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Discharge delays of Medical-Surgical Pediatric Intensive Care Unit (PICU) patients with Obstructive Sleep Apnea (OSA) following tonsillectomy or tonsillectomy with adenoidectomy (T&A) negatively impact hospital bed availability. This project identified process improvements to reduce discharge delays and increase PICU bed availability. A Failure Modes and Effects Analysis (FMEA) was implemented to identify care and process failures that result in discharge delays. Through the FMEA, failure risk profile numbers with the highest impact were recognized for improvement (Institute for Healthcare Improvement, 2017; VHA National Center for Patient Safety, 2023). Forty failure modes were identified. High-impact failures included not administering dexamethasone early for patient pain or desaturation, intervening for desaturations consistent with the patient's baseline, and not anticipating family needs for discharge. The FMEA identified several actionable changes that if implemented, could promote timely discharge of patients with OSA following tonsillectomy or T&A. [ABSTRACT FROM AUTHOR]

Objective: We conducted a systematic review of randomized controlled trials (RCTs) to evaluate the efficacy of tranexamic acid (TXA) in reducing posttonsillectomy hemorrhage (PTH). Data Sources: We searched MEDLINE, EMBASE, and CENTRAL for RCT comparing prophylactic TXA to control in patients undergoing tonsillectomy. Review Methods: Per Preferred Reporting Items for Systematic Review and Meta‐analysis guidelines, the databases were searched from date of inception through October 2023. RCTs of patients undergoing tonsillectomy or adenotonsillectomy and receiving prophylactic TXA versus control were included. Two reviewers screened citations, extracted data, assessed the risk of bias, and classification of Grading of Recommendations, Assessment, Development, and Evaluation independently. Standardized mean difference with 95% confidence interval (CI) was applied for continuous variables. Dichotomous data were expressed as relative risk with 95% CI. Results: A total of 10 RCT were included in our quantitative analysis. Eight studies reported on PTH rate. Prophylactic TXA showed non‐significant decrease in PTH (relative risk or risk ratio [RR]: 0.62 [0.35, 1.10]). Sensitivity analysis showed significant decrease in PTH after exclusion of High‐risk bias studies (RR: 0.48 [0.30, 0.77]). Intraoperative blood loss volume was significantly lower in the TXA group (35.59 mL [−48.19, −22.99]). Conclusion: Overall, this study showed a tendency toward lesser PTH rate with prophylactic TXA. However, this tendency only reaches statistical significance when studies with high risk of bias are excluded. Well‐designed trials are still needed to support our observations. [ABSTRACT FROM AUTHOR]

Objective: To identify barriers and facilitators to implementing shared decision making (SDM) in pediatric otolaryngology. Study Design: A qualitative study. Setting: Semistructured interviews of pediatric otolaryngologists. Methods: The Theoretical Domains Framework (TDF) was used as a guide for data collection and analysis to consider capability, opportunity, and motivation (COM‐B) factors. The focal surgical procedures were tonsillectomy, adenoidectomy, and tympanostomy tube placement. Deductive and inductive coding of interview transcripts according to TDF/COM‐B domains were performed by 2 separate reviewers. Results: A total of 11 interviews were conducted to achieve data saturation. The 4 dominant themes were: (1) inconsistent inclusion of SDM elements in practice, (2) social influences from parents, (3) environmental context, and (4) applicability of SDM in otolaryngology. Theme 1 identified that surgeons perceived SDM as a feature of their practice. However, the discussion of parents' values was seen as less explicit and structured interview formats were not commonly employed. Theme 2 demonstrated that surgeons saw parents' preconsult "agenda" as influencing their openness to consider multiple treatment options. Theme 3 pointed to the barriers of short appointment times, challenges in the use of support staff and lack of decision aids. Theme 4 emphasized surgeons' belief in the value of SDM and that parents' involvement in decision making reduced likelihood of decisional regret. Conclusion: Pediatric otolaryngologists strongly support the value of SDM during clinical encounters, particularly to allow parent ownership of decisions regarding treatment. The major barriers were lack of clinical translation of SDM knowledge, social influences, and environmental factors. [ABSTRACT FROM AUTHOR]

Objective: To describe postoperative analgesic regimens and patient‐reported pain‐related outcomes after tonsil surgery. Method s : Cohort study including perioperative data (n = 9274) and patient‐reported outcome measures (n = 5080) registered in the Swedish Quality Register for Tonsil Surgery during 2023. Results: After tonsil surgery, 92.7% received at least paracetamol and a NSAID/COX inhibitor, while 6.8% received no NSAID/COX inhibitor. Opioids were prescribed after tonsillectomy to 62.9% of adults and less often to adolescents and children (13–17‐year‐olds: 48.2%, 6–12‐year‐olds: 8.8%, 0–5‐year‐olds: 4.0%). Clonidine was frequently prescribed to 0–5‐year‐olds after tonsillectomy (54.4%). Overall, 11.7% reported dissatisfaction with the pain treatment, with the highest dissatisfaction rate after tonsillectomy in adolescents (20.6%) and adults (20.0%), and the lowest after tonsillotomy in children (4.9–6.8%). The most common complaint among dissatisfied patients was analgesics not being sufficiently helpful. Adult patients who received addition of opioids were less dissatisfied with the pain treatment (15.9% vs. 25.9%, p < 0.001), but also reported more side effects (5.7% vs. 2.7%, p = 0.039), compared with patients who received only paracetamol and NSAID/COX inhibitors. Conclusion: Tonsil surgery patients in Sweden receive various analgesic regimens. Although most are satisfied with pain treatment, there is room for improvement, particularly among adolescents and adults undergoing tonsillectomy. Paracetamol and a NSAID/COX inhibitor seem advisable as basic treatment. However, many patients need more effective treatment. The addition of opioids in adults results in greater satisfaction with pain treatment, but safety issues with opioid prescriptions must be taken into consideration. Level of Evidence: 4 Laryngoscope, 135:140–147, 2025 [ABSTRACT FROM AUTHOR]

The article discusses a retrospective study of 448 cases of rebleeding after secondary post-tonsillectomy bleeding, identifying risk factors for rebleeding. The study found that the rebleed rate was 15.4%, with factors such as the use of AgNO3 and higher deprivation levels associated with a higher risk of rebleeding. The study suggests that routine overnight hospital admission for all patients with secondary post-tonsillectomy bleeding may not be necessary, and close monitoring for the first 24 hours after presentation with bleeding is recommended. The findings aim to guide best management practices for this common complication. [Extracted from the article]

ABSTRACT Background Methods Results Conclusion This study investigates the effect of locally applied honey on pain intensity, analgesia consumption, pain relief and nighttime awakenings in children following tonsillectomy, addressing conflicting evidence and the lack of differentiation between adult and paediatric populations in previous reviews.A systematic search was conducted across multiple databases, including Cochrane Library, ClinicalTrials.gov, MEDLINE, Web of Science and Google Scholar. Randomised controlled trials (RCTs) comparing pain outcomes in children receiving honey in addition to standard treatments versus those receiving standard treatments alone were included. Pain intensity was measured with the VAS tool. Meta‐analysis was performed using STATA version 14 software. Also, risk of bias and certainty of evidence were evaluated.Out of 537 articles, seven studies (n = 710) with RCT design met the inclusion criteria. The average duration for measuring pain intensity was 7.37 days. Pooled effect size showed a statistically significant reduction in pain intensity in the honey intervention group compared to the control group (WMD: −0.90, 95% CI [−1.32, −0.48], p < 0.001, I2: 92.5%; certainty of evidence: low). Also, the results demonstrated that honey significantly decreased the average time required for pain relief and analgesic consumption in the intervention group compared to the control group. One study was deemed low risk of bias, four studies were of intermediate quality and two studies were evaluated as high.While honey shows promise in reducing post‐tonsillectomy pain, cautious use is advised due to the limited quality of evidence. More robust RCTs are needed to address biases and reinforce confidence in the findings. [ABSTRACT FROM AUTHOR]

