratórias menores (SpO2 80 - 90%) e maiores (SpO2 < 80%, broncoespasmos intra- e pós-operatório e depressão respiratória). Asma, rinopatia e déficit de atenção foram preditores independentes de complicações respiratórias após AT. Entre as intervenções médicas, 1 criança realizou NBZ contínuas com broncodilatador, 6 necessitaram de reposicionamento de via aérea e NBZ com O2 suplementar e 1 fez uso de Narcan para reverter depressão respiratória. A prevalência de AOS em crianças de 2 a 12 anos foi de 93% (76 crianças), sendo 35% com AOS leve (26 crianças), 41% AOS moderada (34 crianças) e 20% AOS grave (16 crianças). Apenas 7% (6 crianças) não apresentavam AOS. A avaliação clínica por questionário e o exame otorrinolaringológico não foram capaz de estratificar clinicamente as crianças de acordo com sua gravidade, com exceção da DRGE. Conclusão: Crianças com idade entre 2 a 12 anos diagnosticadas com AOS que apresentam déficit de atenção, asma e rinopatia desenvolveram maiores complicações respiratórias após AT. A prevalência de AOS em crianças que aguardam o procedimento de AT foi de 93%.
Objective: To identify risk factors for respiratory complications after adenotonsillectomy in children ≤ 12 years of age with OSA awaiting AT surgery, as well as identify the prevalence and severity of OSA. Methods: Prospective study in a tertiary level Hospital of Botucatu Medical School. Children of both genders, aged 2 to 12 years old, with complaints of respiratory disorders and indication for adenotonsillectomy were included. All children underwent full-night PSG in the pre- and pos-operative. Independent t-test, t-dependent test, Mann-Whitney, Kruskal-Wallis and Chi-square tests were used to identify risk factors for respiratory morbidity after AT and severity of OSA. Results: Eighty-two children who performed AT were divided into 2 groups according to the presence or absence of respiratory complications. Sixteen children (20%) mean age 8.2 ± 2.4 years presented respiratory complications, (9 male). Minor (SpO2 80-90%) and major respiratory complication (SpO2 < 80%, intra and postoperative bronchospasm and respiratory depression) were observed. Asthma, rhinopathy and attention-deficit were independent predictors of respiratory complications after TA. Among the medical interventions, 1 child performed continuous NBZ with a bronchodilator, 6 required airway repositioning and NBZ with supplemental O2, and 1 used narcan to reverse respiratory depression. The prevalence of OSA in children aged 2 to 12 years was 93% (76 children). Out of these, 35% (26 children) were mild, 41% (34 children) moderate and 20% (16 children) severe OSA. Only 7% (6 children) did not present OSA. Clinical evaluation by questionnaire and otorhinolaryngological examination were not able to clinically stratify children according to their severity, with the exception of GER. Conclusion: Children up to 12 years of age diagnosed with OSA who present attention-deficit, asthma and rhinopathy developed greater respiratory complications after AT. The prevalence rate of OSA in children waiting in the surgical row for the AT procedure was 93%.

Orientador: Silke Anna Thereza Weber
Resumo: Objetivo: Identificar preditores de risco para complicações respiratórias após adenotonsilectomia (AT) em crianças menores que 12 anos com AOS que aguardam cirurgia, bem como a prevalência e gravidade da AOS. Métodos: Estudo prospectivo em hospital escola da Faculdade de Medicina de Botucatu. Foram incluídas crianças de ambos os gêneros, 2 a 12 anos de idade, com AOS e indicação de AT. Todos realizaram polissonografia de noite inteira no pré- e pós-operatório. Foram utilizados o teste t independente, teste t dependente, Mann-Whitney, Kruskal-Wallis e Qui-quadrado para identificação de fatores de risco para morbidade respiratória após AT e estratificação da AOS. Resultados: As 82 crianças que realizaram AT foram divididas em 2 grupos de acordo com presença ou ausência de complicações respiratórias. Dezesseis crianças (20%), com idade média de 8,2 + 2,4 anos, apresentaram complicações respiratórias, sendo 9 gênero masculino. Foram observadas complicações respiratórias menores (SpO2 80 - 90%) e maiores (SpO2 < 80%, broncoespasmos intra- e pós-operatório e depressão respiratória). Asma, rinopatia e déficit de atenção foram preditores independentes de complicações respiratórias após AT. Entre as intervenções médicas, 1 criança realizou NBZ contínuas com broncodilatador, 6 necessitaram de reposicionamento de via aérea e NBZ com O2 suplementar e 1 fez uso de Narcan para reverter depressão respiratória. A prevalência de AOS em crianças de 2 a 12 anos foi de 93% (76 crianças), sendo 3... (Resumo completo, clicar acesso eletrônico abaixo)
Doutor

In Sweden over 10.000 patients annually, mostly children, undergo tonsillar surgery. The most common surgical method is total removal of the tonsil, tonsillectomy (TE). During the last decade partial tonsil resection, tonsillotomy (TT), has been reintroduced and is associated with lower primary morbidity and less postoperative pain. The aim of the present study was to evaluate if and to what extent 4-5 year old children’s voice function are affected by tonsillar hypertrophy compared to controls and to study the effects of the two surgical techniques on vocal function. Sixty-seven children with tonsillar hypertrophy, where randomized either to TE or TT. A voice material consisting of words with only sonorants and three sustained vowels was recorded preoperatively and six months postoperatively. Eighty-two preschool children formed two control groups. The material was evaluated perceptually by three voice specialized speech and language pathologist and analyzed acoustically. Before surgery the children with tonsillar hypertrophy are rated to have higher prevalence of hoarseness, hyponasality and ‘compressed/throaty voice’ compared with the controls. The acoustic analysis show that the children with tonsillar hypertrophy have higher prevalence of perturbation (jitter (%), shimmer (%) and NHR) compared to the controls. Postoperatively there are no significant difference between the children with tonsillar hypertrophy and the control group perceptually. The acoustic analysis of the children with tonsillar hypertrophy still show more perturbation compared to the control group. The children operated with TE are rated to have less prevalence of roughness and hyponasality after surgery. The children in the TT-group have less prevalence of roughness, hyponasality and ‘compressed/throaty voice’. The acoustic analysis show no significant difference between the two postoperative groups.

