Update and Comparison of NewUpdate and Comparison of NewUpdate and Comparison of New Update and Comparison of New Techniques for Techniques for

AdenotonsillectomyAdenotonsillectomyDennis J. Dennis J. KitskoKitsko, DO, FACS, FAOCO, DO, FACS, FAOCOAssistant Professor of OtolaryngologyAssistant Professor of Otolaryngology

Children’s Hospital of PittsburghChildren’s Hospital of Pittsburghp gp gUniversity of Pittsburgh School of MedicineUniversity of Pittsburgh School of Medicine

ObjectivesObjectivesObjectivesObjectives

EvidenceEvidence--based review of traditionalbased review of traditionalEvidenceEvidence based review of traditional based review of traditional versus newer methods of tonsillectomyversus newer methods of tonsillectomy

Coblation versus cauteryCoblation versus cautery–– Coblation versus cauteryCoblation versus cauteryComparison of partial versus complete Comparison of partial versus complete tonsillectomytonsillectomytonsillectomytonsillectomyReview of trends in adenoidectomy Review of trends in adenoidectomy techniquetechniqueControversial perioperative considerations Controversial perioperative considerations

Traditional TechniquesTraditional TechniquesTraditional TechniquesTraditional TechniquesCold steel vs electrocauteryCold steel vs electrocautery

–– Good evidence: increased intraop bleeding Good evidence: increased intraop bleeding –– Trend: less postop pain, earlier return to normal diet and Trend: less postop pain, earlier return to normal diet and

activity, longer operative timeactivity, longer operative timeUnproven: rate of postop bleedingUnproven: rate of postop bleeding–– Unproven: rate of postop bleedingUnproven: rate of postop bleeding

–– Workhorses of current tonsillectomy technique (ASPO survey Workhorses of current tonsillectomy technique (ASPO survey 2007):2007):

113 survey respondents:113 survey respondents:yy–– 62 (54.9%) monopolar cautery62 (54.9%) monopolar cautery–– 14 (12.4%) cold + monopolar14 (12.4%) cold + monopolar–– 7 (6.2%) bipolar cautery7 (6.2%) bipolar cautery–– 6 (5.4%) cold + bipolar6 (5.4%) cold + bipolar–– 1 (0.9%) cold1 (0.9%) cold

Total: 90/113 (79.6%)Total: 90/113 (79.6%)Kujawski 1997, Nunez 2000, Walner 2007Kujawski 1997, Nunez 2000, Walner 2007

Newer TechniquesNewer TechniquesNewer TechniquesNewer TechniquesLaser (CO2, Argon, KTP)Laser (CO2, Argon, KTP)( , g , )( , g , )–– No good evidence of significant difference in pain, No good evidence of significant difference in pain,

bleeding, operative time versus electrocauterybleeding, operative time versus electrocautery? No difference in postop pain versus cold steel? No difference in postop pain versus cold steel–– ? No difference in postop pain versus cold steel ? No difference in postop pain versus cold steel technique (Bergler 2001)technique (Bergler 2001)

–– Other considerations:Other considerations:Use in partial tonsillectomy (Unkel 2005)Use in partial tonsillectomy (Unkel 2005)Risk of airway fireRisk of airway fireTime for laser setup / increased costTime for laser setup / increased costHas largely fallen out of favor Has largely fallen out of favor –– ASPO survey 2007 showed ASPO survey 2007 showed 0/120 respondents using laser for either partial or total 0/120 respondents using laser for either partial or total tonsillectomytonsillectomy

Newer techniquesNewer techniquesNewer techniquesNewer techniques

Harmonic scalpelHarmonic scalpelHarmonic scalpelHarmonic scalpel–– Uses ultrasound at extremely high frequencies Uses ultrasound at extremely high frequencies

(55,000 Hz) to dissect and coagulate at lower (55,000 Hz) to dissect and coagulate at lower temperatures than cauterytemperatures than cautery

–– Trend: longer operative timeTrend: longer operative timeNo proven difference in pain or bleeding rates (lack ofNo proven difference in pain or bleeding rates (lack of–– No proven difference in pain or bleeding rates (lack of No proven difference in pain or bleeding rates (lack of good data) versus cauterygood data) versus cautery

–– Other considerations:Other considerations:Increased cost vs cauteryIncreased cost vs cautery2007 ASPO survey: 1/113 respondents 2007 ASPO survey: 1/113 respondents

