Tonsillectomy Circa 1940s [video]

I encountered this interesting video of tonsillectomy being performed in a child with sedation (but NO intubation) performed circa 1940s.

Of course, nowadays, tonsillectomy is performed under general anesthesia with intubation for airway protection. Here’s a video of the way it is now done.

That is, unless, you practice in other parts of the world where modern medicine is not up to United States standards. In those nations, tonsillectomy is STILL being performed WITHOUT general anesthesia or any sedation for that matter. In fact, here’s a blog I wrote earlier this year showing a graphic video depicting tonsillectomy being recently performed in a young child WITHOUT any sedation.

New Webpage on Bumps or Lesions of the Mouth

Our practice has created a new webpage describing the various bumps and lesions commonly seen in the mouth that leads to a doctor’s visit.

Such abnormal things seen in the mouth that’s discussed include:

• aphthous ulcer
• herpetic ulcers
• pyogenic granuloma
• fibroma
• papilloma
• cancer

Click here to read more!

Tonsillectomy Airway Fire

ABC News reported in 2008 about a California family suing doctors as well as Conmed, an electro-surgical instrument company, for an airway fire that occurred on April 18, 2003 on an 8 years old child during a routine tonsillectomy surgery.

Apparently, an electrocautery device was being used to remove the tonsils when the endotracheal tube caught fire resulting in burns to the child’s mouth and airway (no death). It is suspected that the electrocautery device during the surgery either burned a hole into the endotracheal tube where it encountered oxygen resulting in the fire or there was a leak around the endotracheal tube which caught fire. The jury found the surgeon to be negligent, but returned a defense verdict for the device manufacturer Conmed. The other defendants settled.

Use of electrocautery is still popular among ENT surgeons removing tonsils, but has been abandoned by an increasing number of surgeons (including our practice) over the past few years due to risk of airway fire as well as concern for unnecessary thermal injury to surrounding normal peritonsillar tissues. Electrocautery produces temperatures between 400 to 600 degrees Centigrade which both cuts and stops bleeding simultaneously. However, as can be seen in this unfortunate case, it can also burn through an endotracheal tube and cause an airway fire.

Airway fire is another reason why laser tonsillectomy is rarely performed as the risk is the same if not greater than electrocauterization.

Our office uses coblation technology to remove tonsils. Coblation uses a radiofrequency plasma field to cut and stop bleeding simultaneously at near room temperatures thereby avoiding risk of airway fire as well as thermal injury to surrounding oral tissues.

Of note, there are about 500 cases of operating room fires related to use of electrosurgical instruments every year of which 20-30 causes serious injuries.

Read the ABC News report here.

World’s Largest Tonsils Set in Guinness Book of World Records

It’s official…

The world’s largest tonsils was recently set by a Kansas man who had them removed by tonsillectomy. They measured in at 2.1 inches long and 1.1 inches wide, thoroughly beating the competition.


Read the story on ABC news here.

2 Years Old Child Dies After Tonsillectomy

In Wichita, Kansas, jury has begun deliberation regarding the death of a 2 years old boy in 2006 the day after tonsillectomy surgery. Read the story here.

Based on the limited information provided, the relevant facts I have gleaned from the story are as follows:

• Child was appropriately admitted to the hospital after surgery
• There is some question regarding what was going on with his oxygen levels and other vital signs during hospitalization
• Autopsy revealed pneumonia confined to a small part of one lung
• Hydrocodone was prescribed for pain
• Lack of accurate communication between nursing and the surgeon
• Unclear patient/family factors
• Child had history of breathing problems (probably asthma)

Overall, it seems that this child’s death was the result of many errors that piled upon each other. Any single error certainly wouldn’t have resulted in death.

Reading between the lines, I conjecture the following might have occurred, giving as much benefit of the doubt to all parties involved, though I may be totally wrong:

1) Tonsillectomy surgery was uneventful and routine.
2) During extubation, coughing may have occurred with some aspiration of secretions (extubation… cough, cough, cough… strong inhalation with secretions resulting in aspiration)
3) Child was admitted after surgery due to age.
4) Child was overly sedated with hydrocodone and as such, not able to easily cough up secretions. Rather, probably slept more often than not.
5) Vital signs were probably on the low normal side. If truly abnormal, something should have been done immediately (nebulizer treatments, a chest x-ray, etc).
6) Lungs were listened to and potentially clear on auscultation given pneumonia was localized to only a small part of one lung. This exam was probably performed only once or twice. Given the child was sleeping, nursing may have decided (family may also have requested) that he be left alone so he can sleep rather than be disturbed and examined which would have caused him to start crying.
7) Patient was recommended for discharge the next day based on available information.
8) At home, child still overly sedated given hydrocodone administration by parents to treat pain resulting in inadequate lung ventilation thereby not allowing for aspirated secretions to be coughed up and out.
9) Death