ABSTRACT Aim Methods Results Conclusions This study aims to present the clinical characteristics of patients with PFAPA syndrome, and to compare the effects of corticosteroid usage, colchicine prophylaxis, and tonsillectomy on the frequency of attacks in patients with PFAPA syndrome.Patients aged between 6 months and 18 years presenting to our Paediatric Rheumatology clinic between 2017 and 2021 who were diagnosed with PFAPA syndrome and followed up for a minimum of 12 months were included in this study. The demographic and clinical characteristics of the patients, laboratory findings, attack durations, and treatments were recorded.Our study, comprised of 195 patients, included four groups: untreated (n = 58), corticosteroid (n = 43), colchicine (n = 62), and tonsillectomy (n = 32). There was no significant difference between the treatment groups in terms of attack frequencies before treatment initiation (p > 0.05). When attack frequencies before and after treatment initiation were observed, a decrease in attack frequency compared to the pre‐treatment period was observed in the tonsillectomy group (from 12 to 3 attacks) (p < 0.001) and the colchicine group (from 12 attacks to 1 attack) (p < 0.001). It was noted that using steroids during three or more attacks increased attack frequency compared to the pre‐treatment period (p < 0.0001). Tonsillectomy resulted in a more significant reduction in attack frequency compared to the colchicine group (p < 0.001).Using corticosteroids during an attack has been shown to effectively control attacks. However, the repeated use of corticosteroids increases the frequency of attacks. Colchicine prophylaxis leads to a reduction in attack frequency in the majority of cases. Tonsillectomy can successfully control the disease in most cases. [ABSTRACT FROM AUTHOR]

Aim: Obstructive sleep apnea (OSA) is the most prevalent sleep-related breathing disorder. OSA affects approximately 2 million Italians, although only 3% receive a diagnosis and correct treatment. This review aims to provide an overview to guide clinical decision making, ensuring that patients receive the most appropriate treatment for their specific condition. Material and Methods: This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and registered at PROSPERO under the ID CRD42024593760. A search on PubMed, Scopus, and Web of Science was performed to find papers that matched the topic, using the following Boolean keywords: ("obstructive sleep apnea" OR "OSA" OR "sleep apnea, obstructive") AND ("surgery" OR "surgical" OR "surgical techniques" OR "surgical treatment" OR "operative" OR "surgical procedures") AND ("treatment" OR "therapy" OR "management"). Result: The electronic database search found 20337 publications. After the screening and eligibility phase, 15 papers were chosen for the qualitative analysis. Conclusions: Adenotonsillectomy (AT) significantly improves secondary outcomes like behavioral issues and quality of life, compared to watchful waiting with supportive care (WWSC). Alternative approaches such as tonsillotomy and adenopharyngoplasty (APP) offer promising results, with less postoperative discomfort and lower complication rates. However, further large-scale studies are needed to refine surgical techniques, assess long-term outcomes, and optimize individualized treatment strategies for OSA. [ABSTRACT FROM AUTHOR]

Objectives: This review aims to analyze the treatment options for peritonsillar abscess (PTA) in children. Methods: We searched PubMed and EMBASE for studies regarding the treatment of PTA in children. Relevant studies were reviewed based on systematic review (PRISMA) guidelines. Qualitative and quantitative analyses of the extracted data were performed. Results: A total of 12 articles with 2211 cases of PTA were found to be eligible. All the identified studies were retrospective cohorts. The mean age varied from 8.5 to 15.4 years without gender difference. Treatment options included broad-spectrum antibiotic therapy with incision and drainage of the abscess, needle aspiration and immediate tonsillectomy in 69%, 7.6% and 7% of cases, respectively. Antibiotics alone were administered to 16.4% of the subjects. The rate of recurrence of PTA after primary treatment ranged from 2% to 15.8% of cases. The time of recurrence is considered within one or two months. Complications in children with PTA were torticollis, prolonged fever, sepsis, dyspnea and parapharyngeal involvement. Conclusions: The mainstay of treatment of PTA in children is antibiotic therapy with incision and drainage of the abscess. Alternatives include antibiotic treatment alone or in association with needle aspiration. Immediate tonsillectomy is reserved only for a few high-risk patients. [ABSTRACT FROM AUTHOR]

Background: The effects of tonsillectomy combined with steroid pulse (TSP) therapy for IgA nephropathy (IgAN) are little known. Therefore, we examined the effects of TSP therapy on the kidney outcomes of IgAN in a large, nationwide cohort study in Japan. Methods: Between 2002 and 2004, 632 IgAN patients with ≥ 0.5 g/day proteinuria at diagnosis were divided into three groups with mild (0.50–0.99 g/day; n = 264), moderate (1.00–1.99 g/day, n = 216), or severe (≥ 2.00 g/day; n = 153). Decline in kidney function and urinary remission were compared among the three groups after TSP therapy, corticosteroid (ST) therapy, or conservative therapy during a mean follow-up of 6.2 ± 3.3 years. 10.6% and 5.9% of patients in the ST and conservative therapy group underwent tonsillectomy. Results: The rate of urinary remission at the final observation was significantly higher in the TSP therapy group than in the ST or conservative therapy groups (mild proteinuria: 64%, 43%, and 41%; moderate proteinuria: 51%, 45%, and 28%; severe proteinuria: 48%, 30%, and 22%, respectively). In contrast, the rate of a 50% increase in serum creatinine was lower in groups TSP therapy, than ST or conservative therapy (mild proteinuria: 2.1%, 10.1% and 16.7%; moderate proteinuria: 4.8%, 8.8% and 27.7%; severe proteinuria: 12.0%, 28.9% and 43.1%, respectively). In multivariate analysis, TSP therapy significantly prevented a 50% increase in serum creatinine levels compared with conservative therapy in groups with moderate and severe proteinuria (hazard ratio, 0.12 and 0.22, respectively). Conclusion: TSP significantly increased the rate of proteinuria disappearance and urinary remission in IgAN patients with mild-to-moderate urinary protein levels. It may also reduce the decline in kidney function in patients with moderate-to-severe urinary protein levels. [ABSTRACT FROM AUTHOR]

Background: Tonsillectomy with steroid pulse therapy (TSP) and tonsillectomy monotherapy (T) have improved the prognosis of patients with immunoglobulin A nephropathy (IgAN). However, a consensus has not been reached on the best treatment for these patients. This study aimed to compare the efficacies of TSP and T. Methods: Data of patients with IgAN who received TSP or T were retrospectively analyzed. The exclusion criterion was a serum creatinine level > 1.5 mg/dL. The clinical remission and renal survival rates were compared. Results: Patients were divided into groups based on the treatment method: the TSP (n = 82) and T groups (n = 41). No significant differences were observed in patient characteristics, except for the observation period (TSP: 60 months, T: 113 months). The log-rank test revealed that the clinical remission rate was significantly higher in the TSP group than in the T group (p < 0.05). The superiority of TSP was also observed in the urinary protein excretion (> / = or < 1 g/day) of the two subgroups. According to the Cox proportional-hazards model, the treatment method and daily urinary protein extraction were independent factors affecting clinical remission. The 10-year renal survival rates in the TSP and T groups were 100% and 92.5%, respectively. The log-rank test revealed a tendency for a higher renal survival rate in the TSP group than in the T group (p = 0.09). Conclusion: The clinical remission rate was significantly higher with TSP than with T, regardless of urinary protein levels. TSP tended to have a better renal survival rate than T. [ABSTRACT FROM AUTHOR]

Objectives: To identify predictors of obstructive sleep apnea (OSA) after adenotonsillectomy (T&A) in children under 3 years of age and to describe the characteristics of children with OSA under 3 years of age undergoing T&A in an ethnically diverse population. Methods: We examined 87 children under 3 years with T&A and pre- and post-operative polysomnography (PSG) between 8/2012 and 3/2020 at a large tertiary care hospital. Differences were compared for covariates including demographics, comorbidities, and respiratory parameters. Regression was used to identify predictors of persistent severe OSA. Significance was set at P <.05. Results: Of the 87 children in the study, 64 (74%) were male, 26 (30%) were obese, 34 (39%) were Hispanic, and 35 (40%) were Black. Most children (94%) had improvements in OSA severity as measured by the apnea-hypopnea index (AHI) after T&A, but 78% had persistent OSA (AHI ≥1) after surgery. Children with persistent mild, compared to moderate-severe OSA, were more likely to have gastroesophageal reflux disease (GERD) (50% versus 24%, P =.025), a craniofacial disorder (30% versus 10%, P =.025), Down syndrome (20% versus 5%, P =.031), or pre-operative severe OSA. Conclusions: This study of an ethnically diverse population found that T&A is an effective procedure at improving, but not resolving, OSA in children under 3 years. Children with Down syndrome, craniofacial abnormalities, GERD, or pre-operative severe OSA who are under 3 years old are at high risk for persistent OSA and may benefit from post-operative PSG. Future study should examine complications and long-term outcomes of T&A in this age group. [ABSTRACT FROM AUTHOR]