Parsons 2006 Mixson 2007 Kamal 2006Parsons 2006 Mixson 2007 Kamal 2006Parsons 2006, Mixson 2007, Kamal 2006 Parsons 2006, Mixson 2007, Kamal 2006

Newer TechniquesNewer TechniquesNewer TechniquesNewer TechniquesPlasmaknifePlasmaknife (radiofrequency)(radiofrequency)

Si h 2008Si h 2008 4343 tt d ith bi ld ith bi l–– Singh 2008 Singh 2008 –– 43 43 ptspts, compared with bipolar, compared with bipolarStatistical diff in pain at 8 Statistical diff in pain at 8 hrshrsTrend toward decreased pain over 2 Trend toward decreased pain over 2 wkswks3/24 secondary bleeds in PK group3/24 secondary bleeds in PK groupNo diff in No diff in intraopintraop bleeding, OR time, nausea, time to return to normal diet or bleeding, OR time, nausea, time to return to normal diet or activityactivity

–– Stephens 2008, Stephens 2008, ClenneyClenney 2011 2011 –– no difference from no difference from monopolarmonopolaror bipolar cauteryor bipolar cautery

Thermal welding (Thermal welding (OzkirisOzkiris 2012) 2012) -- StarionStarion–– Proposed benefit: creates tissue seal while dividing, less heat transferProposed benefit: creates tissue seal while dividing, less heat transfer–– Several preliminary studies show a trend toward less postoperative Several preliminary studies show a trend toward less postoperative

pain, similar rates ofpain, similar rates of intraopintraop bleeding to cautery, equal op time, similarbleeding to cautery, equal op time, similarpain, similar rates of pain, similar rates of intraopintraop bleeding to cautery, equal op time, similar bleeding to cautery, equal op time, similar rates of sec bleedingrates of sec bleeding

As with many new technologies, preliminary data leans toward As with many new technologies, preliminary data leans toward potential benefit, but larger quantities of higher quality studies are potential benefit, but larger quantities of higher quality studies are needed before drawing conclusionsneeded before drawing conclusionsneeded before drawing conclusionsneeded before drawing conclusions

CoblationCoblationCoblationCoblationRadiofrequency energy through conductive Radiofrequency energy through conductive q y gy gq y gy gmedium (medium (NaClNaCl) to produce plasma field (lower ) to produce plasma field (lower temps than cautery)temps than cautery)Wh fWh f C bl iC bl i ??Why focus on Why focus on CoblationCoblation??–– SixfoldSixfold increase in use from 2002 increase in use from 2002 –– 2007 (2.72007 (2.7––

15.9%) by ASPO survey (84% academic settings)15.9%) by ASPO survey (84% academic settings)15.9%) by ASPO survey (84% academic settings)15.9%) by ASPO survey (84% academic settings)–– Enough data to perhaps draw some conclusions Enough data to perhaps draw some conclusions

((PubmedPubmed –– 100 articles)100 articles)P b bl th t l d f thP b bl th t l d f th–– Probably the most commonly used of the newer Probably the most commonly used of the newer technologies, both inside and outside the academic technologies, both inside and outside the academic setting setting

CoblationCoblation –– Evidence BaseEvidence BaseCoblation Coblation Evidence BaseEvidence Base

Cochrane Database 2009 examinedCochrane Database 2009 examinedCochrane Database 2009 examined Cochrane Database 2009 examined coblationcoblation versus other techniques of versus other techniques of tonsillectomytonsillectomyyy–– 19 RCT’s19 RCT’s

4 excluded 4 excluded –– intracapsularintracapsular5 excluded 5 excluded –– randomisedrandomised to tonsil rather than pt.to tonsil rather than pt.9 trials included:9 trials included:

–– 7 trials Grade C evidence (>20% loss to follow up)7 trials Grade C evidence (>20% loss to follow up)7 trials Grade C evidence ( 20% loss to follow up)7 trials Grade C evidence ( 20% loss to follow up)–– 2 trials Grade A evidence:2 trials Grade A evidence:

Met criteria for Met criteria for randomisationrandomisation, allocation, blinding, , allocation, blinding, loss to follow up < 20%loss to follow up < 20%pp

Coblation vs Cold DissectionCoblation vs Cold DissectionCoblation vs Cold DissectionCoblation vs Cold DissectionAnthony 2006 Anthony 2006 –– 40% lost to follow up (Adult + Child)40% lost to follow up (Adult + Child)

