A Yacht called Grommets Are ENT procedures evidencebased
A Yacht called Grommets Are ENT procedures evidence-based? By Gary Kroukamp
Controversies in Tonsillectomy, Adenoidectomy and Tympanostomy Tubes • Do risks outweigh benefits? • Randomised controlled trials have addressed some issues, but not others
The Problem • Tonsillectomy and adenoidectomy the most common surgical procedure in children • Tympanostomy tube (Grommet) placement the commonest operation after the newborn period • 1 million adenotonsillectomies/year 1970’s • ¼ million adenotonsillectomies/year 1990’s
Certain Indications for T’s and A’s i. e. good evidence • Obstruction – sleep apnoea or cor pulmonale • Failure to thrive, weight loss • Haemorrhage • Sleep apnoea causing ADD
Elective Indications for T’s Recurrent Acute Tonsillitis > 4 per year for 2 years • Trial (Paradise and Bluestone) – T’s vs Non -surgical • T’s better in 3 years post op – less throat infections and less severe • Children usually outgrow the problem • Decision should be individualised
Clinical decision making • • • Assess severity, frequency and duration Assess days lost from school Documented episodes Tonsil exudate Fever Cervical lympadenopathy
Tonsillectomy Methods Pain Relief and Haemorrhage • Blunt dissection and tie • Bipolar Diathermy • Coblation • Monopolar cutting diathermy • Laser
Peritonsillar Abscess/Quinsy • Single episode - recurrence rates low • Easily treated as an outpatient • Tonsillectomy indicated if recurrent or if recurrent tonsillitis
Adenoidectomy • Together with grommets to prevent recurrence of effusions • Quality of life issue if not complete obstruction • Will improve airway, olfaction, mouth breathing, speech, dentofacial morphology • Useful in chronic sinusitis • Determine likelihood of spontaneous improvement • Other treatments e. g antibiotics and nasal steroids not effective
Otitis Media • Otitis media the most common disease – has increased in the USA • Increase due to day care? • Grommets 21% in day care vs 3% at home • 1. 2 episodes in first year • 75% under 7 have 1 episode per year • Grommets 700 000/year in USA
Indications for Grommets • Middle ear effusion for > 3 months bilateral or > 6 months unilateral • Earlier if significant hearing loss, speech delay, retraction pocket, dysequilibrium • Eustachian tube dysfunction • Suppurative complications
Grommets in Recurrent AOM • Reduce frequency, duration, severity of AOM in kids with recurrent AOM • Prophylactic antibiotics (amoxyl) also effective
Is Endoscopic Sinus Surgery a Scam? • • Sinusitis – 31 million cases per year 4 days off work 200 000 surgeries per year Antibiotics or not?
Surgery • Use of endoscopes and CT scans have revolutionised management • Better understanding of anatomical variation and pathophysiology • Symptoms may recur post-op BUT • Improved symptom scores and improvement in Asthma • Try medical management first – Antibiotics – Nasal steroids • FESS as last resort
Coblation Somnoplasty • A new method of snoring treatment – minimally invasive, outpatient based • Coblation wand uses radiofrequency thermal ablation • Significant reduction in snoring volume and frequency • Is it maintained? Is it effective against OSAS?
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