Över 10 000 patienter tonsillopereras årligen i Sverige, de flesta av dem barn. Den vanligaste kirurgiska metoden har sedan länge varit totalt avlägsnande av tonsillerna, tonsillektomi (TE). Under det senaste decenniet har partiellt borttagande av tonsillvävnad, tonsillotomi (TT) erövrat terräng då operationen är förknippad med lägre postoperativ morbiditet och lägre smärta. Syftet med föreliggande studie var att undersöka om och hur röstfunktionen är påverkad av tonsillhypertrofi hos barn i 4-5 års ålder i jämförelse med köns- och åldersmatchade kontroller samt att studera effekterna på röstfunktionen efter två olika typer av kirurgisk behandling, TE respektive TT. I föreliggande studie deltog 67 barn med tonsillhypertrofi som randomiserades till antingen TE eller TT. Ett röstmaterial bestående av ord som till största del bestod av sonoranter samt tre uthållna vokaler spelades in omedelbart före operation samt 6 månader postoperativt. Åttiotvå köns- och åldersmatchade förskolebarn utgjorde två kontrollgrupper. Materialet bedömdes perceptuellt av tre röstlogopeder samt analyserades akustiskt. Barnen med tonsillhypertrofi uppfattas före operation ha högre förekomst av de perceptuella parametrarna heshet, hyponasalitet, och klämd/halsig i jämförelse med köns- och åldersmatchade kontroller. Den akustiska analysen i sin tur visar på mer perturbation (jitter (%), shimmer (%) och NHR) hos barnen med tonsillhypertrofi. Efter kirurgisk behandling visar den perceptuella röstbedömningen att det inte föreligger någon signifikant skillnad mellan de barn som genomgått kirurgisk behandling och kontrollerna. Den akustiska analysen visar på att både barnen som genomgått TE och barnen som genomgått TT har mer perturbation i jämförelse med köns- och åldersmatchade kontroller. Vid jämförelse pre- och postoperativt visar röstbedömningen på en minskning av skrovlighet och hyponasalitet för barnen som genomgått TE samt skrovlighet, hyponasalitet och klämd/halsig för barnen som genomgått TT. Den akustiska analysen visar på att det inte föreligger någon större skillnad mellan barnen som genomgått TE och barnen som genomgått TT.

Aims This study aimed to assess the effectiveness of a storybook, entitled, The Tale of Woody's Tonsils, written by the researcher, in reducing the level of anxiety of children, aged 5 - 11 years who were undergoing tonsillectomy and adenoidectomy. The study also aimed to explore a number of variables which may have had an impact on anxiety and which may be influenced by the administration of the storybook. Background There is evidence, in both adult and paediatric studies, that effective psychological preparation for a surgical procedure has an impact on the individuals' coping ability with reduced levels of anxiety leading to better post operative outcome, faster recovery and a reduction in long term sequelae associated with admission to hospital. A storybook, as a method of preparation, has been recommended by a number of researchers but the effectiveness of a specific storybook has not yet been investigated in the UK. Previous studies have mainly used only one research instrument for anxiety measurement and chi Id self report is not a common feature of such research. Design A quasi-experimental study, using convenience sampling was conducted using a repeated measures design at two points in time. XI Method Eighty children on a waiting list for tonsillectomy and adenoidectomy were alternately allocated to either an experimental group, receiving a copy of the storybook or to a comparative group, receiving a colouring book. Pre intervention testing consisted of the subjects completing a self report Hospital Fears Rating Scale and the Child Drawing: Hospital, a projective technique based on child drawing. This was repeated post intervention and scores obtained from both instruments were used to determine anxiety levels. Results Results indicated that the use of the storybook reduced anxiety levels of children aged 5 - 11 years awaiting admission for tonsillectomy and adenoidectomy. No relationship was found between age, gender, experience of previous hospitalisation or experience of sibling hospitalisation on the level of anxiety experienced. There was evidence from the results to suggest that the storybook was particularly effective in reducing anxiety levels of females, children with no experience of previous hospitalisation, children with experience of sibling hospitalisation and children in the seven year old age group. Conclusion This study demonstrates that, as a method of psychological preparation of children aged 5 - 11 years awaiting tonsillectomy and adenoidectomy, a storybook about a fictional human child undergoing the same procedure was effective in alleviating anxiety pertaining to the admission. It also supports the appropriateness and benefits of a combined approach, using quantitative scoring and impressionistic interpretation, to the measurement of anxiety. Relevance to practice This study fills a gap in the knowledge base regarding psychological preparation of children for ENT surgery. It reinforces the need for assessment to be inclusive of exploration of anxiety triggers and their intensity so that preparation and nursing care can be individualised for each child. The study also provides evidence that there is a need for child focused anxiety measurement tools to be chosen carefully for use within the field of paediatrics. The two anxiety measurement tools used within this study could be effectively used in a number of health care settings, both long and short term care and with a variety of age groups. Finally, this study has demonstrated that the use of a storybook is a particularly effective method for preparing children for an ENT surgical procedure and the principles of its development and use could be extended to other specialties.

A Thesis submitted to The University of Arizona College of Medicine - Phoenix in partial fulfillment of the requirements for the Degree of Doctor of Medicine.
Purpose: Acupuncture at point P6 has proven efficacious in alleviating postoperative nausea and vomiting (PONV). Evidence supporting its use in pediatric patients is not nearly as conclusive. Furthermore, acupuncture’s effects when combined with antiemetics needs to be further elucidated. We conducted a double-blinded, randomized controlled trial to investigate the effects of P6 acupuncture combined with antiemetics on pediatric patients undergoing tonsillectomy. Methods: A total of 109 patients between the ages of 3 – 9 years old were randomly assigned to one of two treatment groups prior to surgery. Each group received standard antiemetic medications while only one group received acupuncture intraoperatively. PONV was assessed via usual protocol while the patients remained at the post-anesthesia care unit (PACU) and Day Stay Unit. A follow-up phone call 24 hours following surgery was conducted to assess for overnight symptoms. Results: 106 patients completed the study with 58 randomly assigned to the Treatment Group, whom receive acupuncture and antiemetic therapy, and 48 to the Control Group, receiving only antiemetic therapy. When comparing baseline characteristics and possible confounding factors for each group, no statistical differences between the groups could be found. For primary outcomes, the only significant difference between the two groups occurred with the incidence of nausea in the PACU following the surgery (P = 0.02), but nausea in the Day Stay Unit trended toward significance (P = 0.06). Retching and vomiting incidence did not occur frequently enough in the hospital to be analyzed. No differences between the Treatment Group and Control group were seen in the 24 hours after the patients were discharged from the hospital. Discussion: With no adverse events from its use and with statistically significant efficacy, P6 acupuncture embodies a useful prophylactic treatment for postoperative nausea in children.

