Jochen P. Windfuhr

A devastating outcome after adenoidectomy and tonsillectomy: Ideas for improved prevention and management

Objective: To develop strategies that may assist the surgeon to prevent and manage severe bleeding complications after adenoidectomy and tonsillectomy. Study Design: Retrospective. Subjects and Methods: Expert reports for malpractice lawsuits or professional boards were reviewed. The review was restricted to “deaths” and “permanent generalized neurological deficiencies.” Results: Forty-three cases matched our search criteria, including 32 deaths. Adenoidectomy cases (2) were associated with immediate bleeding because of direct vascular injury resulting in one death. Tonsillectomy cases were associated with delayed and repeated episodes of bleeding resulting in 31 deaths, including 19 children. Autopsy verified predominantly aspiration and vascular injuries. An apallic syndrome prevailed in surviving patients. Conclusion: Careful inspection of the nasopharynx immediately before adenoidectomy and curettage in a piecemeal fashion under visual control is helpful to prevent direct injury to aberrant arteries. Tonsillectomy cases are associated with delayed and episodic bleeding with spontaneous cessation and young age. Inpatient observation should be strongly considered in cases with repeated bleeding episodes to provide immediate treatment. The follow-up should be focused on disturbed wound healing. Outcome appears to be dependant on adequate airway management. Rigid instruments and tracheotomy in case of intubation failure are highly recommended to facilitate airway protection and ventilation.

Lethal outcome of post-tonsillectomy hemorrhage

Despite the large number of tonsillectomies performed little knowledge exists about post-tonsillectomy hemorrhage (PTH) with lethal outcome. This study was performed to evaluate clinical features in a larger patient population with emphasis on the onset of this complication. A nationwide collection of cases was performed based on personal communication, expert reports to lawsuits and professional boards, and case reports received after a plea published in a professional national journal. Clinical data of 29 patients were collected of whom the 18 were children (64%). With one exception all patients experienced secondary PTH (>24 h) occurring 1–28 days after tonsillectomy. Aspiration contributed to lethal outcome in 13 cases. Fatalities were unavoidable although 21 patients were in the hospital. Massive vomiting of blood was observed in 11 patients. There were 11 patients without (group A) and 18 with (group B) episodes of repeated bleeding. This study suggests that particularly children are endangered by lethal PTH. Inpatient treatment was unable to prevent lethal outcome in this selected patient population. However, it appears wise to re-admit patients with delayed PTH, since excessive PTH may occur. These unexpected and unpredictable situations require an immediate and adequate medical treatment by a skilled staff. The paucity of data currently does not allow calculation of a cut-off point at which the risk of life-threatening PTH significantly decreases. Secondary PTH remains a substantial complication.

Life-Threatening Posttonsillectomy Hemorrhage†

Objectives/Hypothesis: In rare cases, the intensity of posttonsillectomy hemorrhage (PTH) may become life‐threatening requiring major surgical means and intensive care. This study was conducted to assess the outcome of life‐threatening PTH and its clinical features in a larger patient population.

Analysis of the fossa olfactoria using cone beam tomography (CBT)

Abstract Conclusion: A cone beam tomography (CBT) examination of the olfactory area with its different variants allows development of an individual anatomical-radiological risk profile of the ethmoid and the identification of so-called ‘dangerous ethmoids.’ Objective: Preoperative imaging performed with high-resolution CBT is imperative for analysis of the risk of injuring the olfactory fossa during sinus surgery. This study aimed to analyze the relevant parameters. Methods: This was a retrospective, single-center study of 141 patients. The Accu-I-Tomo F17 was used. Keros type, the point of the anterior ethmoid artery, and the angle between the lateral lamella and the cribriform plate (αlc) were evaluated. Results: The Keros types were distributed as follows: type I, 13% (αlc: 131°); type II, 64% (αlc: 116°); type III, 23% (αlc: 108°) (p < 0.001). The angle of the olfactory fossa and the position of the anterior ethmoid artery (free course: αlc=112° vs integrated into the skull base: αlc= 120°) was significantly different. Discussion: Surgical procedures in Keros type III where the height of the lateral lamella is much longer than in type II or type I, with an angle of nearly 107° between the lateral lamella and the cribriform plate, are expected to be safer in comparison with Keros type II with 116° and Keros type I with 131°.