D il i f d bl t d 1 f d ld d 10 diff tD il i f d bl t d 1 f d ld d 10 diff tDaily pain score: favored coblator day 1, favored cold day 10, no diff at Daily pain score: favored coblator day 1, favored cold day 10, no diff at 3,7,14 days3,7,14 daysSecondary bleeding: 13.6 vs 2.1% in favor of cold (Windfuhr 2005)Secondary bleeding: 13.6 vs 2.1% in favor of cold (Windfuhr 2005)Days of analgesia use: 12 vs 9 days favor cold BUT days return to normal Days of analgesia use: 12 vs 9 days favor cold BUT days return to normal diet 1 vs 1 day in both groupsdiet 1 vs 1 day in both groupsdiet 1 vs 1 day in both groupsdiet 1 vs 1 day in both groups

Philpott 2005 Philpott 2005 –– 24% lost to follow up (Adult)24% lost to follow up (Adult)Return to normal diet 6.5 vs 8.6 days favor cold Return to normal diet 6.5 vs 8.6 days favor cold No difference in pain, analgesia, bleeding, return to workNo difference in pain, analgesia, bleeding, return to work

B k 2001B k 2001 Ad ltAd lt ld + tld + tBack 2001 Back 2001 –– Adult Adult –– cold + cauterycold + cautery–– Shorter operative time (18 vs 27 min) and less intraop bleeding (20 vs Shorter operative time (18 vs 27 min) and less intraop bleeding (20 vs

80 cc) favors cold80 cc) favors cold–– No diff pain, return to diet/work, sec bleedingNo diff pain, return to diet/work, sec bleeding

Jayasinghe 2005 Jayasinghe 2005 –– 33% lost to f/u (Adult) 33% lost to f/u (Adult) –– cold + cauterycold + cautery–– Shorter operative time (14 vs 23 min) and less intraop bleeding (19 vs Shorter operative time (14 vs 23 min) and less intraop bleeding (19 vs

69 cc) favors coblation69 cc) favors coblation–– No diff pain complication readmissionNo diff pain complication readmissionNo diff pain, complication, readmissionNo diff pain, complication, readmission

Coblation vs CauteryCoblation vs CauteryCoblation vs CauteryCoblation vs CauteryStoker 2004 Stoker 2004 –– Children: best quality studyChildren: best quality study–– No diff OR time, return to diet/activity, prim and sec bleedingNo diff OR time, return to diet/activity, prim and sec bleeding–– Trend toward less analgesia use, fewer days to no pain, fewer Trend toward less analgesia use, fewer days to no pain, fewer

parental phone calls in coblation group (not statistically parental phone calls in coblation group (not statistically significant: p= 07)significant: p= 07)significant: p .07)significant: p .07)

Tan 2006 Tan 2006 –– Adult Adult –– 3% lost to f/u3% lost to f/u–– No diff pain, prim and sec bleedingNo diff pain, prim and sec bleeding–– Trend toward fewer days return to normal diet/activity in coblatorTrend toward fewer days return to normal diet/activity in coblatorTrend toward fewer days return to normal diet/activity in coblator Trend toward fewer days return to normal diet/activity in coblator

(not statistically significant)(not statistically significant)Temple 2001 Temple 2001 -- ChildrenChildren–– less postop pain days 3,7,10 and fewer days return to normal less postop pain days 3,7,10 and fewer days return to normal p p p y , , yp p p y , , y

diet with coblator (38 pts with 47% lost to f/u)diet with coblator (38 pts with 47% lost to f/u)Shah 2002 Shah 2002 -- ChildrenChildren–– No diff in EBL, pain, normal diet/activity (34 pts with 53% lost to No diff in EBL, pain, normal diet/activity (34 pts with 53% lost to

f/ )f/ )f/u)f/u)

Coblation vs Harmonic ScalpelCoblation vs Harmonic ScalpelCoblation vs Harmonic ScalpelCoblation vs Harmonic Scalpel

Parsons 2006Parsons 2006 –– coblation vs cautery vscoblation vs cautery vsParsons 2006 Parsons 2006 coblation vs cautery vs coblation vs cautery vs harmonic scalpelharmonic scalpel