Background: Snoring and obstructive sleep apnea (OSA) are both common disorders with a number of negative health effects. The safety and efficacy of treating snoring and OSA surgically have been questioned and there has been a lack of studies in the field. Aims: 1) To investigate the frequency of serious complications, including death, after surgery for the treatment of snoring and sleep apnea; 2) to evaluate the effect on daytime sleepiness after radiofrequency surgery of the soft palate in snoring men with mild or no OSA; 3) to evaluate the effect of tonsillectomy on sleep apnea in adults with OSA and tonsillar hypertrophy; 4) to investigate the morphology and cytoarchitecture of muscle fibers in human soft palatal muscles with immunohistochemical and morphological techniques. Methods and results: In paper 1, a retrospective database study. All Swedish adults who were treated surgically because of snoring or OSA from January 1997 to December 2005 were identified in the National Patient Register. None of the surgically treated patients died in the peri- and postoperative period. Severe complications were recorded in 37.1 of 1,000 patients treated with uvulopalatopharyngoplasty (UPPP), in 5.6 of 1,000 patients after uvulopalatoplasty (UPP) and in 8.8 of 1,000 patients after nasal surgery. In paper 2, the study was designed as a randomized, controlled trial. 35 snoring men with mild or no OSA were randomized to either radiofrequency or sham surgery of the soft palate. Radiofrequency surgery was not found to be effective since there was no significant difference between the two groups in relation to the Epworth Sleepiness Scale (ESS) or apnea-hypopnea index (AHI) at follow-up. Paper 3 was a prospective study, including 28 patients with an AHI of >10 and with large tonsils. In these patients, tonsillectomy was an effective treatment for OSA; the mean AHI was reduced from 40 units/h to 7 units/h (p<0.001), and the mean ESS was reduced from 10.1 to 6.0 (p<0.001) at the six-month follow-up after surgery. Minor and moderate swallowing dysfunction was found in seven of eight patients investigated before surgery and the swallowing function improved in 5 of them after surgery, while no one deteriorated. In paper 4, we investigated the morphology and cytoarchitecture in normal soft palate muscles. Human limb muscles were used as reference. The findings showed that the soft palate muscle fibers have a cytoskeletal architecture and cellmembrane complex that differs from that of the limb muscles. Conclusions No case of death related to surgery was found among 4,876 patients treated with UPPP, UPP or nasal surgery for snoring or OSA in Sweden between 1997 and 2005. Radiofrequency surgery of the soft palate has no effect on daytime sleepiness, snoring or apnea frequency in snoring men with mild or no OSA. Tonsillectomy can be an effective treatment for OSA in adults with large tonsils. A subgroup of muscle fibers in the human soft palate appears to have special biomechanical properties and their unique cytoarchitecture must be taken into account while assessing function and pathology in oropharyngeal muscles.
Snarkning och obstruktiv sömnapné (OSA) är idag en global folksjukdom. Snarkning är det ”oljud” som uppstår när luftvägen under sömn förminskas och vävnaden börjar vibrera under andning. Vid obstruktiv sömnapné faller vävnaden samman och blockerar luftflödet till lungorna. Ett andningsuppehåll, en s.k. apné inträffar. Ett andningsuppehåll kan pågå allt ifrån några sekunder till mer än en minut och kan uppstå hundratals gånger per natt. För att klassificeras som en patologisk apné enligt internationell standard måste andningsuppehållet vara längre än 10 sek. Snarksjukdomen förvärras sannolikt över tid och övergår succesivt i obstruktiv sömnapné med ökande antal andningsuppehåll under sömn. Detta leder till ett stresspåslag för kroppen med oftast uttalad dagtrötthet och en mängd negativa hälsoeffekter. Snarksjukdom och sömnapné ökar risken för bl.a. högt blodtryck och hjärt-kärlsjukdom samt också för att den drabbade ska orsaka trafikolyckor på grund av försämrad koncentrationsförmåga och trötthet. En del av den negativa utvecklingen från snarkning till sömnapné anses bero på att snarkvibrationer kan ge neuromuskulära skador i gom och svalg. Dessa vävnadsskador anses också vara orsaken till att personer som snarkat länge ofta uppvisar störd sväljningsfunktion i form av felsväljning, där maten i uttalade fall hamnar i luftstrupen istället för i matstrupen. I dagsläget är förstahandsbehandling vid sömnapné CPAP, en mask som placeras över näsa och mun och som skapar ett övertryck i luftvägen vilket förhindrar att luftvägen faller samman och att andningsstopp uppstår. CPAP har enligt flera studier den bästa effekten mot andningsuppehåll. En annan vanlig behandling är en bettskena som för underkäken nedåt och framåt så att luftvägen bli mer öppen. Bettskenan är en vanlig och effektiv behandlingsmetod för personer utan kraftig övervikt vid vanemässig snarkning eller måttlig sömnapné. För ett tjugotal år sedan var kirurgi förstahandsmetoden vid behandling av snarkning och måttlig sömnapné. Man utförde då ofta operationer i svalg och gomm, s.k. gomplastiker. Bruket av kirurgisk behandling har dock minskat med tiden, dels p.g.a. biverkningar men också för att det saknades vetenskapliga studier som bevisade att kirurgin gav önskad och långsiktig effekt. Kirurgi utgör dock fortfarande ett komplement till behandling av snarkning och sömnapné när CPAP eller bettskena av olika skäl inte fungerar eller kan tolereras av patienten. 8 Även barn kan lida av snarkning och sömnapné men behandlingsprinciperna för barn skiljer sig från dem hos vuxna och berörs inte i avhandlingen. I denna avhandling studeras: i) biverkningsfrekvenser efter olika typer av snarkkirurgi, ii) effekten av radiovågsbehandling i mjuka gommen på vuxna män med snarkning, iii) effekten av att operera bort halsmandlarna på vuxna med sömnapné och stora halsmandlar, iv) muskelvävnadens struktur och molekylära uppbyggnad i mjuka gommen hos friska personer som inte snarkar. Avhandlingen består av fyra delstudier: 1. En registerstudie med kartläggning av svåra biverkningar efter kirurgi i form av uvulopalatopharyngoplastik, uvulupalatoplastik samt näskirurgi för behandling av sömnapné och snarkning och utfört i Sverige mellan åren 1997-2005. Studien omfattade 4 876 patienter. Inga dödsfall noterades. Komplikationsrisken var störst vid operationer där man tog bort delar av mjuka gommen samt halsmandlarna, där i snitt 37 av 1000 opererade fick biverkningar, framförallt p.g.a. infektioner eller blödningar. 2. I en prospektiv, randomiserad placebostudie utvärderades effekten av radiovågsbehandling i mjuka gommen vid snarkning och lindrig sömnapne. Trettiotvå patienter lottades till att få radiovågsbehandling eller placebo behandling. Patienterna visste inte vilken grupp de tillhörde. Vid uppföljning efter 12 månader var det inga statistiska belägg för att radiovågsbehandling minskade vare sig antal andningsuppehåll eller dagtrötthet. 3. Effekten av att ta bort halsmandlarna på patienter med stora halsmandlar och olika grad av sömnapné utvärderades i denna studie. Totalt deltog 28 patienter. Vid uppföljning 6 månader efter operationen hade antalet andningsuppehåll sjunkit drastiskt, från i snitt 40 till 7 andningsuppehåll per timme nattsömn. Inga allvarliga biverkningar uppstod. Dessa fynd talar för att man som förstahandsmetod ska erbjuda patienter med sömnapné och stora halsmandlar att ta bort halsmandlarna. 4. I detta projekt undersökte vi utseendet och uppbyggnaden av cellskelettet i två normala muskler i mjuka gommen hos friska personer utan känd snarkning och sömnapné. Muskler från armar och ben användes som referens. Fynden i studien visar att de normala muskelfibrernas uppbyggnad i mjuka gomen skiljer sig från jämförade muskler i armar och ben. Detta kan vara ett uttryck för en evolutionär utveckling för att möjligöra de komplexa funktioner som krävs av svalgets muskulatur. 9 Sammanfattningsvis kan vi konstatera: Att inga dödsfall har skett i Sverige efter operationer i gom, svalg eller näsa, utförda för att behandla snarkning och sömnapné under åren 1997 till 2005. Att radiovågsbehandling av mjuka gommen hos snarkande män med lindrig sömnapné inte har någon effekt på dagtrötthet, snarkning eller andningsuppehåll vid uppföljning efter 12 månader. Metoden kan därför inte rekommenderas. Att när man opererar bort stora halsmandlar på personer med andningsuppehåll så leder detta ofta till att andningsuppehållen minskar drastiskt. Metoden kan därför oftast rekommenderas som en förstahandsbehandling för denna patientgrupp. Att mjuka gommens muskelfibrer är uppbyggda på ett unikt sätt indikerar att deras specifika biomekaniska egenskaper skiljer sig från referens muskler i armar och ben.