A few areas of concern on my part…

It is possible in the parent’s misguided resolve to ensure their child will not be in pain, that they may have given hydrocodone even if the child was not complaining of pain. It would be important to know what his hydrocodone narcotic level was in his bloodstream. In any event, this only reiterates that hydrocodone should not have been prescribed in a child this age. Rather plain tylenol or at most tylenol with codiene would have been more appropriate and certainly less sedating.

The story also reported the child had a history of breathing problems, most likely asthma. This fact just exacerbated the overall situation. In a healthy child, the lungs would have been much hardier and less prone to compromise.

Second, a pneumonia that has been present for many days is unlikely if localized to only a small part of one lung (one would expect a large area to be affected). Furthermore, if the pneumonia was as severe as they say BEFORE surgery, high fevers would have been present in which case, surgery would have been cancelled regardless of cause due to concern for febrile seizures induced by anesthesia.

In summary, what likely happened was an unrecognized aspiration event in a child with a history of asthma followed by over-sedation with narcotics which led to this unfortunate demise.

But… that’s just my guess based on incomplete information.

Read the story here.

ADDENDUM 7/30/11: Jury ruled in favor of the defendants absolving of any malpractice in this case. Of note, a comment about the case by one of the jurors stated “I was one of the jurors on this case, and it was very hard to come up with a verdict. The reality of the situation is that there was not an acceptable cause of death and there was not enough evidence proving that Wesley and Dr. Kubina more likely than not caused the death.”

Read more here

New Webpage on Peritonsillar Abscess Added to Website

Our office has created a new webpage on the evaluation and treatment of peritonsillar abscess.

Peritonsillar abscess is when a pus collection develops behind the tonsil causing a severe sore throat and trouble swallowing.

Read more on how this condition is treated here.

Why Are You Looking in My Mouth When It’s My Ear Hurting?

One June 20, 2011, NPR aired a great story about how a person may not “see” a person getting beat up on the side of a jogging path when they are focused on a task (pursuing another jogger)… even if they pass RIGHT BY THE FIGHT!!!

In fact, only a third of the subjects reported seeing this mock fight when the experiment was conducted at night. Even more surprisingly, broad daylight didn’t improve the statistics (only 40% noticed the fight).

Though the situation and circumstances do not exactly correspond, there is a lesson to be learned here that applies to a medical visit.

As an ENT, I often see patients for a very specific complaint…

“My right ear hurts.”
“I have a bad cough.”

No matter what the complaint, unless it is for a specific task (there is earwax… can you remove it), I most always still do a complete ear, nose, and throat exam no matter the complaint.

Why???

Because often the symptoms are “the jogger” in the example above which is noticed to all exclusion when “the fight” is the more important event that should have been noticed.

Let’s go to the examples stated above…

“My right ear hurts.”

Though a patient may wonder why the heck I look in the mouth when their ear is the main complaint, it’s mainly because there are other things that can cause ear pain… some of it life-threatening.

Tonsil cancer can cause ear pain (without any other symptoms) as well as a base of tongue abscess. Obviously, giving antibiotics to treat the right ear pain totally misses the fact that there was tonsil cancer that got missed or the tongue abscess which requires an emergency trip to the operating room followed by a few days in the intensive care unit.

“I have a bad cough.”

This statement is pretty self-explanatory. Why bother looking in the ears??? A loose hair in the ear canal can cause a persistent dry cough. Why look in the nose if the cough is coming from the throat? Severe allergies and nasal polyps can lead to post-nasal drainage leading to a chronic cough. Why would an ENT than ask about my blood pressure medications? Because ACE inhibitors like lisinopril cause a chronic dry cough as a side effect.

The point being with these examples is that medical doctors are trained to not just focus in the exact symptom the patient is complaining of, but the entire picture. It doesn’t do the patient any good if a doctor gets tunnel-visioned to the point where they don’t notice what may be a very obvious thyroid mass or the large nasal polyp.

SO… next time you see a doctor for a specific complaint, humor us, and answer fully all questions about your medical history, surgical history, medications you are taking, and the physical exam we will perform on you… even if you are there for just a “simple” earache.

Read the NPR story here and the police beating that triggered this inattention experiment.