Coblator quicker return to normal dietCoblator quicker return to normal diet–– Coblator quicker return to normal dietCoblator quicker return to normal diet–– Cautery quicker intraop timeCautery quicker intraop time

Trend toward coblator less postop painTrend toward coblator less postop pain–– Trend toward coblator less postop pain Trend toward coblator less postop pain --p=.06 vs cautery, p=.007 (ss) vs harmonicp=.06 vs cautery, p=.007 (ss) vs harmonicFlaws: 55% lost to follow up; 8% of coblatorFlaws: 55% lost to follow up; 8% of coblator–– Flaws: 55% lost to follow up; 8% of coblator Flaws: 55% lost to follow up; 8% of coblator and 43% of harmonic group had rescue and 43% of harmonic group had rescue hemostasis with cauteryhemostasis with cauteryyy

CoblationCoblation -- ConclusionsConclusionsCoblation Coblation ConclusionsConclusionsInadequate evidence that coblation is inferior or superior to other Inadequate evidence that coblation is inferior or superior to other forms of tonsillectomyforms of tonsillectomyforms of tonsillectomyforms of tonsillectomyTrend toward longer duration of pain vs cold alone (weak data)Trend toward longer duration of pain vs cold alone (weak data)Trend toward less analgesia use and less days to pain free vs Trend toward less analgesia use and less days to pain free vs cautery in the higher quality studiescautery in the higher quality studiesy g q yy g q yNo difference in primary or secondary bleeding between coblation No difference in primary or secondary bleeding between coblation and cautery; trend toward less secondary bleeding in strict cold vs and cautery; trend toward less secondary bleeding in strict cold vs coblationcoblationMost likely comparable to cautery in terms of operative time andMost likely comparable to cautery in terms of operative time andMost likely comparable to cautery in terms of operative time and Most likely comparable to cautery in terms of operative time and intraop bleedingintraop bleedingExpense Expense –– is it worth the extra cost?is it worth the extra cost?Larger, higher quality data is needed, but the new rage in pediatric Larger, higher quality data is needed, but the new rage in pediatric g , g q y , g pg , g q y , g ptonsillectomy has become…tonsillectomy has become…

Partial Tonsillectomy Partial Tonsillectomy ( S )( S )(Intracapsular, Subtotal)(Intracapsular, Subtotal)

MicrodebriderMicrodebrider (best studied) or other methods (best studied) or other methods vsvs“t diti l”“t diti l” b lb l t t ill tt t ill t“traditional” “traditional” subcapsularsubcapsular cautery tonsillectomycautery tonsillectomyMultiple studies (retrospective and prospective) Multiple studies (retrospective and prospective) have shown:have shown:–– Fewer days of analgesia use, fewer days to return to Fewer days of analgesia use, fewer days to return to

normal activity/diet with normal activity/diet with intracapsularintracapsular tonsillectomytonsillectomy–– Increased Increased intraopintraop blood loss with blood loss with intracapsularintracapsular

T d t d d d t bl di dT d t d d d t bl di d–– Trend toward decreased postop bleeding and Trend toward decreased postop bleeding and increased operative time with increased operative time with intracapsularintracapsular

–– Trend toward similar PSG outcomes versus total Trend toward similar PSG outcomes versus total tonsillectomytonsillectomytonsillectomytonsillectomy

–– Main indication: obstructive sleep apneaMain indication: obstructive sleep apneaSobolSobol 2006, 2006, DerkayDerkay 2006, Lister 2006, 2006, Lister 2006, MixsonMixson 2007, 2007,

TunkelTunkel 2008, 2008, MangiardiMangiardi 2010 2010 SarnySarny 20112011

Partial TonsillectomyPartial TonsillectomyPartial TonsillectomyPartial TonsillectomyASPO survey 2007:ASPO survey 2007:yy

–– 27% use for obstructive indication27% use for obstructive indication–– 11% use for infection as primary indication11% use for infection as primary indicationRegrowth rate 0 Regrowth rate 0 –– 3% between several studies3% between several studies

–– Variation between measurement device Variation between measurement device –– return of return of snoring vs need for completion tonsillectomysnoring vs need for completion tonsillectomysnoring vs need for completion tonsillectomysnoring vs need for completion tonsillectomy

–– Max mean follow up among these four series was Max mean follow up among these four series was 20 months20 monthsP t ti l f di f t i d l tP t ti l f di f t i d l t–– Potential confounding factor: increased loss to Potential confounding factor: increased loss to follow up in those patients with recurrent problems follow up in those patients with recurrent problems