Uvod: Adenoidektomija sa tonzilektomijom je najčešće indikovana hirurška intervencija u dečjem uzrastu. Intervencija se izvodi u opštoj anesteziji. Endotrahealni tubus predstavlja „zlatni standard“ za obezbeđenje disajnog puta u dečjoj otorinolaringološkoj hirurgiji. Upotreba endotrahealnog tubusa nosi rizike od nastanka komplikacija koje se mogu javiti pri uvodu u opštu anesteziju, u toku hirurške intervencije i nakon ekstubacije deteta. Učestalost komplikacija se može smanjiti upotrebom supraglotičnih sredstava. Fleksibilna laringealna maska spada u prvu generaciju supraglotičnih sredstava, koja omogućava zadovoljavajuću oksigenaciju i ventilaciju bolesnika u ORL hirurgiji. Cilj istraživanja: Utvrditi: efikasnost fleksibilne laringealne maske u zaštiti disajnog puta od aspiracije krvi i sekreta gornjih disajnih puteva u odnosu na endotrahealni tubus u toku adenotonzilektomije; da li primena fleksibilne laringealne maske u zbrinjavanju disajnog puta u toku adenotonzilektomije utiče na učestalost postekstubacionih komplikacija u odnosu na zbrinjavanje disajnog puta endotrahealnim tubusom; da li zbrinjavanje disajnog puta fleksibilnom laringealnom maskom u toku adenotonzilektomije ima uticaj na intenzitet postoperativnog bola u odnosu na zbrinjavanje disajnog puta endotrahealnim tubusom; da li zbrinjavanje disajnog puta fleksibilnom laringealnom maskom u toku adenotonzilektomije ima uticaj na pojavu postoperativne mučnine i povraćanja u odnosu na zbrinjavanje disajnog puta endotrahealnim tubusom. Metodologija: Prospektivnom, randomizovanom, studijom bilo je obuhvaćeno 160 dečaka i devojčica uzrasta od 3 do 8 godina planiranih za elektivnu hiruršku intervenciju adenotonzilektomiju u opštoj anesteziji. Bolesnici su bili podeljeni u dve grupe: 80 bolesnika kod kojih je disajni put bio obezbeđen endotrahealnim tubusum (ET grupa) i 80 bolesnika kod kojih je disajni put bio obezbeđen laringealnom maskom (LMA grupa). Na kraju hirurške intervencije, u obe grupe bolesnika, izvršena je provera prisustva krvi na larinksu i u traheji pomoću fiberoptičkog bronhoskopa. Postekstubacione respiratorne komplikacije vezane za upotrebu fleksibilne laringealne maske odnosno endotrahealnog tubusa (kašalj, opstrukcija disajnog puta i laringospazam) bile su praćene neposredno nakon ekstubacije bolesnika. Procena postoperativnog bola bila je vršena pomoću Face, Legs, Activity, Cry, Consolability Scale 2 i 4 sata nakon hirurške intervencije kao i prvog postoperativnog dana u 7 sati ujutro. Postojanje postoperativne mučnine i povraćanja bilo je utvrđivano heteroanamnestički, anketom roditelja, dan nakon hirurške intervencije u 7 sati ujutro. Statistička analiza izvršena je pomoću statističkog paketa Statistical Package for Social Sciences – SPSS 21. Podaci su predstavljeni tabelarno i grafički, a statistička značajnost je određivana na nivou p<0.05. Rezultati: Ni kod jednog deteta iz ET odnosno LMA grupe bolesnika nakon hirurške intervencije fiberoptičkim bronhoskopom nije uočeno prisustvo krvi, sekreta niti regurgitiranog želudačnog sadržaja na larinksu odnosno u traheji. Bolesnici iz ET grupe su imali statistički značajno više komplikacija u odnosu na bolesnike iz LMA grupe (χ2=4.254; p=0.039; p < 0.05). Ne postoji statistički značajna razlika u distribuciji bolesnika sa i bez respiratornih komplikacija izmeĊu ET i LMA grupe (χ2=3.413; p=0.065; p > 0.05). U proceni postoperativnog bola FLACC skalom 2 sata nakon hirurške intervencije postoji statistički značajna razlika u intenzitetu postoperativnog bola kod bolesnika iz ET u odnosu na bolesnike iz LMA grupe (χ2=31.316; p=0.000; p<0.05). Četiri sata nakon hirurške intervencije, statistički je značajno više bolesnika sa umerenim bolom u ET grupi u odnosu na LMA grupu (χ2=40.705; p=0.000; p<0.05). Na dan otpusta, statistički je značajno više bolesnika sa blagim diskomforom u ET grupi bolesnika u odnosu na LMA grupu (χ2=8,012; p=0,005; p < 0.05). U LMA grupi bolesnika jedan ili 1.49% bolesnika je imao postoperativnu mučninu i povraćanje, dok je u ET grupi troje ili 3.56% bolesnika imalo postoperativnu mučninu i povraćanje. Zaključak: Fleksibilna laringealna maska pruža podjednaku zaštitu distalnih delova disajnog puta od krvi i sekreta tokom adenotonzilektomije kao i endotrahealni tubus. Učestalost postoperativnih komplikacija i intenzitet postoperativnog bola su manji kada se za obezbeđenje disajnog puta u toku adenotonzilektomije koristi fleksibilna laringealna maska. Primenom fleksibilne laringealne maske smanjuje se učestalost postoperativne mučnine i povraćanja u toku adenotonzilektomije.
Introduction: Adenoidectomy with tonsillectomy is the most indicated surgery in childhood. The intervention is performed under general anesthesia. Endotracheal tube represents the „gold standard“ for airway management in paediatric ENT surgery. The use of endotracheal tube carries the risk of complications that may occur during the induction of general anesthesia, during the surgery and after extubation of the child. The frequency of complications may be reduced by the use of supraglottic airway devices. Flexible laryngeal mask is first generation of supraglottic airway devices, which allows sufficient oxygenation and ventilation of patients in ENT surgery. Aims: To determine the effectiveness of the flexible laryngeal mask which protectes the airway from aspiration of blood and secretions of the upper airways compared to the airway management with endotracheal tube during adenotonsillectomy; to determine does the usage of the flexible laryngeal mask in airway management during adenotonsillectomy affects the frequency of post extubation complications compared to the airway management with endotracheal tube, as wll as does the usage of the flexible laryngeal mask in airway management during adenotonsillectomy has an impact on the intensity of postoperative pain compared to the airway management with endotracheal tube, and does the usage of the flexible laryngeal mask in airway management during adenotonsillectomy has an impact on the incidence of postoperative nausea and vomiting compared to the airway management with endotracheal tube. Methodology: One hundred and sixty boys and girls aged from 3 to 8 years scheduled for elective surgical intervention adenotnosillectomy in general anaesthesia were included in this prospective, randomized study. Patients were divided into two groups: 80 patients in whom the airway was managed with a cuffed endotracheal tube (ET group) and 80 patients in whom airway was managed with a laryngeal mask (LMA group). At the end of surgical procedure, in both groups of patients, fiberoptic bronchoscopy was performed to verify the presence of blood in the larynx and trachea. Immediate respiratory complications associated with the use of flexible laryngeal mask or endotracheal tube (cough, airway obstruction and laryngospasm) were monitored following extubation of patients. Postoperative pain assessment was performed using Face, Legs, Activity, Cry, Consolability Scale 2 and 4 hours following surgery as well as the first postoperative day at 7 o'clock a.m. The presence of postoperative nausea and vomiting was confirmed heteroanamnestically by polling the parents the day after surgery at 7 o'clock a.m. The statistical analysis was performed using Statistical Package for Social Sciences - SPSS version 21. The data were presented in tables and graphs, statystical significance was set at p value of less than 0.05. Results: Following surgery there were no any patient in ET or LMA group in which the presence of blood, secretion or regurgitated stomach contents on larynx or in the trachea could be observed by using the fiberoptic bronchoscope. Patients in the ET group had statistically more significant complications compared to patients in the LMA group (χ2 = 4.254; p = 0.039; p <0.05). There is no statistically significant difference in the distribution of patients with and without respiratory complications between ET and LMA groups (χ2 = 3.413; p = 0.065; p> 0.05). In the assessment of postoperative pain using FLACC scale 2 hours following surgical intervention, there is a statistically significant difference in the intensity of postoperative pain in ET patients compared to patients in the LMA group (χ2 = 31.316, p = 0.000, p <0.05). Four hours following surgical intervention, a statistically significant number of patients had mild pain in the ET group compared to the LMA group (χ2 = 40.705; p = 0.000; p <0.05). On the day of release, statistically significant numbers of patients with mild discomfort in the ET group were compared to the LMA group (χ2 = 8,012; p = 0,005; p <0.05). In the LMA group, one or 1.49% of the patients had postoperative nausea and vomiting, while in the ET group, three or 3.56% of the patients had postoperative nausea and vomiting. Conclusion: Flexible laryngeal mask provides equal protection of the distal parts of airway from the blood and secretions during adenotonsillectomy as the endotracheal tube. The frequency of postoperative complications and the intensity of postoperative pain are smaller when a flexible laryngeal mask is used for airway management during adenotonsillectomy. The usage of the flexible laryngeal mask reduces the frequency of postoperative nausea and vomiting during adenotonsillectomy.