Innovative Research to Treat Tonsil Stones by Dr. Chris Chang Accepted for Publication

There are some unfortunate individuals who suffer from an annoying problem called tonsil stones. This aggravating problem is when the tonsils produce tiny stones that extrude into the mouth resulting in chronic bad breath and throat discomfort. When it does pop out into the mouth, the stone itself tastes terrible. For many individuals, this may occur every few weeks. In others, it can happen on a daily basis causing significant quality of life issues.

In the past, there has been only 3 ways to address this problem:

1) Conservative management with gargles and manual expression (kind of like popping a pimple, but it’s the tonsil)

2) Tonsillectomy (no tonsils to produce the stones than)

3) Laser cryptolysis (a laser beam is used to obliterate the tonsil surface causing the crypts and holes where tonsils stones are produced to disappear)

However, there are disadvantages to each of these different methods. For tonsillectomy, the pain during recovery is excruciating and can last up to 3+ weeks. Also, the surgery has to be performed under general anesthesia. Laser cryptolysis is rarely performed mainly because of the risks associated with laser use (eye damage, facial and lip burns, bleeding, etc).

As such, Dr. Chang has developed a new technique that minimizes the drawbacks with these methods called coblation cryptolysis. Pain does not typically last more than 1 week and does not have any of the risks associated with laser use. Furthermore, it can be done without any sedation. Only local anesthesia is used.

His technique and findings has been accepted for publication in ENT Journal, a peer-reviewed specialty journal, and hopefully will be available to read in the near future! Stay tuned!

Tonsillectomy Causes Obesity?

MSNBC published a story on Feb 1, 2011 regarding a new study suggesting a link between childhood obesity and tonsillectomy.

What they found was a greater than expected weight gain in both normal weight and overweight children after tonsillectomy over a 6-12 month period of time. In one study, the average body mass index of the kids increased by about 7 percent. In another analysis of 249 children, 50 to 75 percent of kids had weight gain after surgery. While most weight gain happened in the first year after surgery, scientists don’t know definitively whether it levels off after that.

What is unclear about this research is whether this common surgery to remove tonsils is contributing to the nationwide “epidemic” of obesity.

Several theories have been proposed:

1) One reason why tonsillectomy is performed is because of difficulty breathing. In this scenario, more calories are expended on trying to breath. After tonsillectomy, all the energy expended on breathing is now being used to gain weight instead.

2) Having difficulty swallowing food due to large tonsils may prevent children from eating very much. In this scenario, after tonsillectomy, the child can now eat without problems leading to eating more and gaining weight.

3) In young and school-age children there’s evidence of both a weight gain and a “growth spurt” after tonsillectomy that may be triggered by higher levels of growth factors.

One needs to be careful and realize that this study does NOT prove cause and effect. It suggests a possible association and the only way to know for sure if this common surgery actually causes obesity is to perform a double-blinded, placebo-controlled, prospective study… or at the very least, a prospective study (given it will be near-impossible to have a placebo group and be double-blinded… after all, you can just look to know if the tonsils were removed or not). What will likely end up being true is the fact that obesity is due to a number of factors of which tonsillectomy may play one possible role in certain pediatric populations. In the end, more study is needed.

Regardless of the cause, perhaps the best advice for parents is to have tonsillectomy done for their child only if it is absolutely necessary and if done, keep an eye on how much they are eating and to encourage healthy eating habits.

Read the MSNBC report here.

Reference:
Pending in Feb 2011 Issue of Otolaryngology-Head & Neck Surgery

The Doctors TV Show Does Surgery for Obstructive Sleep Apnea

The Doctors TV show at some point in the past (not sure when), did a segment on surgery used to treat obstructive sleep apnea. The surgery portrayed was UPPP (uvulopalatopharyngoplasty). Dr. Brian Weeks, the featured otolaryngologist, removed the tonsils and uvula followed by suturing the cut mucosa to reposition the soft tissues of the patient’s throat.

This operation is a basic surgical method addressing obstructive sleep apnea. However, prior to considering surgical treatment, I typically recommend trial of CPAP for 3 months.

Some things to keep in mind is that obstructive sleep apnea is often due to multiple levels of obstruction. UPPP only addresses mouth-level problems. Other sleep apnea surgery options need to be considered when obstruction exists at other levels including the back of tongue (below the mouth level). Base of tongue reduction helps in this situation.

Watch the video of the TV show here. Watch the video our office produced on this surgery here.

http://r.unicornmedia.com/content.aspx?uid=AC26FE85-334B-4A21-B72C-154F743F5739&at=af886c81-206b-4c7c-ac4e-dc553df1fb75