Haim Gavriel

Tonsillectomy vs. partial tonsillectomy for OSAS in children—10 years post-surgery follow-up

BACKGROUNDnToday, obstructive hypertrophic tonsils are completely resected to remove the obstruction. Since tonsillar tissue has important protective characteristics, it is more logical to resect only the obstructive tonsillar tissue and leave remnants in the tonsillar beds, thereby presuming to preserve the immunological function of the tonsillar tissue. However, it is as yet unclear whether or not rehypertrophy of this remnant of the tonsils and/or tonsillitis reoccur in the long-term.nnnOBJECTIVESnTo evaluate the remnants of the tonsils 10-14 years post-tonsillotomy in children who suffered from obstructive sleep apnea syndrome (OSAS) due to obstructive tonsils.nnnMETHODSnWe conducted a retrospective study, telephone survey and selective physical examination of 33 children who had obstructive hypertrophic tonsils (suffered from OSAS due to hypertrophic tonsils), and underwent tonsillotomy (TT) at Assaf Harofeh Medical Center between July 1990 and April 1993, and compared them with a group of 16 children treated by tonsillectomy (TE) for the same diagnosis.nnnRESULTSnNo statistically significant difference was found between the TT and TE groups in all parameters compared: non-obstructing tonsils recurred (97% vs. 87%); snoring (3% vs. 12.5%); recurrent tonsillitis (6% vs. 6.25%); and recurrent obstruction and unilateral enlargement (3% vs. 12.5%).nnnCONCLUSIONSnTT is as effective as TE for the long-term treatment of children suffering from OSAS due to hypertrophic tonsils.

Hypothyroidism following partial thyroidectomy

Objective To compare rates of hypothyroidism following three types of partial thyroidectomy for multinodular goiter. Study Design and Methods All cases of partial thy-roidectomies (hemi-, near-total, or subtotal) carried out at one Israeli and one Russian medical center (1990–2006) were retrospectively studied to determine the incidence of hypothyroidism after each procedure. Results There were 881 near-total, 1538 subtotal, and 1051 hemithyroidectomies (total 3470). Postoperative follow-up was 2 to 15 years. Twenty-eight percent of the hemithyroidectomy patients suffered permanent hypothyroidism compared to 100% of the near-total and 87% of the subtotal patients. Forty-six percent of the hemithyroidectomy patients suffered temporary hypothyroid-ism compared to 100% of the near-total and 93% of the subtotal patients. Conclusion Subtotal and near-total thyroidectomies produced a rate of hypothyroidism close to that of total thyroidectomy compared to 28% after hemithyroidectomy. Significance Partial thyroidectomies provide no decisive advantage over total thyroidectomies in terms of subsequent requirements of supplemental hormone therapy.

Dimension of Subperiosteal Orbital Abscess as an Indication for Surgical Management in Children

Objective. Eyelid edema in children is one of the signs of orbital complications secondary to acute rhinosinusitis, and identifying abscess formation is crucial for management decision. The objective of this study is to determine whether there are different computed tomography scan abscess dimensions and volumes in children requiring medical versus surgical management for subperiosteal orbital abscess (SPOA). Study Design. Case series with chart review. Setting. The study was conducted at Assaf Harofeh Medical Center. Subjects and Methods. Clinical and radiological parameters of 95 children admitted with eyelid edema between January 2005 and December 2007 were studied. Results. Of 95 cases of orbital cellulitis, a total of 48 children with sinogenic orbital complications with a mean (SD) age of 4.03 (3.46) years were included. No significant difference was found between the surgically and medically treated SPOA groups regarding the use of preadmission antibiotic and clinical presentation. Statistically significant larger abscesses in the surgically treated group were noted (mean volume 1.389 vs 0.486 mL in the conservatively treated group; P = .013) and a longer mean anterior-posterior and medial-lateral dimension (P = .001 and .017, respectively). Conclusion.Children presenting with significant or progressing ocular findings or failure to improve after 48 hours of medical therapy, together with an abscess volume of more than 0.5 mL, a length greater than 17 mm, and a width greater than 4.5 mm, should be strongly considered to have surgical drainage.

Variations in the microbiology of peritonsillar abscess.