Introduction: Tonsillectomy is commonly associated with significant postoperative challenges such as pain management, complication monitoring, and patient recovery. Traditional care methods, while effective, often do not adequately address these issues, particularly in personalized care and remote monitoring. This study assesses the impact of Artificial Intelligence (AI)-assisted postoperative care on recovery outcomes in tonsillectomy patients compared to conventional care methods. Methods: Conducted at a tertiary care hospital's Otolaryngology Department from January to December 2023, this observational cohort study involved 100 elective tonsillectomy patients. Participants were divided into two cohorts: one receiving traditional care and the other AI-assisted care, which utilized machine learning for pain management, continuous symptom monitoring through wearable devices, and virtual assistance. Results: AI-assisted care significantly improved early postoperative pain management, reducing pain scores to 5.2 ± 1.1 from 6.5 ± 1.2 in traditional care (p = 0.01). Dehydration rates decreased from 6 to 1% (p = 0.05), and the average hospital stay was reduced to 2.8 ± 1.1 days from 3.5 ± 1.2 days. While no significant differences were found in readmission rates for haemorrhage and infection, patient satisfaction notably increased, with pain management improving to 4.4 ± 0.7 and overall satisfaction to 4.1 ± 0.6 (p = 0.03). Conclusion: AI-assisted care offers significant advantages over traditional methods in managing tonsillectomy recovery, optimizing surgical outcomes, and enhancing patient satisfaction. This study supports further exploration into AI's long-term outcomes and its application across various surgical fields. [ABSTRACT FROM AUTHOR]

Tonsillectomy is a commonly performed procedure in pediatric ENT departments worldwide. To comprehensively evaluate the morbidity associated with tonsillectomy techniques and potential factors that impact outcomes The present study examined the entirety of pediatric patients who underwent tonsillectomy or adenotonsillectomy at CUCH during the years 2021 and 2022. Comprehensive scrutiny was conducted on admissions and readmission data, which encompassed hospital episode statistics, operative notes, patient questionnaires, and electronic records. A total of 690 procedures were identified in our records, with 399 males and 291 females ranging in age from 1 to 13 years. The main indications for surgery included sleep-disordered breathing and recurrent tonsillitis. Among the patients, 233 underwent the surgery as a day case. Coblation intracapsular technique was used in 52% of cases, dissection method in 37%, and coblation extracapsular method in 10%. The incidence of post tonsillectomy bleeding (&infection) was 8.19%(1.75%),14.89%(2.08%), 1.65%(1.65%) for dissection, coblation extracapsular and coblation intracapsular techniques respectively. Coblation intracapsular tonsillectomy has shown the lowest rate of postoperative hemorrhage compared to other techniques. Senior surgeons (consultants) had the lowest rate of post-tonsillectomy hemorrhage; however, this difference did not reach statistical significance. [ABSTRACT FROM AUTHOR]

Objectives: Individuals with obstructive sleep apnea (OSA) suffer from a multitude of concurrent morbidities including cardiovascular disease (CVD). Limited data exists comparing long term cardiovascular disease (CVD) clinical outcomes for patients treated with surgical intervention versus continuous positive airway pressure (CPAP). The purpose of this study was to compare CVD outcomes at multiple time points comparing those treated with sleep surgery versus CPAP alone. Methods: A research database was used to assess outcomes: death, myocardial infarction, atrial fibrillation, heart failure, essential hypertension, and pulmonary hypertension at 5, 8, and 20 years for patients with OSA treated with surgical interventions (upper airway stimulation [UAS], uvulopalatopharyngoplasty [UPPP], and tonsillectomy) or CPAP alone. Subjects were identified using ICD and CPT codes and analyses were conducted with and without propensity score matching for age, sex, race, BMI, myocardial infarction (MI), essential hypertension, pulmonary hypertension, atrial fibrillation, and heart failure. Results: All surgical interventions demonstrated benefit over CPAP alone at most time points for most surgical interventions. At 8 years, for all sleep surgeries (UAS or UPPP or tonsillectomy) (n = 6627) versus treatment with CPAP alone (n = 6627), matched subjects demonstrated decreased risk (odds ratios) and superior survival (hazard ratios and log ranks tests) for death (OR = 0.49 [0.39, 0.62] P ≤.0001, HR = 0.29 [0.23, 0.37], χ2 = 109.58 P ≤.0001), myocardial infarction (OR = 0.67 [0.54, 0.84] P =.0005*, HR = 0.48 [0.38, 0.60], χ2 = 42.40 P ≤.0001), atrial fibrillation (OR = 0.70 [0.59, 0.83] P ≤.0001, HR = 0.54 [0.45, 0.64], χ2 = 51.53 P ≤.0001), heart failure (OR = 0.55 [0.47, 0.64] P ≤.0001, HR = 0.41 [0.35, 0.47], χ2 = 137.416 P ≤.0001), essential hypertension (OR = 0.88 [0.82, 0.94] P =.0002, HR = 0.78 [0.74, 0.82], χ2 = 76.38 P ≤.0001), and pulmonary hypertension (OR = 0.51 [0.40, 0.65] P ≤.0001, HR = 0.38 [0.29, 0.48], χ2 = 60.67 P ≤.0001) where P ≤.00037 indicated statistical significance*. Conclusion: This investigation suggests surgical management of obstructive sleep apnea may contribute to the mitigation of long-term clinical CVD morbidity. [ABSTRACT FROM AUTHOR]

The article describes a case of parotitis following endoscopy. Topics include the rarity of parotitis, particularly in children, with causes ranging from viral and bacterial infections to noninfectious factors; the occurrence of post-endoscopy parotitis, a seldom-seen complication that can lead to serious conditions such as osteomyelitis and sepsis; and the clinical case of a 4-year-old girl who developed parotitis after an EGD procedure for Helicobacter pylori gastritis.

Objective: The efficacy of hypoglossal nerve stimulation (HGNS) therapy is limited by obstruction of the oropharyngeal lateral walls (OLWs). Our objective was to investigate the effect of palatine tonsillectomy on HGNS efficacy in obstructive sleep apnea (OSA) patients with OLW collapse. Study Design: Case‐control study of patients with moderate‐to‐severe OSA, complete‐or‐partial OLW collapse, and small tonsils (1 − 2+). Concomitant palatine tonsillectomy and HGNS (HGNS+T) were compared against a control group of patients who underwent HGNS alone. Setting: Single academic institution. Methods: Study outcomes were measures of HGNS efficacy defined as a %reduction in apnea‐hypopnea index (AHI) (primary) and successful treatment response (50% AHI reduction to <15/h, logistic regression), respectively. Regression analyses quantified the additional effect of tonsillectomy (HGNS+T vs HGNS alone, independent variable) on HGNS efficacy. Analyses were adjusted for OLW collapse severity (complete vs partial), tonsil size, age, sex, body mass index, and baseline AHI. Results: Nineteen patients underwent HGNS+T and had follow‐up sleep testing for the current analysis. The control group (HGNS alone) consisted of 78 patients. Baseline demographics and OSA severity were similar between the groups, except HGNS+T group had increased prevalence of complete OLW collapse. Linear regression demonstrated that adding tonsillectomy resulted in an additional 22.9% [7.5, 35.2] reduction in AHI [95% confidence interval, CI] (P =.006), and 8.6 [1.7,43.4] (P =.010) greater odds [95% CI] of a successful treatment response with HGNS. Conclusion: Compared to historically poorer outcomes of HGNS in patients with OLW collapse, these early results suggest combining tonsillectomy with HGNS may represent a promising strategy to improve success rates. [ABSTRACT FROM AUTHOR]

Objective: To determine the impact of the release of updated American Academy of Otolaryngology–Head and Neck Surgery (AAO‐HNSF) Clinical Practice Guidelines (CPG) for Tonsillectomy in Children in 2019 on adherence to evidence‐based practice. Methods: Patients between ages 1 and 18 who had tonsillectomies and encounters for throat infection (tonsillitis or pharyngitis) between of February 5, 2015 and February 4, 2023 were identified by International Classification of Diseases and Current Procedural Terminology codes, excluding those with obstructive sleep‐disordered breathing. Retrospective chart review was performed to determine adherence to evidence‐based practice. Results: There was a significant increase in adherence to evidence‐based practice post‐CPG release compared to pre‐CPG (85.4% vs 73.1%, P =.0088). There was an observed trend for improved adherence to evidence‐based practice for pediatric tonsillectomy for recurrent infection for most of the post‐CPG period. There were fewer tonsillectomies performed post‐CPG, despite more total encounters for throat infection. Discussion: The publication of the updated AAO‐HNSF CPG corresponded with improved adherence to evidence‐based practice for tonsillectomy in children for recurrent infection and an observed decrease in overall rate of tonsillectomy. This suggests the CPG may be an effective quality improvement tool for reducing variation and unnecessary patient morbidity or harm. Implications for Practice: These findings suggest that the updated AAO‐HNSF CPG for Tonsillectomy in Children may have effectively impacted practice patterns, and further work should be done to expand their reach to other specialties and settings. Consideration should also be given to further understand any balancing factors associated with reduced tonsillectomies for recurrent infections including quality of life impact on children managed expectantly. [ABSTRACT FROM AUTHOR]