En el ámbito médico actual se considera cada vez más importante el incluir la valoración del paciente en la toma de decisiones. Los cuestionarios que evalúan la calidad de vida percibida y directamente expresada por los pacientes (“Patient Rated Outcome Measures” – PROMs), son herramientas muy útiles que permiten al clínico conocer el grado de afectación subjetivo de una patología, así como tener en cuenta al paciente y sus síntomas, y no sólo la enfermedad; para poder hacer más realistas las expectativas del paciente con respecto a los resultados. Hoy en día, la utilización de estos cuestionarios en la práctica clínica diaria es de capital importancia. Su uso juega un valiosísimo papel en la comprensión e identificación de la enfermedad, individualizar y definir los objetivos del tratamiento, priorizar los problemas principales del paciente; e incluso, poder medir la posterior respuesta. También permite la elaboración de guías, indicaciones y protocolos o evaluar actividad asistencial. Utilizar PROMS posibilita y facilita la realización de auditorías comparativas, como el cotejo de la prestación de asistencia sanitaria por diferentes proveedores, la comparación entre diferentes tratamientos, y por lo consiguiente, ayudar a mejorar la futura prestación de asistencia sanitaria. Con todo ello, las PROMs se consideran como elementos cruciales para garantizar en la actualidad y en el futuro, la calidad asistencial. Previo a las PROMs, la mayoría de los estudios sobre indicación de cirugía para las amigdalitis recurrentes, evaluaban sólo la frecuencia de las infecciones como medida de resultado; o en los casos de clínica obstructiva de hipertrofia adeno-amigdalar, evaluaban la mejoría sólo con estudios respiratorios del sueño. La toma de decisiones médicas basándose solamente en estos datos, ha dado lugar a una amplia variabilidad en la indicación quirúrgica entre diferentes comunidades y a cierta controversia. Sin embargo, a día de hoy, existen numerosos cuestionarios de salud específicos de patología adeno-amigdalar que miden distintas variables, aunque ninguno de ellos está validado en lengua española. Este trabajo se ha centrado en la validación y adaptación de dos PROMs, el TAHSI-s (versión española del Tonsil and Adenoid Health Status Instrument) y el T-14-s (versión española del Paediatric Throat Disorders Outcome Test – T-14). Ambos cuestionarios han demostrado ser instrumentos válidos, fiables y sensibles para su aplicación clínica. Son herramientas útiles para su uso en ensayos clínicos y en investigación de servicios de salud, para asegurar la calidad asistencial, y para la atención clínica de rutina, por lo que su uso es recomendado.
In the current medical field, it is considered increasingly important to include the assessment of the patient in decision making. Questionnaires that assess the quality of life perceived and directly expressed by patients (“Patient Rated Outcome Measures” – PROMs), are a useful evaluation tool that allows the clinician to comprehend the subjective affectation of a pathology, as well as having consider the patient and his symptoms, and not only the disease; in order to be able to make the patient’s expectations more realistic with respect to the results. Nowadays, the daily clinical use of these questionnaires is of paramount importance. Its use plays an invaluable role in understanding and identifying the disease, identifying and defining treatment objectives, prioritizing the patient's main problems; and even, to be able to measure the subsequent response. It also allows guidelines, indications and protocols’ development and evaluate care activity. Using PROMS enables and facilitates the performance of comparative audits, such as the comparison of the provision of health care by different providers, the comparison between different treatments, and therefore, help to improve the future provision of health care. With all this, the PROMs are considered crucial elements to guarantee at present and in the future, the quality of care. Prior to PROMs, most of the surgery indication’ studies for recurrent tonsillitis evaluated only the frequency of infections as an outcome measure; or in cases of obstructive symptoms of adeno-tonsillar hypertrophy, they evaluated the improvement only with respiratory sleep studies. Medical decision-making based solely on these data has led to a wide variability in the surgical indication among different communities and to some controversy. However, to date, there are numerous health questionnaires specific to adeno-tonsillar pathology that measure different variables, although none of them is validated in Spanish language. This work has focused on the validation and adaptation of two PROMs, TAHSI-s (Spanish version of the Tonsil and Adenoid Health Status Instrument) and T-14-s (Spanish version of the Pediatric Throat Disorders Outcome Test - T-14). Both questionnaires have proven to be valid, reliable and sensitive instruments for their clinical application. They are useful tools for use in clinical trials and health service research, to ensure quality of care, and for routine clinical care, so their use is recommended.