Sorin 2004, Solares 2005, Schmidt 2007, Bitar 2008Sorin 2004, Solares 2005, Schmidt 2007, Bitar 2008

Partial TonsillectomyPartial TonsillectomyPartial TonsillectomyPartial Tonsillectomy

Appears at this point to have significantAppears at this point to have significantAppears at this point to have significant Appears at this point to have significant decrease in recovery time BUT two huge decrease in recovery time BUT two huge questions remain:questions remain:1.1.Regrowth rate, specifically symptomatic and Regrowth rate, specifically symptomatic and

necessitating repeated surgery (longer f/u than necessitating repeated surgery (longer f/u than currently reported)currently reported)currently reported)currently reported)

2.2.Use when infection is primary indication for Use when infection is primary indication for tonsillectomytonsillectomyyy

“With current data, partial tonsillectomy should be limited to “With current data, partial tonsillectomy should be limited to patients with sleep disordered breathing” (Derkay 2007)patients with sleep disordered breathing” (Derkay 2007)

Trends In AdenoidectomyTrends In AdenoidectomyTrends In AdenoidectomyTrends In AdenoidectomyIn general, there has been a shift away from In general, there has been a shift away from g yg ycurette/adenotome over the past 15 yearscurette/adenotome over the past 15 years–– 86% usage 15 years ago, now just 30%86% usage 15 years ago, now just 30%

Increase in usage of cautery and other techniquesIncrease in usage of cautery and other techniquesIncrease in usage of cautery and other techniquesIncrease in usage of cautery and other techniques–– Cautery alone Cautery alone –– 26%26%–– Microdebrider Microdebrider –– 27%27%–– CoblationCoblation –– 7%7%–– Coblation Coblation –– 7%7%

Little data that one method is superior to another in Little data that one method is superior to another in terms of pain, complications or regrowth and not well terms of pain, complications or regrowth and not well studiedstudiedstudiedstudied–– Significantly less blood loss in cautery groupSignificantly less blood loss in cautery group

Walner 2007 Walner 2007

Other Controversial IssuesOther Controversial IssuesOther Controversial IssuesOther Controversial Issues

Intraoperative IV steroid?Intraoperative IV steroid?Intraoperative IV steroid?Intraoperative IV steroid?Intraoperative local anesthesia?Intraoperative local anesthesia?P i ti tibi ti ?P i ti tibi ti ?Perioperative antibiotics?Perioperative antibiotics?NSAID’s?NSAID’s?Tonsillectomy in PFAPATonsillectomy in PFAPA–– Systematic reviews of all of the above haveSystematic reviews of all of the above haveSystematic reviews of all of the above have Systematic reviews of all of the above have

been performed by the Cochrane Database of been performed by the Cochrane Database of Systematic ReviewsSystematic Reviews

Intraoperative IV steroidIntraoperative IV steroidIntraoperative IV steroidIntraoperative IV steroid9 studies included, dosage varied from 0.159 studies included, dosage varied from 0.15--1.0 1.0 , g, gmg/kg dexamethasone (max 8mg/kg dexamethasone (max 8--25 mg)25 mg)Two times less likely to vomit in the first 24 hours Two times less likely to vomit in the first 24 hours versus placebo (NNT = 4)versus placebo (NNT = 4)versus placebo (NNT = 4)versus placebo (NNT = 4)Greater likelihood of advancing to soft diet on POD Greater likelihood of advancing to soft diet on POD 11Gallagher JAMA 2012 Gallagher JAMA 2012 –– no statistical difference in no statistical difference in bleeding between bleeding between intraopintraop steroid and placebosteroid and placebo

Ref tes JAMA 2008 articleRef tes JAMA 2008 article–– Refutes JAMA 2008 articleRefutes JAMA 2008 articleCDSR Steward 2011CDSR Steward 2011

Good supportive evidence forGood supportive evidence for periopperiop steroidssteroidsGood supportive evidence for Good supportive evidence for periopperiop steroidssteroids

Intraoperative Local AnesthesiaIntraoperative Local AnesthesiaIntraoperative Local AnesthesiaIntraoperative Local Anesthesia6 RCTs6 RCTsNo significant difference in postoperative pain in No significant difference in postoperative pain in any of the studiesany of the studies?Confounded by concomitant use of opiate ?Confounded by concomitant use of opiate Co ou ded by co co ta t use o op ateCo ou ded by co co ta t use o op ateanalgesia in the perioperative periodanalgesia in the perioperative periodMost excluded studies had either lack of Most excluded studies had either lack of randomization or additional procedures withrandomization or additional procedures withrandomization or additional procedures with randomization or additional procedures with tonsillectomytonsillectomyComplications?Complications?