Objectives: Previous studies indicate children who pass an Asleep Room Air Challenge (AsRAC) do not have significant postoperative adverse respiratory events after adenotonsillectomy (T&A). Subsequently, we revised our overnight monitoring (OM) criteria, allowing patients with an obstructive apnea/hypopnea index (OAHI) ≤20 or nonsevere obesity (Class I) to be considered for same‐day surgery (SDS) if they passed an AsRAC. Our hypothesis is that our modified OM criteria would not increase the return visits or readmission rates for patients undergoing SDS within 48 h or 15 days of T&A. Methods: A retrospective review of all children aged ≥3 and <21 years who underwent T&A at a tertiary children's hospital and its satellite locations was performed from January 2017 to September 2022. Descriptive statistics and outcome measures were compared using a 3% margin noninferiority test before and after the new criteria implementation. Results: Before intervention, 3,266 (58%) T&As were performed as SDS. Afterward, 74% of T&As were performed as SDS (p‐value <0.05). There was no difference in the ED revisit rate for SDS within the 3% noninferiority margin. Following intervention, 29% more children with Class I obesity (62% vs. 33%) underwent SDS (p‐value <0.001). Afterward, 19% more children with polysomnography underwent SDS (39% vs. 20%), p‐value <0.001. After intervention, within 48 h of SDS, six (0.9%) children had revisits for bleeding and seven (1.2%) for vomiting. There were no perioperative respiratory events. Conclusion: Our revised monitoring criteria did not demonstrate an increase in ED visit or readmissions rates within 48 h or 15 days of T&A. Additionally, we found a 29% increase in Class I obese children undergoing SDS T&A. Level of Evidence: 3 Laryngoscope, 134:5223–5230, 2024 [ABSTRACT FROM AUTHOR]

Simple Summary: Patients presenting with cystic metastasis in the neck lymph nodes and no obvious primary tumor, neck cancer of unknown primary (NCUP), represent a very complex management challenge, especially today in the Human Papillomavirus (HPV) era. Given the increasing incidence of HPV-related oropharyngeal squamous cell carcinoma (OPSCC), further detection methods other than p16 IHC (immunohistochemistry) for HPV testing are crucial. An HPV-positive status can localize the tumor to the oropharynx, a common site for occult primaries. Furthermore, up to 15% of p16 protein-positive tumors are actually HPV-negative. Failure to perform additional HPV testing can have dangerous prognostic and therapeutic implications such as de-escalation strategies that hesitate in an undertreatment. The other important topic faced in this study is the role of smoking and p53 mutations, especially their significance in HPV-positive cancers and the role of extranodal extension (ENE) in HPV-positive patients. In this paper, biomolecular, diagnostic, prognostic and therapeutical aspects are critically analyzed to make a precise diagnosis and accurately estimate the prognosis of such patients. Background: The incidence of patients showing neck metastasis and no obvious primary tumor at the initial diagnostic evaluation or neck cancer of unknown primary (NCUP) is rising. It is estimated that a relevant part of these tumors arises in the tonsillar crypts or base of the tongue and are p16+-related. However, today, the detection rate of the primary tumor is suboptimal. Identifying the primary tumor and its biomolecular characterization is essential since it influences the treatment administered, possibly reducing radiation fields and providing de-escalation to primary surgical management. However, p16 IHC (immunohistochemistry) might not be sufficient to diagnose HPV-related OPSCC. The other subset of patients discussed are the HPV-positive patients who have a history of tobacco exposure and/or p53 mutations. Possible factors that could negatively influence the outcomes of these patients are investigated and discussed below. So, this paper aims to analyze the diagnostic, bio-molecular, clinico-radiological, morphological, prognostic and therapeutical aspects of p16-positive OPSCC, highlighting the possible bias that can occur during the diagnostic and prognostic process. Methods: A narrative review was conducted to investigate the biases in the diagnostic and therapeutic process of two groups of patients: those who are p16-positive but HPV-negative patients, and those who are p16-positive and HPV-positive with exposure to traditional risk factors and/or p53 mutations. The keywords used for the literature research included the following: NCUP, OPSCC, p16IHC, HPV testing, p16 positive HPV negative OPSCC, p16 positive HPV positive OPSCC, tonsillectomy, tobacco exposure, p53 mutations, cystic neck metastasis, extranodal extension (ENE), radiotherapy, de-escalation and neck neck dissection. Results: HPV-positive OPSCC has specific clinico-radiological features. Bilateral tonsillectomy should be considered for the identification of the primary tumor. P16 IHC alone is not sufficient for diagnosing HPV-related OPSCC; additional detection methods are required. The role of tobacco exposure and p53 mutations should be investigated especially in cases of HPV-positive tumors. Extranodal extension (ENE) must be taken into consideration in the prognostic staging of HPV-positive tumors. Surgical primary treatment involving neck dissection (ND) and bilateral tonsillectomy followed by adjuvant radiation may represent the most appropriate approach for N3 cases. Diagnosis, prognosis and therapeutical implications must be addressed considering clinical, biomolecular and morphological aspects. At least today, the numerous biases that are still present influencing the diagnostic and prognostic process do not permit considering de-escalation protocols. Conclusions: A precise and accurate diagnosis is required in order to adequately stage and manage p16+ OPSCC, particularly with neck metastasis. The role of tobacco exposure and/or p53 mutations must be considered not only in p16+ OPSCC but especially in HPV-positive OPSCC. Until a more accurate diagnosis is possible, ENE should be considered even in p16+HPV+ OPSCC. Primary surgery with unilateral ND and bilateral tonsillectomy might be the treatment of choice given the numerous diagnostic and prognostic pitfalls. Therefore, it is inappropriate and risky to propose de-escalation protocols in routine clinical practice due to the risk of undertreatment. [ABSTRACT FROM AUTHOR]

Importance: Obstructive sleep apnea (OSA) in children is linked with alterations in the gut microbiome. The influence of adenotonsillectomy (AT), a primary intervention for OSA, on gut microbiota dynamics relative to disease severity remains to be elucidated. Objective: This study aimed to investigate the impact of OSA severity and AT on the gut microbiome in pediatric patients. Design: A prospective observational study. Setting: Tertiary referral center. Participants: A cohort of 55 pediatric patients treated with AT for OSA. Intervention: Total tonsillectomy and adenoidectomy procedures. Main Outcome Measures: Comprehensive evaluations included in-laboratory polysomnography and 16S rRNA gut microbiome profiling at baseline, and again at 3rd and 12thmonth following surgery. Results: Initial findings showed uniform α-diversity across different severities of OSA, while β-diversity was significantly elevated in the severe OSA subgroup. Certain gut microbiota taxa (Lachnospiraceae NK4A136 group, Ruminococcaceae UCG-002, Ruminococcaceae UCG-014, Alloprevotella, Christensenellaceae R-7 group, Ruminococcaceae UCG-005, Lactobacillus murinus, and Prevotella nigrescens) were found to inversely correlate with the apnea-hypopnea index (AHI). Significant post-AT improvements in AHI and other polysomnographic metrics were observed. Notably, AHI changes post-AT were positively associated with microbial α-diversity (species richness), β-diversity, and specific bacterial taxa (Enterobacter, Parasutterella, Akkermansia, Roseburia, and Bacteroides plebeius DSM 17135), but negatively with other taxa (Fusicatenibacter, Bifidobacterium, UBA1819, Ruminococcus gnavus group, Bifidobacterium longum subsp. Longum, and Parabacteroides distasonis) and specific metabolic pathways (purine metabolism, transcription factors, and type II diabetes mellitus). The postoperative patterns of α- and β-diversity mirrored baseline values. Conclusions and Relevance: This study documents significant changes in the gut microbiome of pediatric patients after AT, including variations in α- and β-diversities, bacterial communities, and inferred metabolic functions. These changes suggest a potential association between the surgical intervention and microbiome alterations, although further studies are necessary to discern the specific contributions of AT amidst possible confounding factors such as antibiotic use. [ABSTRACT FROM AUTHOR]

