A validation study of data in the National Tonsil Surgery Register in Sweden: high agreement with medical records ensures that data can be used to monitor clinical practices and outcomes

Background The ambition of the National Tonsil Surgery Register in Sweden (NTSRS) is to improve otorhinolaryngological care by monitoring trends in the clinical practices, complications, and outcomes of tonsil surgery. The NTSRS collects data from both surgeons and patients and provides the participating clinics with daily updated data on a publicly available website. On the website, national and local results can be compared and monitored. The use of NTSRS data necessitates that the data is valid, but the NTSRS has not yet been validated. With approximately half of the registered patients responding to the postoperative questionnaires, an analysis of responders and non-responders is also necessary. The aim of this study was to assess the criterion validity of NTSRS data. Another aim was to compare the characteristics and rates of complications between postoperative questionnaire responders and non-responders. Methods Data in the NTSRS were compared with data in electronic medical records. The 200 most recent surgeries, up to 31 Dec 2019, in each of 11 surgical units were included. Criterion validity was analysed in terms of observed agreement, Cohens kappa, Gwet’s AC1, and positive and negative agreement. The sign test was used to analyse systematic differences between the NTSRS and the medical records. Comparisons of rates between groups were made with Fisher’s exact test, the chi-square test, and Fisher’s non-parametric permutation test. Results A total of 1991 registrations were included in the study. All variables showed very high observed agreement ranging from 0.91 to 1.00, and all variables had AC1 values corresponding to almost perfect agreement. The analysis of questionnaire responders and non-responders showed no statistically significant differences regarding age, indication, or type of surgery. The proportion of women was higher in the responder group. The rate of reoperation due to bleeding was higher in the responder group, but there were no differences regarding other complications. Conclusions The results of this study show that data in the NTSRS have criterion validity. The NTSRS is thus well suited for monitoring the clinical practices and outcomes of tonsil surgery. The quality of the data also implies that the registry can be used in both clinical improvement projects and research.

Preventing the Catastrophe: Aberrant Carotid in Adenoid and Tonsil Surgery: Two Case Reports

Background: Adenoid and tonsil surgeries are the most commonly done surgical procedures, with haemorrhage being an important complication. Fatalities due to haemorrhage almost never occur, but the occasional devastating outcomes that are life-threatening become a frequent source of litigations and audits. Catastrophic bleeds are usually due to an aberrant vessel or carotid protruding in the pharyngeal airway. The aberrant carotid poses a risk during routine pharyngeal surgeries like adenoidectomy, tonsillectomy, Quincy and Para-pharyngeal abscess drainage, UPPP, pharyngeal biopsies, etc. and injuries during routine pharyngeal surgical procedures can be catastrophic due to massive bleeding. Case report: We report two cases of routine Adeno-tonsillectomy surgeries where aberrant carotid vessels protruding in the adeno-tonsil surgical area were identified by endoscopic transoral evaluation intraoperatively. The surgery in these cases was postponed for further investigation due to the risk of injury and catastrophic bleeding. Conclusion: Aberrant carotids are usually clinically silent, and adenoid removal in most cases is a blind procedure done by curettage. There are no guidelines to identify aberrant vessels pre or intraoperatively, and preventing injury and catastrophic bleeding depends on surgeon’s experience and caution. These cases underline the importance of due vigilance and taking steps before starting the procedures, particularly pre-and intraoperative transoral endoscopic assessment for identifying aberrant vessels in the upper airway area, thus preventing injury and avoiding devastating complications. We report these cases and underline the steps to identify aberrant vessels in the upper airway surgical field before starting surgery to prevent a potentially catastrophic complication.

Analysis of Droplet Splatter Patterns During Coblation Tonsil Surgery in the Covid-19 Pandemic

Objectives: To assess droplet splatter around the surgical field and surgeon during simulated Coblation tonsil surgery to better inform on mitigation strategies and evaluate choice of personal protective equipment. Methods: This was an observational study performed using a life-size head model to simulate tonsil surgery and fluorescein-soaked strawberries to mimic tonsils. The Coblation wand was activated over the strawberries for 5 minutes. This was repeated 5 times with 2 surgeons (totalling 10 data sets). The presence of droplet around the surgical field and anatomical subsites on the surgeon was assessed in binary fashion: present or not present. The results were collated as frequency of droplet detection and illustrated as a heatmap; 0 = white, 1-2 = yellow, 3-4 = orange, and 5 = red. Results: Fluorescein droplets were detected in all 4 quadrants of the surgical field. The frequency of splatter was greatest in the upper (nearest to surgeon) and lower quadrants. There were detectable splatter droplets on the surgeon; most frequently occurring on the hands followed by the forearm. Droplets were also detected on the visor, neck, and chest albeit less frequently. However, none were detected on the upper arms. Conclusion: Droplet splatter can be detected in the immediate surgical field as well as on the surgeon. Although wearing a face visor does not prevent splatter on the surgical mask or around the eyes, it should be considered when undertaking tonsil surgery as well as a properly fitted goggle. Level of evidence: 5