Microbiologic studies are routinely performed in the assessment of peritonsillar abscess (PTA). Though the bacterial growth rates of PTA are expected to be uniform due to high accessibility and reasonable sterility, they demonstrate a vast range of results, which is partially explained by the differing culturing methods and incubation times. Our aim was to retrospectively examine the changing features identified in the occurrence of PTA bacterial growth rates over a period of seven years. A retrospective study was undertaken on all cases of PTA admitted from January 1996 to December 2002. Details regarding sex, age and country of birth were obtained. Population data and the maximum residue level (MRL) of antibiotics in food were collected. Bacteriologic studies were analysed for gram stain, aerobic and anaerobic culture results, and also antibiotic sensitivities, if obtained. Four hundred and fifty-seven consecutive hospitalisations due to PTA were identified; 281 patients who had 310 hospitalisations with known results of the microbiologic studies were included. The most common pathogens were Streptococcus pyogenes and Prevotella. A statistically significant escalation was seen in the anaerobic growth rate from 6.8% of cases in 1996 to 37% in 1999. A similar change, though not significant, was noticed with the polymicrobial growth rate. None of the parameters investigated showed any statistically significant influence on this tendency. These results may clarify the immense range of bacterial study results reported, suggest a change in the biologic behaviour of the studied bacteria and direct further research.

Fibrin sealant reduces pain after tonsillectomy: prospective randomized study.

Objectives: Postsurgical pain in adults following tonsillectomy with fibrin sealant or electrocoagulation was assessed by surface electromyography (sEMG), a dysphagia severity rating scale (DSRS), and a visual analog scale (VAS) pain score. Methods: For group 1 (n = 40), hemostasis was achieved by fibrin sealant spraying to the tonsillar fossae. For group 2 (n = 40), hemostasis was achieved by bipolar or needle point electrocautery. The timing of single swallowing and continuous drinking and the mean electrical activity of the masseter, infrahyoid, and submental-submandibular muscles were compared with a normative database during 30 days and with DSRS and VAS scores. Results: Electrical activity of the masseter and infrahyoid muscles was significantly higher in both groups in comparison with the normative database (p > .05 to p > .005), whereas timing was less affected. The combined sEMG, DSRS, and VAS assessment showed that tonsillectomy ended with sealant causes less pain than electrocoagulation (p > .05). The DSRS score data were in strong positive correlation with the sEMG records, whereas the VAS pain score was less informative. Conclusions: The combined sEMG and pain score data indicate that the electrocautery hemostatic technique is more painful and traumatic than the sealant technique. Surface electromyography of swallowing is a simple, reliable evaluation method for postsurgical odynophagia complaints and might be used as an objective tool for pain assessment.

Microbiology of peritonsillar abscess as an indication for tonsillectomy.

No conclusive data are available regarding the influence of the microbial content of a peritonsillar abscess (PTA) on the development of recurrence. We conducted the current study to evaluate the effect of microbiologic growth on the recurrence rate of PTA and the need for tonsillectomy. Of 469 patients with PTA, 295 patients who underwent bacteriologic studies were subdivided into 2 groups, nonrecurrent group (273 patients) and recurrent group (22 patients), and their results were compared. A higher rate of anaerobic growth (10 anaerobic pathogens, 57.1% of total pathogens found) was identified in the recurrent PTA group compared with the nonrecurrent group (39 anaerobic pathogens, 45.8%), with a higher rate of anaerobic growth in the recurrent group in the first episode (60% vs. 45.8% in the nonrecurrent group) (odds ratio, 1.76; sensitivity, 80%; specificity, 45%). Anaerobic bacterial growth correlates with a higher rate of recurrence, and may serve as an additional relative indicator for tonsillectomy. Abbreviations: NPV = negative predictive value, OR = odds ratio, PTA = peritonsillar abscess.

The electrodiagnostic examination of psychogenic swallowing disorders.

The article discusses the usefulness and technique of investigation of suspected psychogenic dysphagia by surface electromyography (sEMG) of deglutition. Thirty-two patients with suspected psychogenic dysphagia (Group 1) and 40 healthy individuals (Group 2) were involved in the study. The timing, amplitude and graphic patterns of activity of the masseter, submental, infrahyoid and trapezius muscles were examined during voluntary single water swallows (“normal”), and continuous drinking of 100xa0cc of water. The muscle activity in oral, pharyngeal and initial oesophageal stages of swallowing was measured, and graphic records were evaluated in relation to timing and voltage. Globus hystericus was found in only 14 patients of the Group 1 (43.75%). The main sEMG pattern of psychogenic dysphagia is a lack of any pathologic changes of timing, voltage and graphic patterns of deglutition. In 28% of cases tension of skeletal muscles not involved in deglutition was observed during single swallowing (vs. 0% in controls). Psychogenic/hysteria-conversion dysphagia has no pathologic sEMG patterns associated with deglutition. Skeletal muscle tension during deglutition, being observed in some cases has no connection with the act of swallowing itself. Surface EMG, being non-invasive and non-radiographic, can be used for screening purposes for patients with dysphagia thus avoiding expensive and time-consuming investigation.