Tonsillar marginal zone hyperplasia may mimic mucosa-associated lymphoid tissue lymphoma, a rare diagnosis in children. Histologically, both entities can demonstrate expansion of the marginal zone with disruption of follicular architecture. However, marginal zone hyperplasia may appear polyclonal by flow cytometry. We present two pediatric tonsillectomy cases with tonsillar marginal zone hyperplasia and discuss the diagnostic challenges this poses in the pediatric population. Both tonsillectomies demonstrated expansion of marginal zones with partial architectural effacement, and flow cytometric analysis of both cases detected lambda light chain restricted, CD20(bright) B cells without CD38. Authors have suggested that the lambda restricted B cells in this setting represent naïve, unmutated B cells with preferential, but polyclonal, lambda expression. Our cases are in line with this thought. While robust, BIOMED-2 primer PCR can show dominant IgK peaks, which may be misinterpreted. This presents a diagnostic pitfall in the workup of pediatric tonsils that community pathologists must consider. [ABSTRACT FROM AUTHOR]

Background: Tonsillectomy is an effective treatment option for obstructive sleep apnoea in selected adult patients, but there has been a lack of long-term follow-up data. Objectives: To analyse the long-term outcomes of extracapsular tonsillectomy in the treatment of obstructive sleep apnoea in adults, with the longest follow-up periods to date. Materials and methods: We recruited adults who had undergone extracapsular tonsillectomy because of obstructive sleep apnoea between 2004 and 2018 in the Hospital District of Southwest Finland. A new home sleep study, questionnaires, and a structured phone interview were conducted on these patients 4–17 years after surgical treatment. The primary outcome was the change in the apnoea-hypopnoea index. Results: The mean apnoea-hypopnoea index was reduced from 27.1 preoperatively to 14.1 after the long-term follow-up (mean 12 years), and the mean Epworth Sleepiness Scale score decreased from 9.2 to 4.6. The long-term surgical success rate was 38.5%. Four out of five patients would choose the surgery again according to the phone interview. Conclusions and significance: This study supports the notion that extracapsular tonsillectomy alone can be considered as a surgical treatment option for selected adults with obstructive sleep apnoea and tonsillar hypertrophy. For most of the patients, the obstructive sleep apnoea is alleviated. [ABSTRACT FROM AUTHOR]

Background: The presence of Actinomyces can be associated with complications. Aims: This study aimed to determine the frequency of post-tonsillectomy hemorrhage (PTH), the presence of Actinomyces in palatine tonsils and serum inflammatory biomarker levels in PTH. Material and methods: The cases who underwent tonsillectomy at a single center were included in the study. Neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR), systemic immune inflammation index (SII) and systemic inflammation response index (SIRI) values were calculated from the complete blood count test. The presence of Actinomyces was recorded from histopathological tonsillectomy material. Results: A total of 1137 patients were included in the study. Actinomyces was detected in 93 (8.18%) patients. Bleeding complications were encountered in 65 cases (5.72%). No relationship was detected between the presence of Actinomyces and PTH rates (p = 0.433). While a relationship was found between age, NLR, and SIRI values and Actinomyces status (respectively, p < 0.001, p = 0.017, p = 0.038), no statistically significant relationship was found between tonsil size, PLR, and SII (p > 0.05). Conclusion and significance: According to the data in our study, NLR and SIRI values were elevated in subjects with Actinomyces. Our findings suggest that this entity has a systemic manifestation. Serum inflammatory biomarkers and the presence of Actinomyces were not found to be associated with PTH. [ABSTRACT FROM AUTHOR]

Tonsillectomy is considered the standard of care in patients with obstructive sleep apnea (OSA) and large tonsils; however, there are selected cases where this procedure should not be considered. We present two patients with tonsil grade 4 and severe OSA where tonsillectomy was not the solution for their problem and could be a superfluous procedure. In our experience, a preoperatory drug-induced sleep endoscopy (DISE) and proper patient phenotyping will prevent this type of surgical failure. [ABSTRACT FROM AUTHOR]

Objectives: Although the guidelines clearly recommend the fasting time of children before anesthesia, it is usually difficult to control. For pediatric patients, prolonged fasting time before surgery will lead to dehydration and hypoglycemia. Adenotonsillectomy is one of the most common operations in pediatric patients, but its complications are not rare. The purpose of this study is to analyze the relationship between preoperative fasting time and postoperative complications in children undergoing adenotonsillectomy. Methods: The medical and surgical records of 480 pediatric patients who underwent adenotonsillectomy were analyzed retrospectively. They were divided into three groups, including adenoidectomy group, tonsillectomy group, and adenotonsillectomy group. Logistic regression analysis was used to analyze the effect of preoperative fasting time on postoperative complications and hospital stay in pediatric patients of the three groups. Results: The postoperative bleeding rate in the adenoidectomy group (5.16%) was lower than tonsillectomy group and adenoidectomy group (P <.001). Logistic regression analysis showed that the fasting time was positively correlated with the vomiting and pain in adenoidectomy group, tonsillectomy group, and adenotonsillectomy group. And, the postoperative hospital stay was also positively correlated with fasting time in three groups. Conclusion: The prolonged fasting time before otolaryngology surgery in children is related to the occurrence of postoperative complications like vomiting and pain, and also to the increase of postoperative hospital stay. [ABSTRACT FROM AUTHOR]

Objective: To assess the effect of intraoperative cryoanalgesia on subjective pain scores of patients after tonsillectomy. Methods: A systematic review of PubMED, Web of Science, EMBASE was performed using the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) standards. For the first time, we included and quantitative synthesized English-language randomized controlled trials (RCT) evaluating patients of all age groups with benign pathology who underwent tonsillectomy with intraoperative cryoanalgesia versus without. Results: A total of 835 publications were identified, and 7 articles with 463 participants met our criteria were selected for meta-analysis. The standard mean difference for overall subjective pain score, subjective pain scores at postoperation Day1 (POD1), POD7 were −1.44 with 95% confidence interval (CI) [−2.17, −0.72], P =.0001; −1.20 with 95% CI [−1.89, −0.50], P =.0007; −0.90 with 95% CI [−1.46, −0.35], P =.001 respectively, both in favor of cryoanalgesia. Nevertheless, subgroup analysis by surgical technique showed no robust effect between hot technique and "relative" hot technique on overall pain: (−1.72, 95% CI [−2.71, −0.73]) vs. (−1.06, 95% CI [−2.20, 0.07]), p=.39; on POD1: (−1.56, 95% CI [−2.78, −0.33]) vs. (−0.97, 95% CI [−1.83, −0.11]), p=.39; and on POD7 (−1.11, 95% CI [−1.81, −0.40]) vs. (−0.89, 95% CI [−2.02, 0.25]), p=.13. The standard mean difference for postoperative secondary bleeding rate was 1.29 with 95% CI 0.37,4.52], p =.06, no difference in 2 groups. Conclusion: Limited evidence suggests that intraoperative cryoanalgesia during tonsillectomy leads to lower subjective pain score on overall, POD1 and POD7 without differences on post-operation bleeding rate. [ABSTRACT FROM AUTHOR]

Purpose: Access to high-quality and comprehensible patient information is crucial. However, information provided by increasingly prevalent Artificial Intelligence tools has not been thoroughly investigated. This study assesses the quality and readability of information from ChatGPT regarding three index ENT operations: tonsillectomy, adenoidectomy, and grommets. Methods: We asked ChatGPT standard and simplified questions. Readability was calculated using Flesch-Kincaid Reading Ease Score (FRES), Flesch-Kincaid Grade Level (FKGL), Gunning Fog Index (GFI) and Simple Measure of Gobbledygook (SMOG) scores. We assessed quality using the DISCERN instrument and compared these with ENT UK patient leaflets. Results: ChatGPT readability was poor, with mean FRES of 38.9 and 55.1 pre- and post-simplification, respectively. Simplified information from ChatGPT was 43.6% more readable (FRES) but scored 11.6% lower for quality. ENT UK patient information readability and quality was consistently higher. Conclusions: ChatGPT can simplify information at the expense of quality, resulting in shorter answers with important omissions. Limitations in knowledge and insight curb its reliability for healthcare information. Patients should use reputable sources from professional organisations alongside clear communication with their clinicians for well-informed consent and making decisions. [ABSTRACT FROM AUTHOR]