碩士
美和科技大學
護理系健康照護碩士班
106
Background: Tonsillectomy is surgery occur regularly worldwide. Tonsillectomy has many complications in which the most dangerous complication is bleeding after tonsillectomy and leading to death risk or long hospital treatment. This complication can be prevented. However, not all patients follow the guidance of the medical staff even though they had been educated during hospitalization. This has led to the possibility of patients in danger of bleeding after tonsillectomy. Objective: The purpose of this study was to determine compliance rates of tonsillectomy patients after having the health education of preventing bleeding and determine the factors related to tonsillectomy patient’s compliance. Methods: The cross sectional design was conducted from April 15 to May 1, 2018 at Thu Duc District Hospital in Ho Chi Minh City. The sample size was estimated by the rule of thumb with 127 participants. Participants in the study were patients with tonsillectomy, aged over 15 years, mentally normal, who were able to answer the questionnaire. These participants were interviewed when they came back to the clinic after discharge about 7 days at the ENT department. The questionnaire on compliance with prevention of bleeding after tonsillectomy was designed based on the Ministry of Health guidelines. The validity of this questionnaire was confirmed by three experts in the field of ENT. Cronbach’s alpha levels for internal consistent reliability were above 0.7. Results: Compliance levels in this study were found to be high (mean = 13.91 ± 1.23, range from 11 to15). Education level (t = -2.19, p <0.05) were found to be related to the general compliance among participants. Conclusion: High compliance after health education prevents bleeding after tonsillectomy is a more positive outcome than originally anticipated. This study has never been done in Vietnam so this result gives an objective and specific view of the compliance status of patients after tonsillectomy. The patient's personal characteristics that are related to compliance help the health worker have a positive impact on the treatment process.

A research report submitted to the faculty of Health Sciences, University of the Witwatersrand, Johannesburg, in fulfilment of the requirements for the degree of Master of Science in Medicine in Anaesthesiology Johannesburg, 2017.
Background Adeno-tonsillectomy remains one of the most frequently performed surgical procedures in children. Despite improvements in anaesthetic and surgical techniques, severe pain is reported in as many as 25 – 50 % of children. Pain assessment and knowledge of drug pharmacodynamics and pharmacokinetics in the paediatric patient, is a prerequisite for optimal care. Much has been written on peri-operative pain management following tonsillectomy. However, no consensus has been reached on what the ideal analgesic regime should be. This audit is a review of current practice at Chris Hani Baragwanath Academic Hospital. It aims to identify problems and develop possible solutions to improve anaesthetic practice. Methods A prospective, contextual, descriptive study design using a data collection sheet was used on paediatrics patients presenting for tonsillectomy. Results Eighty five patients aged three to 12 years of age, with ASA grading I or II were enrolled in the study. The choice of anaesthetic was variable with a combination of simple analgesics, opioids and adjuvants. This affected postoperative pain scores. Snare dissection and monopolar cautery haemostasis, was the standard surgical technique. Surgical seniority influenced the duration of tonsillectomy, with an effect on postoperative pain scores. Conclusions Audits are necessary to evaluate what resources are needed to optimise care. The occurrence of pain after tonsillectomy continues to be poorly managed. Appropriate premedication and no more than two hours of starvation (after clear liquid ingestion) needs to be introduced. Where possible surgical technique should involve bipolar cautery and be limited to less than 45 minutes. A preemptive, multimodal, opioid-sparing anaesthetic should be routinely practiced.
LG2018

碩士
高雄醫學大學
醫務管理暨醫療資訊學系碩士在職專班
104
Abstract Background and Purpose: Proper post-operation pain management can decrease the risk of co-morbidity and hospitalization. Tonsillectomy is among the most common surgeries performed by Otolaryngologists. Resection of palatine tonsils(RPT) and Uvulopalatopharyngoplasty(UPPP)both includes extirpation of tonsils. Due to the anatomy of the tonsils, post-operation sorethroat and odynophagia cause nausea, vomiting, difficult oral intake, prolonged hospitalization and increased medical fees. There is no consensus to injection of steroid to relieve post-operation pain among Otolaryngologists. The purpose of this study is to investigate the effect of post-operation steroid injection on post-operation pain control, hospitalization and medical fees. Methods: The study adopted retrospective cohort research design. The data used in our study was obtained from the National Health Insurance Research Database from 1997 to 2012. RPT and UPPP patients were selected as samples to study the tonsillectomy surgery trend, post-operation steroid use trend, predicting factor of steroid use, post-operation pethidine use, hospitalization days and medical fees. The SPSS 20.0 was used as statistical software. Chi-square test, T-test, multiple linear regression analysis and logistic regression analysis were used to verify the hypotheses. Results: The trends of tonsillectomy and post-operation steroid injection were both rising after 1997. The odds ratio of pethidine use in RPT patients with steroid injection is 0.61 compared with RPT patients without steroid injection. RPT patients with steroid injection has longer hospitalization days (+0.29 days) and higher fees (+2,898 dollars) compared with RPT patients without steroid injection. UPPP patient with steroid injection has longer hospitalization days (+0.30 days) and higher fees (+2,077 dollars) compared with UPPP patients without steroid injection. RPT patients have higher medical fees in medical centers compared with regional hospitals (+2,070 dollars) and district hospitals (+6,264 dollars). UPPP patients have higher medical fees in medical centers compared with regional hospitals (+1464 dollars) and district hospitals (+5,107 dollars). Conclusions and suggestions: The trends of tonsillectomy and post-operation steroid injection are rising. Post-operation steroid injection may decrease post-operation pain, but may not decrease hospitalization days and medical fees. For tonsillectomy patients, we suggest post-operation steroid injection to relieve post-operation pain. However, hospitalization days and medical fees are dependent on insurance paymen system and customary practice of the surgeons. The medical fees is higher in medical centers compared with regional hospitals or district hospitals. Due to the lower risk of tonsillectomy surgery, patients without comorbidity may receive tonsillectomy in regional hospitals or district hospitals to save medical resources.