The impact of new evidence on regional variation in paediatric tonsillectomy and adenoidectomy: a historical review

BackgroundTonsillectomy and adenoidectomy have been among the most commonly performed procedures in children for approximately 100 years. These procedures were the first for which unwarranted regional variation was discovered, in 1938. Indications for these procedures have become stricter over time, which might have reduced regional practice variation.MethodsThis paper presents a historical review on practice variation in paediatric tonsillectomy and adenoidectomy rates. Data on publication year, region, level of variation, methodology and outcomes were collected.ResultsTwenty-one articles on practice variation in paediatric tonsil surgery were included, with data from 12 different countries. Significant variation was found throughout the years, although a greater than 10-fold variation was observed only in the earliest publications.ConclusionNo evidence has yet been found that better indications for tonsillectomy and adenoidectomy have reduced practice variation. International efforts are needed to reconsider why we are still unable to tackle this variation.

Frequency and Predictors of Tonsil Surgery: A Systematic Review of Evidence

Tonsillectomy and adenoidectomy are common procedures, performed typically on children. Evidence suggests that these procedures may be associated with health conditions, as well as with demographic, socioeconomic, and environmental factors. This review examines worldwide evidence related to the frequency and predictors of tonsil surgery for all age groups. Using PubMed, Web of Science, and Ovid Cochrane, a systematic review was conducted which retrieved 11 relevant articles. This review suggests that tonsil surgery is associated with age, geographical region of residence, and race. Further studies to evaluate factors associated with tonsil surgery will provide more information regarding the frequency of tonsil surgery, as well as the disparities in incidence of the surgery among different population groups.

Lasers in Tonsillectomy: Revisited With Systematic Review

Introduction: In 2005, the National Prospective Tonsillectomy Audit was conducted by the Royal College of Surgeons England, reporting hot tonsillectomy techniques being associated with more postoperative pain and hemorrhage when compared with dissection. In 2006, the National Institute of Clinical Excellence declared its position on laser tonsillectomy reporting that bleeding may be less intraoperatively but is more postoperatively, that initial pain may be less but medium term is more and that healing is delayed. Aim: To revisit the literature surrounding laser tonsil surgery and assess the aforementioned factors for any trend changes. Methodology: A Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-style systematic review conducted in July 2019 searched Embase, Medline, and Cochrane databases for randomized controlled trials comparing laser tonsil surgery with other techniques with the terms laser, tonsillectomy, and tonsillotomy for nonmalignant indications. A total of 14 articles were evaluated. Results: A total of 1133 patients received surgery accounting for a total of 2266 tonsil removals. A variety of laser techniques were used including CO2 (66%) potassium-titanyl-phosphate (19%) and contact diode (15%). Nonlaser techniques included dissection (62%), diathermy (20%), and coblation (18%). The summated conclusions suggest that laser techniques are superior regarding intraoperative bleeding and procedure duration. Laser techniques also provide equivocal or superior outcomes regarding postoperative hemorrhage, pain, and total healing time. Conclusion: Outcomes following laser surgery in recent years suggest an overall improvement. This could be due to enhanced familiarity with techniques and established centers performing laser procedures more routinely.

The Safety of Early Administration of Oral Fluid Following General Anesthesia in Children Undergoing Tonsil Operation: A Prospective Randomized Controlled Trial

Background: The feasibility and safety of giving a small amount of water to children in the recovery period after tonsillectomy under general anesthesia to reduce the thirst and its associated restlessness reaction remain unknown. Methods: This study was approved by our institutional ethics committee, and which adhered to CONSORT guidelines. Pediatric patients undergoing tonsil surgery who met the inclusion and exclusion criteria of our study were randomized into the experimental and control groups. In the experimental group, patients were given a small amount of water instantly after recovering from the general anesthesia, which included the recovery of cough and deglutition reflex, and attaining grade V of muscle strength. The control group was given a small amount of water 4 to 6 hours after the operation. The incidence of nausea and vomiting and the degree of thirst relief were measured and compared between the two groups. Results：300 patients were randomized into each group. There was no significant difference in the incidence of nausea and vomiting 20 minutes after drinking water between the two groups (P>0.05). The thirst score of children over 5 years old in the experimental group was significantly lower than that of the control group (P<0.05). Conclusion: The early administration of a small amount of oral fluid in children undergoing tonsil surgery and recovering from the general anesthesia is not only safe but also effective in reducing postoperative thirst. Trial registration: Current Controlled Trials ChiCTR1800020058, 12-12-2018.