Introduction: This quality improvement initiative is a continued pursuit to optimize outcomes by iteratively improving our opioid sparing anesthesia protocol for tonsillectomy with or without adenoidectomy at our pediatric ambulatory surgical center through data driven Plan‐Do‐Study‐Act cycles. Methods: From 1/2015 through 12/2023, our standardized tonsillectomy protocol underwent nine procedure‐specific perioperative Plan‐Do‐Study‐Act cycles, three procedure‐specific postoperative prescription Plan‐Do‐Study‐Act cycles, and four general ambulatory surgical center enhanced recovery Plan‐Do‐Study‐Act cycles. We analyzed data from the medical record using statistical process control charts. The primary outcome measure was the percent of patients requiring intravenous opioid in the post anesthesia care unit. Secondary outcomes included maximum post anesthesia care unit pain score, the percent of patients requiring treatment for nausea and/or vomiting in the post anesthesia care unit, and the number of postoperative opioid prescription dosages. Balancing measures were average post anesthesia care unit length of stay, percent of patients with prolonged Post Anesthesia Care Unit length of stay (>120 min), and 30‐day reoperation rate. Results: A total of 5654 tonsillectomy with or without adenoidectomy cases were performed at our ambulatory surgical center from 2015 to 2023. The incidence of intravenous opioid administered in the post anesthesia care unit initially rose with opioid free anesthesia launch, but subsequently decreased below the target of 10%. Maximum post anesthesia care unit pain scores rose from mean 3.6 to 4.5, but subsequently returned to the baseline of 3.5, while the incidence of postoperative nausea and/or vomiting improved. The average post anesthesia care unit length of stay increased by 10 min with opioid free anesthesia; however, prolonged post anesthesia care unit stay and 30‐day reoperation rates were unchanged. Conclusions: The continued refinement of our opioid sparing anesthesia protocol has led to reduced perioperative and home opioid use, stable maximum post anesthesia care unit pain scores, and improved postoperative nausea and vomiting rates, with only a slight increase in mean post anesthesia care unit length of stay. [ABSTRACT FROM AUTHOR]

Objective: The aim of this study was to investigate the trends in post‐tonsillectomy analgesic utility and incidence of post‐tonsillectomy hemorrhage before and after the 2013 FDA Boxed Warning against codeine use after pediatric tonsillectomy. Methods: A retrospective study was conducted using TriNetX. A search for patients up to 18 years from 2008 to 2022 within the US Collaborative Network identified 15,648,542 subjects. CPT and ICD‐10 codes were used to identify children who experienced post‐tonsillectomy hemorrhage within 14 days of a tonsillectomy. Analgesics given within 14 days of tonsillectomy were tabulated annually from 2008 to 2022, including codeine, ibuprofen, acetaminophen, oxycodone, ketorolac, and hydrocodone. Bleeding percentage and analgesic utility were grouped into events before and after 2013. Results: Mean age at tonsillectomy was 5.6 years (SD = 3.0). Before 2013, the median percentage of children who experienced postoperative bleeding was 1.8% with 0.73% returning to the OR for bleeding control. After 2013, the median percentage of children who experienced postoperative bleeding was 2.4% (p = 0.029), and 0.99% returned to the OR (p = 0.008). Use of post‐tonsillectomy codeine fell from 10.4% to 0.5% (p = 0.003) whereas ibuprofen rose from 2.0% to 63.9% (p = <0.001), acetaminophen from 42.8% to 77.2% (p = <0.001), ketorolac from 1.2% to 9.2% (p = <0.001), and oxycodone from 2.0% to 30.9% (p = <0.001). No change was detected in use of hydrocodone. Conclusion: Analgesics used post‐tonsillectomy in children have changed since the FDA Boxed Warning against codeine. There has been a small but statistically significant increase in post‐tonsillectomy bleeding. Level of Evidence: 4 Laryngoscope, 134:4783–4788, 2024 [ABSTRACT FROM AUTHOR]

Objectives: To determine the cause of obstructive sleep-disordered breathing using drug-induced sleep endoscopy (DISE) in infants without co-morbidities and with normal clinical examination. Methods: This prospective study was conducted between December 2019 and June 2022 (31 mo). All infants referred for obstructive sleep-disordered breathing with normal clinical examination and flexible laryngoscopy were included and underwent DISE. The location of the obstructive sites was scored similarly according to the NAVOTEL scoring system, previously established and validated by authors' team. Results: Thirty-two infants were included. DISE identified an obstructive site in 94% of cases. The mean age was 16.4 mo, and the median was 16.7 mo. The obstructive sites found were isolated sleep laryngomalacia (37.4%), adenotonsillar hypertrophy (21.8%), isolated adenoidal hypertrophy (6.3%), adenotonsillar hypertrophy associated with sleep laryngomalacia (6.3%), circumferential upper airway narrowing (6.3%), glossoptosis (6.3%), isolated inferior turbinate hypertrophy (3.1%), adenoidal and tongue base hypertrophy (3.1%), and adenoidal hypertrophy with sleep laryngomalacia (3.1%). No obstructive causes could be found in 2 cases (6.3%). DISE identified an obstructive site in 30/32 patients (93.8%) and guided the surgical management in 26/32 cases (81.3%) during the same general anesthesia. The infants without surgical obstacles were referred for medical treatment. Conclusions: DISE is an excellent diagnostic and pre-therapeutic tool in infants with no apparent cause at the awake examination to identify the obstructive sites and guide the treatment. [ABSTRACT FROM AUTHOR]

Objective To explore the effects of tonsillectomy under general anesthesia on articulatory characteristics and blood levels of procalcitonin (PCT), platelet membrane protein-140 (GMP-140), and T lymphocyte subsets in children with obstructive sleep apnea-hypopnea syndrome (OSAHS). Methods Forty-three children with OSAHS who underwent tonsillectomy under general anesthesia in the Department of Otorhinolaryngology Head and Neck Surgery of Xi’an Children’s Hospital, Shaanxi Province from June 2020 to March 2022 were randomly selected for the study. The children were evaluated for articulatory characteristics, blood levels of PCT, GMP-140, and T lymphocyte subsets, as well as sleep status before surgery and at 1 and 3 months after surgery. Results The longest duration of articulating /a/ was significantly prolonged and the second formant was significantly enhanced at 1 and 3 months after surgery (F=43.07,39.65,P

Abstract Background Pediatric autoimmune neuropsychiatric disorders associated with streptococcus (PANDAS) is a controversial diagnosis with limited evidence-based treatment guidelines available, particularly for severe and treatment-resistant cases. Case presentation : This report describes a 9-year-old male presenting with sudden onset, severe obsessive-compulsive disorder (OCD) symptoms one month following a streptococcus infection. His symptoms included suicidality and recurrent self-injurious behaviors, which led to multiple inpatient hospitalizations. He was diagnosed with PANDAS and was treated with psychotropic medications, antibiotics, immunotherapy, and a tonsillectomy. Over the two years since initial admission, the patient’s condition improved, with a decrease in symptom severity and an increase in adaptive functioning, though symptom remission was slow to occur. Conclusions This paper explores the controversies surrounding the PANDAS diagnosis, reviews potential treatments, and discusses the dilemmas of medical decision-making in the setting of severe treatment-resistant symptoms and limited evidence-based guidelines. We hope that this case report will be valuable to healthcare providers facing similar presentations and inspire further investigation into this complex condition.