Hitzschke, Maria: Der Einsatz von FloSeal® bei der Blutstillung im Rahmen der Tonsillektomie Universität Leipzig, Dissertation 76 S., 79 Lit., 14 Abb., 17 Tab. Referat: Die Tonsillektomie ist eine der häufigsten operativen Eingriffe in der HNO-Heilkunde in Deutschland. Trotz neuer Techniken der Präparation und Blutstillung kann es dabei zu teilweise lebensbedrohlichen Komplikationen kommen. Ziel der vorliegenden randomisierten, monozentrischen Einfachblindstudie, welche auf prospektiv erfassten Patientendaten beruht, war es zu prüfen, ob der Einsatz einer Gelatine-Thrombin-Matrix (FloSeal®) bei der Blutstillung im Rahmen der Tonsillektomie einen Einfluss auf die Operationsdauer, den postoperativen Schmerzverlauf, die Wundheilung oder auf die Nachblutungsrate im Vergleich zur konventionellen elektrischen Blutstillungstechnik aufweist. Im Ergebnis konnten die Operationszeiten, vor allem für erfahrene Operateure, durch FloSeal® nicht verkürzt werden. Die bessere Planbarkeit der Operationsdauer durch die vordefinierte Blutstillungszeit bei der FloSeal®-Anwendung ist aber vor allem für unerfahrene Operateure von Bedeutung. Die postoperativen Schmerzen ab dem 4. postoperativen Tag waren in der FloSeal®-Gruppe geringer, auch die Schmerzdauer konnte um knapp 3 Tage verkürzt werden. Dies ist am ehesten auf eine verbesserte Wundheilung bei den mittels FloSeal® behandelten Patienten zurückzuführen, die sich in den stets signifikant geringeren Wundbelägen widerspiegelte. Der verminderte Einsatz der bipolaren Koagulation durch die Anwendung von FloSeal® konnte jedoch nicht zu einer signifikanten Reduktion der Nachblutungsrate führen. Trotz ermittelter Vorteile des Einsatzes von FloSeal® im Rahmen der Tonsillektomie sollte FloSeal® aber aus unserer Sicht den Patienten mit diffusen flächigen Blutungen im Rahmen einer Tonsillektomie vorbehalten bleiben, bei denen eine großflächige bipolare Koagulation die postoperative Morbidität deutlich steigern würde.:Inhaltsverzeichnis 1. Einleitung 1 1.1. Anatomie der Tonsilla palatina 2 1.2. Indikationen zur Tonsillektomie 6 1.3. Tonsillektomie - Verfahren 8 1.4. Komplikationen der Tonsillektomie 9 1.5. Wirkmechanismus von FloSeal® und klinische Anwendung 13 2. Zielstellung 20 3. Material und Methoden 21 3.1. Studienablauf 21 3.1.1. Präoperative Parameter 26 3.1.2. Intraoperative Parameter 26 3.1.3. Postoperative Parameter 27 3.2. Statistische Auswertung der Daten 28 4. Ergebnisse 30 4.1. Präoperative Parameter 32 4.1.1. Epidemiologische Daten 32 4.1.2. Präoperative Labor- und Blutdruckwerte 33 4.2. Intraoperative Parameter 33 4.2.1. Erfahrung des Operateurs 33 4.2.2. Operationszeiten 34 4.2.3. Koagulation nach FloSeal® bzw. Tupfereinlage 37 4.2.4. Weitere Maßnahmen zur Blutstillung 38 4.2.5. Beurteilung von FloSeal® 38 4.3. Postoperative Parameter 39 4.3.1. Verlauf postoperativer Schmerzen 39 4.3.2. Postoperativer Schmerzmittelverbrauch 43 4.3.3. Verlauf der Wundheilung 44 4.3.4. Nachblutungen und unerwünschte Ereignisse 46 4.3.5. Postoperative Laborwerte 47 5. Diskussion 48 6. Zusammenfassung der Arbeit 60 7. Literaturverzeichnis 63 8. Erklärung über die eigenständige Abfassung der Arbeit 72 9. Lebenslauf 73 10. Publikationen 75 11. Danksagung 76

Introduction : Il a été démontré que les enfants opérés pour une amygdalectomie éprouvaient des niveaux de douleur modérée à sévère, et ce pendant plusieurs jours suite à la chirurgie. Suite au retour à domicile, plusieurs parents ont tendance à administrer l’analgésie de façon non-optimale à leur enfant et ce pour diverses raisons, ce qui contribue au maintien de niveaux de douleur élevés et à l’incidence de complications postopératoires. But : Cette étude avait pour but d’évaluer l’effet d'un suivi infirmier téléphonique, effectué auprès de parents d'enfants opérés pour une amygdalectomie, sur la gestion de la douleur et la prévention de complications postopératoires. Méthode : Cette étude clinique randomisée a comparé un groupe expérimental (suivi infirmier téléphonique) à un groupe contrôle (traitement standard) (n = 52). Le suivi infirmier téléphonique fut effectué au 1er, 3e, 5e et 10e jour postopératoire et permettait d’évaluer l’évolution du client et d’offrir un enseignement personnalisé selon un cadre prédéfini. Les critères d’évaluation furent l’intensité de la douleur, la quantité d’analgésie administrée à l’enfant, les complications postopératoires et le recours à des services de santé non-planifiés. Résultats : Les enfants du groupe expérimental ont présenté une intensité de douleur plus faible au 3e jour postopératoire, le matin (P= 0.041) et le soir (P= 0.010). Les enfants de ce groupe ont reçu davantage de doses d’analgésiques au 1er jour postopératoire (P= 0.007) et au 5e jour postopératoire (P= 0.043). Ils ont eu moins de vomissements au congé de l’hôpital (P= 0.040) et au 3e jour postopératoire (P= 0.042), moins de somnolence au 1er jour postopératoire (P= 0.041), une meilleure hydratation au 1er (P= 0.014) et 3e jour postopératoire (P= 0.019), mais ont souffert davantage de constipation au 3e jour postopératoire (P< 0.001). Aucune différence significative n’a été observée quant au recours à des services de santé. Conclusion : Le suivi infirmier téléphonique, effectué auprès de parents d'enfants opérés pour une amygdalectomie, a certains effets bénéfiques sur la gestion de la douleur et la prévention de complications postopératoires, mais n’a pas eu d’effet significatif sur le recours à des services de santé.
Background: After tonsillectomy, children experience moderate to severe pain for several days. Following discharge from the hospital, many parents give insufficient analgesia to their child, based on numerous misguided beliefs. This contributes to more pain and an increase of postoperative complications. Aim: Evaluation of the efficacy of a nurse telephone follow-up with parents of children who underwent tonsillectomy, on pain intensity, occurrence of postoperative complications and frequency of resort to other health services. Methods: This randomised clinical trial compared an intervention group (nurse telephone follow-up) with a control group (standard care, without follow-up) (n=52). Nurse telephone follow-up was made on the 1st, 3rd, 5th and 10th postoperative day and included advice and explanation regarding problems experienced by parents, using an algorithm of interventions. Outcomes evaluated were pain intensity, frequency of analgesics administered to the child, occurrence of postoperative complications and resort to health services. Data was collected at hospital discharge, and on the 1st, 3rd, 5th and 10th postoperative days (POD). Results: Children in the experimental group had lower pain intensity scores after medication than the control group in the morning (P= 0.041) and evening (P= 0.010) of POD 3. Children in the nurse follow-up group received more doses of analgesics on POD 1 (P= 0.007) and POD 5 (P= 0.043). Significant differences were observed, in favour of the nurse follow-up group, regarding vomiting at POD 0 (P= 0.040) and POD 3 (P= 0.042), dizziness at POD 1(P= 0.041), and fluid intake at POD 1(P= 0.014) and POD 3 (P= 0.019) - although, constipation was more frequent in the nurse follow-up group at POD 3 (P< 0.001). There was no significant difference, between both groups, regarding resort to other health services. Conclusion: Nurse telephone follow-up with parents of children who underwent tonsillectomy was beneficial for some aspects of pain management and occurrence of some postoperative complications, but did not decrease resort to other health services.