From the expert’s office: localized neural lesions following tonsillectomy

Due to various reasons, localized neural lesions following tonsillectomy are presumably an under-reported complication in the literature. This study was undertaken to compile our experiences including a literature review to disseminate useful insights in the etiology and prognosis of this rare entity. A retrospective chart review of expert reports written by at least one of the authors for malpractice claims in relation to tonsillectomy was undertaken. Additionally, a retrospective analysis of 648 patient documents that had undergone tonsillectomy in 2001 at our institution and a comprehensive literature review were performed. The research was restricted to the item “localized neural lesion”. Seven cases from the expert’s offices, one of our patients who had undergone tonsillectomy at our institution and 122 cases from the literature matched our search criteria. Including our own cases, the glossopharyngeal nerve was affected in 82 patients. Other lesions encompassed injury of the hypoglossal nerve as solitary (15) or combined (5) lesion, recurrent nerve paralysis with (2) or without additional nerve lesions (7), facial nerve paralysis (10) in combination with other nerve lesions (1), and a lingual nerve deficiency as solitary (4) or combined lesion (9). A single report existed for lesion of the phrenic nerve. There were five reported cases with blindness and nine cases with Horner’s syndrome. Albeit rare, localized neural lesions may occur as a troublesome complication following tonsillectomy and/or means to achieve hemostasis. Some of these cases may not result from the dissection itself but injection procedures. Surgical dissection should include careful mouth gag insertion and meticulous dissection to minimize the risk of localized neural complications. A long-term follow-up is recommended for patients with dysgeusia related to glossopharyngeal nerve injury and patients with recurrent nerve dysfunction. Other lesions are much less likely to resolve in the long-term. Localized neural lesions should adequately be included in the informed consent for tonsillectomy as well as for surgical treatment of post-tonsillectomy hemorrhage.

Post-tonsillectomy pseudoaneurysm: an underestimated entity?

OBJECTIVE To identify patients undergoing arteriography to verify vascular complications of tonsillectomy, with an emphasis on pseudoaneurysm. PATIENTS AND METHODS We undertook a retrospective analysis of the case records of 8837 patients who had undergone tonsillectomy between 1988 and 2004 at our institution, together with a review of expert reports written for professional boards and civil courts as well as personal experiences or communication. We also conducted a literature review using the PubMed database. RESULTS We identified seven cases with vascular abnormalities. In addition, we identified three cases of pseudoaneurysm formation, involving two children and one adult patient, with bleeding 21, 36 and 58 days after tonsillectomy. Successful management included embolisation (two patients) and revision surgery (one patient). CONCLUSION Post-tonsillectomy pseudoaneurysm formation is extremely rare and unrestricted by age. Correct diagnosis depends largely on a high index of clinical suspicion. Delayed and repeated episodes of gushing haemorrhage with spontaneous cessation appear to be a significant clinical marker. Immediate arteriography, with simultaneous embolisation, is highly recommended. The lingual artery is the most commonly involved vessel.

Complications of midline-open tracheotomy in adults

Percutaneous tracheotomy is progressively replacing open tracheotomy as a consequence of promising results of comparative studies. However, this comparison has four considerable weaknesses: 1) selected indications (high‐risk patients excluded for percutaneous tracheotomy); 2) varying spectra of complications included in different studies; 3) varying operative settings (experienced surgeons exclusively, surgeons in training, or both); and 4) missing differentiation between different surgical techniques. Our study was performed to collect complete datasets of unselected patients who all underwent a tracheotomy in a uniform technique in an academic teaching hospital setting.