Yanling Liao,1,&ast; Siyu Xie,2,&ast; Yifen Zhuo,3,&ast; Sisi Chen,1 Yuxin Luo,1 Ying Wei,4 Yusheng Yao1 1Department of Anesthesiology, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou, People’s Republic of China; 2Department of Anesthesiology, Longyan First Affiliated Hospital of Fujian Medical University, Longyan, People’s Republic of China; 3Department of Anesthesiology, Xiamen Haicang Hospital, Xiamen, People’s Republic of China; 4Department of Anesthesiology, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, People’s Republic of China&ast;These authors contributed equally to this workCorrespondence: Ying Wei, Department of Anesthesiology, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, 18 Daoshan Road, Fuzhou, 350025, People’s Republic of China, Email whm444@fjmu.edu.cn Yusheng Yao, Department of Anesthesiology, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, 134 Dongjie Street, Fuzhou, 350001, People’s Republic of China, Email fjslyys@126.comPurpose: Emergence delirium and postoperative negative behavioral changes (PNBC) are common complications in pediatric anesthesia. This study evaluated whether intranasal premedication combining dexmedetomidine and esketamine more effectively reduces these complications compared to either drug alone in children undergoing tonsillectomy and/or adenoidectomy with sevoflurane anesthesia.Patients and Methods: This randomized, double-blind trial involved 198 children aged 2− 5 years undergoing tonsillectomy and/or adenoidectomy. Participants received intranasal premedication with either dexmedetomidine (2 μg/kg), esketamine (1 mg/kg), or their combination (dexmedetomidine 1 μg/kg plus esketamine 0.5 mg/kg). The primary outcome was the incidence of emergence delirium, defined as a Pediatric Anesthesia Emergence Delirium (PAED) scale score ≥ 10. Secondary outcomes included the incidence of PNBC, sedation depth, easiness of separation from parents, acceptance of the mask for induction, emergence time, postoperative pain score, parental satisfaction, and adverse events.Results: The combination premedication significantly reduced emergence delirium incidence (9.4%) compared to esketamine alone (38.1%; relative risk [RR] 0.25, 95% confidence interval [CI] 0.11– 0.57, p < 0.001), but not compared to dexmedetomidine alone (17.2%; RR 0.55, 95% CI 0.21– 1.39, p = 0.193). PNBC incidence at day 7 was lower with the combination (28.1%) versus dexmedetomidine (48.4%; RR 0.58, 95% CI 0.36– 0.93, p = 0.018), but not significantly different from esketamine alone (20.6%; RR 1.38, 95% CI 0.74– 2.58, p = 0.326). The combination also provided significantly superior sedation, improved ease of separation from parents, better acceptance of the mask for induction, shorter emergence time, and higher parental satisfaction than both monotherapies.Conclusion: In children undergoing tonsillectomy and/or adenoidectomy with sevoflurane anesthesia, intranasal dexmedetomidine-esketamine premedication more effectively reduces emergence delirium compared to esketamine alone and PNBC compared to dexmedetomidine alone. This combination also improves sedation, shortens emergence times, and enhances parental satisfaction compared to monotherapy without significant adverse effects.Trial Registration: The Chinese Clinical Trial Registry, ChiCTR2300076709. Keywords: adenoidectomy, dexmedetomidine, emergence delirium, esketamine, intranasal administration, pediatric anesthesia, postoperative complications, tonsillectomy

Abstract Background To investigate the association between surgical removal of tonsils and risk of COVID-19 with different severity. Methods Through a nested case–control study during January 31st to December 31st 2020, including 58,888 participants of the UK Biobank, we investigated the association of tonsillectomy with the future risk of mild and severe COVID-19, using binomial logistic regression. We further examined the associations of such surgery with blood inflammatory, lipid and metabolic biomarkers to understand potential mechanisms. Finally, we replicated the analysis of severe COVID-19 in the Swedish AMORIS Cohort (n = 451,960). Results Tonsillectomy was associated with a lower risk of mild (odds ratio [95% confidence interval]: 0.80 [0.75–0.86]) and severe (0.87 [0.77–0.98]) COVID-19 in the UK Biobank. The associations did not differ substantially by sex, age, Townsend deprivation index, or polygenic risk score for critically ill COVID-19. Levels of blood inflammatory, lipid and metabolic biomarkers did, however, not differ greatly by history of surgical removal of tonsils. An inverse association between tonsillectomy and severe COVID-19 was also observed in the AMORIS Cohort, primarily among older individuals (> 70 years) and those with ≤ 12 years of education. Conclusions Surgical removal of tonsils may be associated with a lower risk of COVID-19. This association is unlikely attributed to alterations in common blood inflammatory, lipid and metabolic biomarkers.

Abstract Background Dysgeusia or altered taste is a rare complication following suspension microlaryngoscopy with the incidence ranging from 2.9 to 12.1%. We report this with recommendations to avoid similar complications following suspension laryngoscopy, tonsillectomy, and tongue base surgery which require pressure to be placed on the tongue for better surgical field visualization. Case presentation A 53-year-old man with underlying diabetes mellitus presented with long standing history of irritative cough, globus sensation, and evidence of laryngopharyngeal reflux. A left ventricle swelling was noted on flexible laryngoscopy and neck. He underwent direct laryngoscopy and biopsy of the left ventricle lesion which revealed to be acute on chronic inflammation. Day 1 postoperatively, patient complained of reduced sensation over left hemi-tongue. A referral to a neurologist was made for further examination and he was found to have loss of taste over anterior two-third of tongue and treated with vitamin B complex. To date, dysgeusia remains persistent. Patient relayed his grievances to the hospital following these complications. Review of literature on relevant topic was made through PubMed, Web of Science, and Cochrane Library Database by two reviewers, working independently. Twenty-three papers, available in full, written in English language, containing number of cases, type of surgery, and complications were extracted and studied. Conclusions Risk of dysgeusia and paresthesia postoperatively should be informed during consent taking for all patients undergoing tonsillectomy, laryngeal microsurgery, and tongue base surgery. Zinc deficiency should be investigated in patients with persistent taste disturbance post-tonsillectomy. Intermittent release during suspension laryngoscopy beyond 30 min to reduce post-surgical complications. Greater care should be taken to reduce the amount of force during the suspension laryngoscopy due to smaller oral and oropharyngeal structure in female. Keeping close to the tonsillar capsule particularly in mid and lower pole areas should be done in tonsillectomy using diathermy dissection.

Introduction: PFAPA syndrome is an autoinflammatory disease seen in childhood characterized by recurrent fever, aphthous stomatitis, pharyngitis, and cervical adenitis. This study aims to examine the clinical and laboratory features of PFAPA syndrome, assess responses to treatment, and particularly evaluate the disease from an immunological perspective. Materials and Methods: Forty-nine patients presenting to the Pediatric Immunology and Allergy outpatient clinic and meeting the diagnostic criteria for PFAPA were evaluated. Demographic information, symptoms, physical examination findings, laboratory results, and responses to treatment were meticulously recorded. Results: Our study included a total of 49 patients, comprising 30 males and 19 females, with a mean age at diagnosis of 3.5 years. Notable findings in immunological assessments included neutrophilia, leukocytosis, and in a few cases, lymphopenia, as well as changes in CD3 and CD19 subsets that highlighted the immunological aspect of the disease, indicating significant alterations in the adaptive immune system. Prednisolone treatment resulted in a response rate of 92.5%, with most patients showing a rapid improvement. Eighty-one point eight percent of patients receiving colchicine prophylaxis reported a decrease in symptoms. The symptoms in 13.5% of patients who underwent tonsillectomy either significantly decreased or completely resolved. Conclusion: Management of PFAPA syndrome varies in terms of immunological findings and response rates to treatment. Our study elucidates the effectiveness of prednisolone treatment, the benefits of colchicine prophylaxis, and the improvement in symptoms following tonsillectomy. Furthermore, it underscores the necessity of considering immunological factors in the diagnosis and treatment processes of PFAPA syndrome.

Abstract The dose–response of intravenous lidocaine in preventing postoperative vomiting (POV) in children remains unclear. This study investigated whether intravenous lidocaine dose-dependently decreased POV risk within 24 h postoperatively in children undergoing tonsillectomy (with or without adenoidectomy) without severe complications. Patients aged 3–12 years (American Society of Anesthesiologists grade I–II) scheduled for elective tonsillectomy (with or without adenoidectomy) were enroled from December 2021 to March 2022. They were randomly grouped according to the lidocaine dose (A [0 mg kg−1], B [1 mg kg−1], C [1.5 mg kg−1], and D [2 mg kg−1]) and were administered the same induction protocol (sufentanil, propofol, and suxamethonium chloride). Anaesthesia was maintained with sevoflurane. The incidence of POV within 24 h postoperatively was 46, 40, 36, and 20% in groups A, B, C, and D, respectively, with significant differences between groups D and A. Postoperative analgesic rescues in groups A, B, C, and D were 62, 36, 34, and 16%, respectively, with significant differences between groups D and B, C and A, and D and A. No severe adverse events were reported. Intravenous lidocaine has a dose-dependent effect on reducing the risk of POV in children undergoing tonsillectomy (with or without adenoidectomy) without serious adverse events. Trial registration: Chinese Clinical Trial Registry, ChiCTR2100053006.