Trabalho Final do Mestrado Integrado em Medicina apresentado à Faculdade de Medicina
O anel de Waldeyer é constituído pelas adenoides, amígdalas tubárias, amígdalas palatinas e amígdala lingual, além do tecido linfoide das bandas laterais da faringe. Localizadas na entrada do trato aerodigestivo superior, estas estruturas linfoides encontram-se divididas em compartimentos morfológicos especializados: epitélio superficial, epitélio da cripta, folículos linfoides e tecido linfoide interfolicular. Devido à sua localização, sujeita a exposição antigénica contínua, e como componente do MALT, as amígdalas agem como uma primeira linha de defesa física e imunológica. A sua função abrange a iniciação de respostas imunes inatas e adaptativas. A captação epitelial de antigénios, ativação de linfócitos T e estimulação de linfócitos B resultam na produção e disseminação de células B de memória e de células plasmáticas secretoras de anticorpos.A remoção das adenoides e amígdalas é um procedimento cirúrgico comummente realizado. A adenoidectomia e/ou amigdalectomia pode ter diversas indicações, sendo as mais validadas os distúrbios respiratórios do sono, a otite média com efusão, a amigdalite recorrente e suspeita de malignidade. As sequelas imunológicas pós-cirúrgicas têm sido fonte de debate, devido ao potencial impacto adverso associado. Grande parte da evidência disponível relata a ausência de um efeito negativo significativo, mas a variabilidade entre estudos é importante, persistindo trabalhos controversos que sugerem uma maior incidência de determinadas doenças a longo prazo.
Waldeyer's ring consists of adenoids, tubal tonsils, palatine tonsils and lingual tonsil, as well as the lymphoid tissue of the lateral pharyngeal bands. Located at the entrance of the upper aerodigestive tract, these lymphoid structures are divided into specialized morphological compartments: superficial epithelium, crypt epithelium, lymphoid follicles and interfollicular lymphoid tissue. Because of its location, subject to continuous antigenic exposure, and as a component of MALT, the tonsils act as a first line of physical and immunological defense.Its function encompasses the initiation of innate and adaptive immune responses. Epithelial uptake of antigens, T lymphocytes activation and B lymphocytes stimulation result in the production and dissemination of memory B cells and antibody secreting plasma cells.Removal of the adenoids and tonsils is a commonly performed surgical procedure. Adenoidectomy and/or tonsillectomy may have several indications, the most valid being respiratory sleep disorders, otitis media with effusion, recurrent tonsillitis and suspicion of malignancy. Post-surgical immunological sequelae have been a source of debate, due to the associated potential adverse impact. Much of the available evidence reports the absence of a significant negative effect, but the variability between studies is important, with controversial studies suggesting a higher incidence of certain diseases in the long term. Much of the available evidence reports the absence of a significant negative effect, but the variability between studies is important, with controversial studies suggesting a higher incidence of certain diseases in the long term.

Trabalho Final do Mestrado Integrado em Medicina apresentado à Faculdade de Medicina
Introdução: O abcesso periamigdalino é a infeção cervical profunda mais comum, resultante da acumulação de pus no espaço periamigdalino. Permanece controversa a orientação terapêutica ideal para esta infeção potencialmente fatal, após o episódio agudo. Enquanto alguns autores recomendam a realização de amigdalectomia após o primeiro episódio, outros excluem, absolutamente, essa hipótese. Objetivo: Este estudo tem como objetivo caraterizar a epidemiologia, a clínica, o tratamento e o follow-up dos pacientes com abcesso periamigdalino e identificar eventuais fatores preditivos de recorrência de abcesso periamigdalino. Métodos: Foram analisados, retrospetivamente, os doentes diagnosticados com abcesso periamigdalino no período compreendido entre 2011 e 2015, num serviço terciário de Otorrinolaringologia. Resultados: Este estudo incluiu 283 doentes com 37.2 ± 14.8 anos [18-89 anos]. Antecedentes de amigdalite de repetição foram significativamente mais prevalentes em mulheres (p=0.03). A taxa de recorrência de abcesso periamigdalino foi de 14.1%. O grupo de doentes com recorrência de abcesso periamigdalino foi mais jovem e apresentou mais frequentemente história de amigdalite recorrente. Não foram encontradas diferenças estatisticamente significativas em outras características clínicas ou demográficas entre pacientes com ou sem recorrências de AP. Setenta e cinco porcento dos doentes recidivaram no período de 1 ano. No total, 40.8% dos doentes foram propostos para amigdalectomia. Conclusão: Neste estudo, menos de metade dos doentes foram propostos para amigdalectomia após o primeiro episódio de AP. Quando se optou por uma estratégia conservadora de tratamento, obteve-se uma taxa de recorrência não negligenciável, principalmente, durante o primeiro ano de follow-up. Doentes com história de amigdalite recorrente e doentes mais jovens desenvolveram mais recorrências de AP.
Introduction: Peritonsillar abscess (PTA) is the most common deep neck space infection, resulting from the accumulation of pus in the peritonsillar space. Controversy exists regarding the best management for this potentially fatal infection after the acute episode. Some authors recommend performing a tonsillectomy after the first episode, while others do not recommend a tonsillectomy at all.Objective: This study aims to characterize epidemiology, clinical features, management and follow-up of patients with PTA, to identify possible predictors of peritonsillar abscess recurrence. Methods: We retrospectively analyzed patients diagnosed with PTA, hospitalized between 2011 and 2015, at a tertiary otorhinolaryngology department.Results: This study included 283 patients, aged 37.2 ± 14.8 years [18-89 years]. An history of recurrent tonsillitis was significantly more common in females (p=0.03). In total, 14.1% of patients had PTA recurrence. PTA recurrence`s population was younger and had more frequently a previous history of recurrent tonsillitis. There were no significant differences in other clinical or demographic characteristics between patients with or without PTA recurrence. Seventy five percent of patients had a recurrent episode in the period of 1 year. In total, 40.8% of patients were proposed to tonsillectomy. Conclusion: In this cohort of PTA, less than half of patients are proposed to tonsillectomy after the first episode. When the option if for a conservative strategy, there is a non-negligible recurrence rate, mainly during the first year. Previous recurrent tonsillitis and younger age patients showed more frequent recurrent PTA episodes.