CDSR Hollis 2009CDSR Hollis 2009CDSR Hollis 2009CDSR Hollis 2009Conclusion: No evidence to support Conclusion: No evidence to support intropintrop local local anesthesiaanesthesia

Perioperative AntibioticsPerioperative AntibioticsPerioperative AntibioticsPerioperative Antibiotics9 RCTs9 RCTsConclusion: little or no evidence that antibiotics reduce Conclusion: little or no evidence that antibiotics reduce pain, need for analgesia or secondary hemorrhage ratepain, need for analgesia or secondary hemorrhage rateStatistical difference in fever with antibioticsStatistical difference in fever with antibioticsStatistical difference in fever with antibioticsStatistical difference in fever with antibioticsMultiple sources of bias within these studies toward Multiple sources of bias within these studies toward antibioticsantibiotics–– Inadequate allocation concealmentInadequate allocation concealment–– Only half were double blindedOnly half were double blinded–– High drop out ratesHigh drop out rates

CDSR CDSR DhiwakarDhiwakar 20122012Conclusion: no evidence to support the routine use of Conclusion: no evidence to support the routine use of antibioticsantibiotics

Perioperative NSAID UsagePerioperative NSAID UsagePerioperative NSAID UsagePerioperative NSAID Usage15 RCTs 15 RCTs –– children < 16 y/o, 1046 children < 16 y/o, 1046 ptspts –– most included most included onlyonly periopperiop useuseonly only periopperiop useuseNo difference in perioperative bleeding No difference in perioperative bleeding –– Either requiring or not requiring surgical interventionEither requiring or not requiring surgical intervention

Significantly less nausea and vomiting (Odds ratio 0 40Significantly less nausea and vomiting (Odds ratio 0 40Significantly less nausea and vomiting (Odds ratio 0.40 Significantly less nausea and vomiting (Odds ratio 0.40 ––95% CI 0.2395% CI 0.23--0.72)0.72)Ketorolac most studied (6 studies)Ketorolac most studied (6 studies)Harley 1998Harley 1998 –– Ibuprofen postoperatively found noIbuprofen postoperatively found noHarley 1998 Harley 1998 –– Ibuprofen postoperatively found no Ibuprofen postoperatively found no increase in bleeding rate but statistically significant increase in bleeding rate but statistically significant difference in bleeding time (2 minutes) on POD 3 difference in bleeding time (2 minutes) on POD 3 –– no no change in PT or PTTchange in PT or PTTC l i G d id f i d i k fC l i G d id f i d i k fConclusion: Good evidence for no increased risk of Conclusion: Good evidence for no increased risk of bleedingbleeding

CDSR Cardwell 2010CDSR Cardwell 2010

PFAPA and TonsillectomyPFAPA and TonsillectomyPFAPA and TonsillectomyPFAPA and TonsillectomyPeriodic fever, Periodic fever, aphthousaphthous stomatitis, pharyngitis, stomatitis, pharyngitis, pp p y gp y gcervical adenitis (Marshall syndrome)cervical adenitis (Marshall syndrome)2 high quality studies suggest benefit from 2 high quality studies suggest benefit from tonsillectomy:tonsillectomy:tonsillectomy:tonsillectomy:–– GaravelloGaravello 2009: Recurrence 19/20 control, 6/18 2009: Recurrence 19/20 control, 6/18

surgical groupsurgical groupRequired only one of the symptoms/signs of stomatitisRequired only one of the symptoms/signs of stomatitisRequired only one of the symptoms/signs of stomatitis, Required only one of the symptoms/signs of stomatitis, pharyngitis, adenitis for inclusionpharyngitis, adenitis for inclusion

–– RenkoRenko 2007: Recurrence 6/12 control, 0/14 surgical 2007: Recurrence 6/12 control, 0/14 surgical groupgroupg pg p

Did not require stomatitis, pharyngitis, adenitis for inclusionDid not require stomatitis, pharyngitis, adenitis for inclusionCDSR Burton 2010CDSR Burton 2010