Background: Pediatric autoimmune neuropsychiatric disorders associated with streptococcus (PANDAS) is a controversial diagnosis with limited evidence-based treatment guidelines available, particularly for severe and treatment-resistant cases. Case presentation: : This report describes a 9-year-old male presenting with sudden onset, severe obsessive-compulsive disorder (OCD) symptoms one month following a streptococcus infection. His symptoms included suicidality and recurrent self-injurious behaviors, which led to multiple inpatient hospitalizations. He was diagnosed with PANDAS and was treated with psychotropic medications, antibiotics, immunotherapy, and a tonsillectomy. Over the two years since initial admission, the patient's condition improved, with a decrease in symptom severity and an increase in adaptive functioning, though symptom remission was slow to occur. Conclusions: This paper explores the controversies surrounding the PANDAS diagnosis, reviews potential treatments, and discusses the dilemmas of medical decision-making in the setting of severe treatment-resistant symptoms and limited evidence-based guidelines. We hope that this case report will be valuable to healthcare providers facing similar presentations and inspire further investigation into this complex condition. [ABSTRACT FROM AUTHOR]

The article discusses a study on a cold-steel dissection tonsillectomy protocol that resulted in few complications in pediatric patients. The study included 953 patients who underwent tonsillectomy using this technique and a strict protocol. The results showed low rates of post-operative hemorrhage and readmission, indicating that the cold-steel dissection method can be effective in pediatric tonsillectomy. The study also highlighted the importance of minimizing risks associated with tonsillectomy, such as hemorrhage, and the need for advocating methods that reduce these risks. [Extracted from the article]

Background : To investigate the association between surgical removal of tonsils and risk of COVID-19 with different severity. Methods: Through a nested case–control study during January 31st to December 31st 2020, including 58,888 participants of the UK Biobank, we investigated the association of tonsillectomy with the future risk of mild and severe COVID-19, using binomial logistic regression. We further examined the associations of such surgery with blood inflammatory, lipid and metabolic biomarkers to understand potential mechanisms. Finally, we replicated the analysis of severe COVID-19 in the Swedish AMORIS Cohort (n = 451,960). Results: Tonsillectomy was associated with a lower risk of mild (odds ratio [95% confidence interval]: 0.80 [0.75–0.86]) and severe (0.87 [0.77–0.98]) COVID-19 in the UK Biobank. The associations did not differ substantially by sex, age, Townsend deprivation index, or polygenic risk score for critically ill COVID-19. Levels of blood inflammatory, lipid and metabolic biomarkers did, however, not differ greatly by history of surgical removal of tonsils. An inverse association between tonsillectomy and severe COVID-19 was also observed in the AMORIS Cohort, primarily among older individuals (> 70 years) and those with ≤ 12 years of education. Conclusions: Surgical removal of tonsils may be associated with a lower risk of COVID-19. This association is unlikely attributed to alterations in common blood inflammatory, lipid and metabolic biomarkers. [ABSTRACT FROM AUTHOR]

Aim: Halitosis is a condition that impacts both the individual and their social interactions. The most common source of halitosis is the oral cavity. Caseum accumulated in the crypts of the tonsils can cause halitosis. In treating tonsil caseum, total tonsillectomy or tonsil ablation surgeries are performed with instruments such as coblator. This retrospective study evaluates the effectiveness of tonsil ablation with coblator in treating halitosis caused by caseous tonsillitis in children. Patients and Methods: A total of 116 children who underwent tonsil coblation for caseous tonsillitis between June 2016 and June 2019 were included in the study. Patients who underwent simultaneous adenoidectomy were not included in the study. The presence of odor before and after the operation was evaluated using the Finkelstein test. The pre-operative and post-operative halitosis levels were evaluated with a Visual Analog Scale. The recovery levels were determined by the postoperative halitosis recovery scale. Results: The presence of caseum was confirmed perioperatively in all patients. The mean age of the patients was 6.77 years, with 65 males and 51 females included in the study. The follow-up periods of the patients varied between 10 and 43 months (mean: 25.9). The level of halitosis on the visual analog scale before tonsil coblation was 6.97, and it was found to be 1.75 in the postoperative evaluation. The results were statistically significant (p< 0.001). The mothers were asked about recovery in postoperative halitosis levels. Mothers reported that 82% of patients (n = 95) had complete or nearly complete improvement in halitosis. 6% of patients (n = 7) showed no improvement. Conclusion: Palatine tonsil coblation is an effective and safe method for the treatment of halitosis because of tonsil caseum. [ABSTRACT FROM AUTHOR]

Introduction and objective: Obstructive sleep apnea (OSA) is a multifactorial etiology disease that leads to the collapse of the upper airway. Hypertrophy of lymphoid tissues contributes to airway collapsibility. Conceptual review of adenotonsillectomy in the adult patient with OSA. Synthesis: In the presence of grade ≥3 tonsillar hypertrophy, tonsillectomy is the first-line treatment. The different available adenotonsillectomy techniques are suitable for treating patients with OSA. The integrity of the palatoglossus and palatopharyngeus muscles must be respected. In addition to healing and surgical success, tonsillectomy offers benefits such as reducing necessary pressure applied to CPAP and consequently increasing its tolerance. Conclusions: The removal of hypertrophic lymphoid tissues in adult patients with OSA is essential. This surgery eliminates obstructive elements from the upper airway, favoring its patency and stability. [ABSTRACT FROM AUTHOR]

Objective: The aim of this study is to measure the distance from the midline of the upper incisors to the lower pole of the tonsils in paediatric patients of varying ages. This will enable the design of accurately sized tonsil tie simulators. Methods: Two hundred patients between 1 year and 16 years old were recruited in this prospective observational study. The patient's age and the mean distance from the midline of the upper incisors to the lower pole of the tonsils were plotted into a scatter plot and the line of best fit was calculated. Results: The equation for the line of best fit was: distance (mm) = 1.9604 × age (digitalised years) + 72.436. Conclusion: This is the first study to measure the anatomical distance from the upper incisor teeth to the inferior tonsillar pole in a paediatric population. This can be used to accurately size tonsil tie simulators and enhance their fidelity. [ABSTRACT FROM AUTHOR]

Tonsillectomy is one of the most common surgical procedures in childhood. While generally safe, it often is associated with a difficult early recovery phase with poor oral intake, dehydration, difficult or painful swallowing, postoperative bleeding, infection and/or otalgia. Better pain management and the availability of more child friendly medications are within the top consumer priorities in perioperative medicine, highlighting the importance of alternative pain treatments. This review focuses on the potential role of honey in the postoperative setting, its effects, and mechanisms of action. While the application of honey post‐tonsillectomy may offer analgesic and healing benefits, it may also reduce postoperative bleeding. A systematic search was carried out using the search terms honey, tonsillectomy. Filters were applied to human studies and English. No other search terms were used or age filters applied to yield a broader range of results. Seven pediatric, four adult, and two studies of mixed pediatric and adult patients with sample sizes ranging from 8 to 52 patients were included in this review. Effect sizes ranged from small to huge across the studies. While the application of honey post‐tonsillectomy may offer analgesic and healing benefits, it may also reduce postoperative bleeding. However, while there are potential benefits based on the chemical composition of honey, the current literature is of variable quality and there is need for high quality clinical trials. [ABSTRACT FROM AUTHOR]

Introduction: In pediatric tonsillectomy management, the consistent tracking of surgical outcomes and adherence to guidelines are vital. This study explores how a surgical dashboard can serve as a tool in research analysis, translating AAO‐HNSF guidelines into measurable performance improvements. Methods: Using a prospective registry from three pediatric hospitals, a Tableau dashboard was constructed to graphically visualize key demographic and postoperative outcomes (including intensive care unit [ICU] utilization, 30‐day emergency department (ED) visits, and postoperative bleed rates) in children undergoing tonsillectomy from 2020 to 2024. From the dashboard data, a retrospective cohort study analyzing 6767 tonsillectomies was conducted from January 2, 2020, to June 20, 2023. Patients were categorized into low‐risk, OSA‐only (by ICD‐10 codes), and high‐risk groups based on comorbidities. Logistic regression identified factors influencing ED revisits and unplanned nursing calls. Three quality initiatives were assessed: preoperative school absence notes, perioperative dexamethasone recording, and post‐tonsillectomy parental education. Results: A total of 2122 (31%) were low‐risk, 2648 (39%) were OSA‐only, and 1997 (30%) high risk. Risk factors that increased the likelihood of ED visits were high‐risk comorbidities (OR = 1.46; 95% CI = 1.24–1.74; p < 0.001) and older age (OR = 1.05; 95% CI = 1.03–1.08; p < 0.001). Risk factors that increased the likelihood of an unplanned nursing communication were high‐risk comorbidities (OR = 1.53; 95% CI = 1.34–1.75; p < 0.001), older age (OR = 1.03, 95% CI = 1.01–1.04; p = 0.001), and Medicaid insurance (OR = 1.25; 95% CI = 1.09–1.43; p = 0.002). Postoperative bleed control was generally comparable between the groups, at 2.8% (low risk), 2.7% (OSA), 3.2 (high risk) (p = 0.651). Conclusion: The dashboard aided in data collection, data visualization, and data analysis of quality improvement initiatives, effectively translating guidelines into tangible measures to enhance care. Level of evidence: NA. [ABSTRACT FROM AUTHOR]