Complementary and Alternative Medicine Treatment Options for Otitis Media: A Systematic Review.

AbstractOtitis media (OM) has numerous presentations in children. Together with conventional medical therapies aimed to prevent and/or treat OM, a rising number of complementary and alternative medicine (CAM) treatment options can be offered. Since OM is common in children, parents may ask healthcare professionals about possible CAM therapies. Many physicians feel that their knowledge is limited regarding these therapies, and that they desire some information. Therefore, we conducted a literature review of CAM therapies for OM, taking into account that many of these treatments, their validity and efficacy and have not been scientifically demonstrated.We performed a search in MEDLINE (accessed via PubMed) using the following terms: “CAM” in conjunction with “OM” and “children. Retrieved publications regarding treatment of OM in children which included these terms included randomized controlled trials, prospective/retrospective studies, and case studies.The following CAM options for OM treatment in children were considered: acupuncture, homeopathy, herbal medicine/phytotherapy, osteopathy, chiropractic, xylitol, ear candling, vitamin D supplement, and systemic and topical probiotics. We reviewed each treatment and described the level of scientific evidence of the relevant publications.The therapeutic approaches commonly associated with CAM are usually conservative, and do not include drugs or surgery. Currently, CAM is not considered by physicians a potential treatment of OM, as there is limited supporting evidence. Further studies are warranted in order to evaluate the potential value of CAM therapies for OM.

The correlation of microbiology growth between subperiosteal orbital abscess and affected sinuses in young children.

Background Subperiosteal orbital abscess (SPOA) typically presents as a collection of pus in the space between the periorbit and the lamina papyracea adjacent to the infected paranasal sinuses. The aim of this study was to investigate the simultaneous microbiological growth from an SPOA and the paranasal sinuses in the same children. Methods A retrospective study was performed on cultures obtained from involved sinuses and surgically drained abscesses in young children with SPOA from January 1992 to March 2009. Results Twenty-two children with a mean age of 5.9 years were included. Results of the microbiological studies were available from the sinuses of 17 children (77.2%) and from the SPOA in 18 children (81.8%). High rates of staphylococci bacteria and Streptococcus viridans were observed compared with lower-than-expected upper respiratory tract infection pathogens. Both groups showed scarce anaerobic and polymicrobial growth. In 13 children (59%), both sinus and abscess culture results were available with correlation found in only 4 (30.7%) of these children. Conclusion In this study we report the results of bacteriological studies of nasal sinuses and SPOAs in young children, with a low rate of correlation between both sites and low rates of anaerobic growth, but high rates of staphylococcal growth in the SPOA cultures. These observations might be related to the trend toward conservative treatment in children.

Swallowing before and after tonsillectomy as evaluated by surface electromyography

OBJECTIVES: Surface electromyography (sEMG) was performed on adult patients (n = 40) following tonsillectomy to evaluate recovery by objective means. METHODS: Evaluated parameters included timing of swallowing and continuous drinking, electric amplitude and graphic patterns of masseter (MS), and measurement of infrahyoid (INF) and submental (SUB) muscles after tonsillectomy and comparison with normative database. RESULTS: The duration of drinking periods showed significant increase among patients; single-swallow durations remained normal. The electric activity of MS and INF muscles was significantly higher among the patients compared with normative database. It took one month until all the EMG data returned to normal. CONCLUSION: Tonsillectomy affects muscle activity during swallowing by involving additional muscles in deglutition. EMG is a simple reliable method for postoperative evaluation and might contribute to comparative analysis of different tonsillectomy techniques. EMG can be used during pre- and postoperative stages to monitor recovery and functional improvement of throat muscles and deglutition. SIGNIFICANCE: The reported sEMG method and obtained data might be further used: 1) As an additional tool for comparison of different methods of tonsillectomy (eg, cold vs hot dissection, laser surgery, etc); 2) For further development of objective postsurgical pain assessment; 3) As an additional tool for assessment and development of less traumatic surgical technique; and 4) For monitoring of recovery in difficult cases