Tonsillotomy: it's time to clarify the facts

Finger nails, wires, specialized knives, slings and guillotines in the 19th and 20th century were used for subtotal tonsillectomy to reduce the risk of serious bleeding complications associated with complete removal of tonsillar tissues. Therefore, success of tonsil procedures at that time was widely based on revision surgery to cure patients suffering from diseases associated with tonsillitis. Complete, i.e., extracapsular, tonsillectomy (TE) was conceived in the first decade of the 20th century but became widespread only with safer anesthesiological techniques, particularly orotracheal intubation and introduction of halothan in the 1950s [1, 2]. In 1990, Rosenfeld registered a dramatic rise in obstructive sleep apnea (OSA) as a significant indication for TE. He assumed that this phenomenon is due to the increasing awareness of the prevalence and seriousness of adenotonsillar hypertrophy as a cause of sleep apnea, particularly in children [3]. His statement and findings were confirmed recently by Parker and Walner [4]. OSA belongs to the category of sleep-disordered breathing (SDB), characterized by abnormal respiratory patterns or the inadequate ventilation during sleep in terms of snoring, mouth breathing, or interrupted breathing. The patients may become symptomatic with excessive sleepiness, inattention, poor concentration, or hyperactivity during daytime. According to the latest statement of the American Academy of Otolaryngology-Head and Neck Surgery, TE still plays a major role to resolve SDB related to tonsillar hypertrophy in children [5]. Morbidity following TE is widely determined by pain and significant limitations in activity and diet. Return to normal diet and activity, intake of analgesics and type of consumed analgesics are therefore common endpoints of studies evaluating the benefit of newer surgical TE instruments. Complications like hemorrhage and dehydration eventually occur with the potential of a devastating outcome [6, 7]. While the best method to avoid surgical complications is not to operate, this is not an option for upper airway obstruction caused by tonsillar hypertrophy. TE, however, is acknowledged to control SDB in only 60–70 % of children with significant tonsillar hypertrophy, emphasizing the multifactorial background of this disease [5]. In the light of the limited success rate and the potential complications of TE alternative surgical procedures such as a Bochon loop have been suggested in 1993 [8], cited after [2]. In 1994, Krespi and Ling [9] recommended the CO2LASER for ‘‘serial tonsillectomy’’ to treat recurrent infection, sore throat, and halitosis in adults. In children, a considerably reduced morbidity after ‘‘tonsillotomy’’ with modern techniques was first reported in 1999 by Linder et al. [10] and Hultcrantz et al. [11], followed by Densert et al. [12], and Helling et al. [13] in 2001 and 2002, respectively. The results were confirmed with the first large retrospective study in 2003 by Koltai et al. [14] who used a microdebrider as surgical instrument. However, in a small pediatric patient population, a significant impact of ‘‘intracapsular tonsillectomy’’ on OSA—albeit not successful in all patients—was proven by means of polysomnographic J. P. Windfuhr (&) Department of Otorhinolaryngology, Plastic Head and Neck Surgery, Kliniken Maria Hilf Monchengladbach, Sandradstr 43, 41061 Monchengladbach, Germany e-mail: jochen.windfuhr@mariahilf.de

Tonsillectomy 30 years after Paradise: implosion of arguments

Sore throat remains a common disease to be managed by family physicians, pediatricians or otolaryngologists. Patients of all ages present with pain and odynophagia, with fever typically occurring in the pediatric population. It is imperative to decide whether the tonsils are involved or not, since viral inflammation of the entire oropharyngeal mucosa will not respond to antibiotic therapy. Therefore, clinically relevant and validated scores are suggested to decide whether prescription of antibiotic therapy is justified or not [1, 2]. Astonishingly, these considerations are commonly not transferred to tonsillectomy, frequently acknowledged as a simple and minor procedure that will readily eradicate the source of infection in the throat. This misinterpretation of tonsillectomy ignores a guaranteed number of painful days after surgery and the risk of a potentially life-threatening bleeding complication [3]. What is the scientific point of view? By the 1970s, the few existing randomized trials were seriously biased by many factors and the scientific evidence of the procedure was at best questionable [4, 5]. In March 1984, the New England Journal published the results of a complex clinical trial of Paradise and colleagues who evaluated the efficacy of tonsillectomy in children with sore throat [6]. The authors concluded that in severely affected children (C7 throat infections in the past year or C5 in each of the past 2 years or C3 in each of the past 3 years) the incidence of throat infections during the first 2 years after tonsillectomy was significantly lower and in the third year consistently favored the surgical groups compared to the non-surgical group. The benefit from surgery for children with less severe throat infections was insignificant due to spontaneous resolution of throat infections. During the past decades, this unique paper served as an adequate answer to the allegation of tonsillectomy as ‘‘ritualistic surgery’’ [7]. Until this time, the teeth and tonsils in particular were acknowledged as major sources of primary infections that spread secondary to other body organs. Therefore, a wide array of unproven indications had existed to justify tonsillectomy, including rheumatic fever, endocarditis, myocarditis, pericarditis, nephritis, pancreatitis, chorea, peptic ulcer, appendicitis, and arthritis. Particularly the focal theory of infection considered tonsils as portals of infection and served for many years as a promoter of a technically trivialized tonsillectomy [8]. In the light of hundreds of thousands of procedures performed annually worldwide it is noteworthy to emphasize, that only seven studies dealing with the efficacy of tonsillectomy on the incidence of sore throat were found eligible for analysis in the latest and updated meta-analysis of the Cochrane Collaboration [4]. The evidence in two studies with adult patients was considered to be of low quality and their conclusion limited to 5–6 months after surgery. In five studies with children adequate information was considered to be available only for the first year following surgery which contrasts to the original statement of the authors. Children after tonsillectomy had three episodes of sore throat on average compared to 3.6 episodes experienced by children of the control group. A closer look to the few obtainable national guidelines concerning indications for tonsillectomy reveals that the selection criteria of a 30-year-old study are still in practice conceding slight modifications. In other words, the & Jochen P. Windfuhr jochen.windfuhr@mariahilf.de