Codeine and TonsillectomyCodeine and TonsillectomyCodeine and TonsillectomyCodeine and Tonsillectomy“A new “A new BOXED WARNINGBOXED WARNING, FDA’s strongest warning, , FDA’s strongest warning,

ill b dd d h d l b l f d iill b dd d h d l b l f d i i ii iwill be added to the drug label of codeinewill be added to the drug label of codeine--containing containing products about the risk of codeine in postproducts about the risk of codeine in post--operative operative pain management in children following tonsillectomy pain management in children following tonsillectomy and/or adenoidectomy ”and/or adenoidectomy ”and/or adenoidectomy.”and/or adenoidectomy.”“Health care professionals should prescribe an “Health care professionals should prescribe an alternate analgesic for postalternate analgesic for post--operative pain control in operative pain control in hild h d i t ill t d/hild h d i t ill t d/children who are undergoing tonsillectomy and/or children who are undergoing tonsillectomy and/or

adenoidectomy. Codeine should not be used for pain adenoidectomy. Codeine should not be used for pain in children following these procedures.”in children following these procedures.”

fdfd 2/20/132/20/13www.fda.govwww.fda.gov 2/20/132/20/13

Codeine and TonsillectomyCodeine and TonsillectomyCodeine and TonsillectomyCodeine and Tonsillectomy“These 4 children (ages two to five) had evidence of “These 4 children (ages two to five) had evidence of

i h i d ( i ) bili d i ii h i d ( i ) bili d i ian inherited (genetic) ability to convert codeine into an inherited (genetic) ability to convert codeine into lifelife--threatening or fatal amounts of morphine in the threatening or fatal amounts of morphine in the body. All children had received doses of codeine that body. All children had received doses of codeine that were within the typical dose range ”were within the typical dose range ”were within the typical dose range.”were within the typical dose range.”“RECOMMENDATION“RECOMMENDATION: Health care professionals : Health care professionals should be aware of the risks of using codeine in should be aware of the risks of using codeine in hild ti l l i th h h dhild ti l l i th h h dchildren, particularly in those who have undergone children, particularly in those who have undergone

tonsillectomy and/or adenoidectomy for obstructive tonsillectomy and/or adenoidectomy for obstructive sleep apnea syndrome. If prescribing codeinesleep apnea syndrome. If prescribing codeine--containing drugs the lowest effective dose for thecontaining drugs the lowest effective dose for thecontaining drugs, the lowest effective dose for the containing drugs, the lowest effective dose for the shortest period of time should be used on an asshortest period of time should be used on an as--needed basis (i.e., not scheduled around the clock).”needed basis (i.e., not scheduled around the clock).”

www fda govwww fda gov 2/20/20132/20/2013www.fda.govwww.fda.gov 2/20/20132/20/2013

ConclusionsConclusionsConclusionsConclusionsNo good data to suggest one method of complete tonsillectomy is No good data to suggest one method of complete tonsillectomy is superior to anothersuperior to anothersuperior to anothersuperior to another–– Particularly with regards to pain, sec bleedingParticularly with regards to pain, sec bleeding

?future ?future –– biological dressing?biological dressing?Good data that partial tonsillectomy results in decreased painGood data that partial tonsillectomy results in decreased painp y pp y p–– regrowth and indication in infection still issuesregrowth and indication in infection still issues

Overall, trend away from curette/adenotome in adenoidectomy but Overall, trend away from curette/adenotome in adenoidectomy but not good data for one method over anothernot good data for one method over another

Most patients do well with adenoidectomy regardless of techniqueMost patients do well with adenoidectomy regardless of technique–– Most patients do well with adenoidectomy regardless of techniqueMost patients do well with adenoidectomy regardless of techniqueVery good evidence that a single dose of intraop steroid decreases Very good evidence that a single dose of intraop steroid decreases incidence of nausea/vomiting with no side effectsincidence of nausea/vomiting with no side effectsNo good evidence for periop antibiotics or local anesthesiaNo good evidence for periop antibiotics or local anesthesiag p pg p pEvidence for periop NSAID use to decrease nausea with no Evidence for periop NSAID use to decrease nausea with no increased bleeding risk, postop less well studied increased bleeding risk, postop less well studied

Thank YouThank You –– Questions?Questions?Thank You Thank You Questions?Questions?