Bacteremia IS Present During Tonsillectomy!

@ENTHouse brought to my attention a very interesting research regarding the presence of bacteria in the bloodstream during tonsillectomy, both elective and quinsy. Elective tonsillectomy is when the tonsils are removed in the absence of any significant infection. Quinsy tonsillectomy is when the tonsils are removed in the setting of a peritonsillar abscess.

The research involved obtaining blood cultures, tonsillar swabs, core tissue, and pus aspirates during the operation on 80 patients undergoing elective surgery and 36 undergoing quinsy surgery.

What they found was,

"Bacteremia was detected in 73% of patients during elective tonsillectomy compared to 56% during quinsy tonsillectomy. Significantly more blood culture bottles were positive for each isolate obtained from elective tonsillectomy cases compared to quinsy tonsillectomy cases. In all, 59% and 42% of electively and acutely tonsillectomized patients, respectively, had bacteremia with microorganisms that are predominant in bacterial endocarditis. Ninety-three percent of the isolated strains were sensitive to amoxicillin, and all were sensitive to amoxicillin with clavulanic acid." [link]

Amoxicillin with clavulanic acid is also known as Augmentin.

What is fascinating is the high rate of bacteria presence in the bloodstream during a routine elective tonsillectomy... even higher rates than tonsils which are actively and terribly infected. Perhaps because those with an active infection are already on antibiotics thereby suppressing bacteria in the bloodstream? Also, with an abscess, the pus pocket is already walled off by inflammatory tissue thereby preventing further leaching of bacteria into the bloodstream?

Regardless, these findings are especially interesting in light of the fact that antibiotics are not routinely recommended before, during, or after surgery!

Reference:
Bacteremia during quinsy and elective tonsillectomy: an evaluation of antibiotic prophylaxis recommendations for patients undergoing tonsillectomy. J Cardiovasc Pharmacol Ther. 2012 Sep;17(3):298-302. Epub 2011 Oct 24.

Singulair May Help Cure Mild Sleep Apnea in Children

Singulair (generic montelukast as of Aug 2012) is a medication often prescribed for asthma as well as allergies and works by blocking the leukotriene receptor. This mechanism is different than that found in common allergy medications like claritin and benadryl which work by blocking the histamine receptor (anti-histamine).

Singulair has also incidentally been found to possibly help reduce the size of tonsils and adenoids. Given this beneficial affect, singulair may be a helpful intervention in those kids with mild obstructive sleep apnea or nasal obstruction due to adenoid hypertrophy avoid surgical intervention (tonsillectomy and adenoidectomy).

The most recent research published in Sept 2012 suggests that singulair may lessen symptoms in children with non-severe apnea and potentially allow them to skip the surgery.

In the study, 46 children with non-severe sleep apnea received singulair or a placebo for 12 weeks. The kids who received the drug showed improvements in their sleep apnea, their sleep-related symptoms, and the size of their adenoids compared to the placebo group. There were no side effects seen among kids who took the study drug.

Beyond singulair, steroid nasal sprays have also been found helpful to reduce adenoid size.

Singulair can be given from the age of 1 year old.

References:
Leukotriene modifier therapy for mild sleep-disordered breathing in children. Am J Respir Crit Care Med. 2005 Aug 1;172(3):364-70. Epub 2005 May 5.

Leukotriene pathways and in vitro adenotonsillar cell proliferation in children with obstructive sleep apnea. Chest. 2009 May;135(5):1142-9. Epub 2008 Dec 31.

The role of mometasone furoate aqueous nasal spray in the treatment of adenoidal hypertrophy in the pediatric age group: preliminary results of a prospective, randomized study. Pediatrics. 2007 Jun;119(6):e1392-7. Epub 2007 May 28.

Intranasal corticosteroids for nasal airway obstruction in children with moderate to severe adenoidal hypertrophy. Cochrane Database Syst Rev. 2008 Jul 16;(3):CD006286.

New Minimally Invasive Technique to Treat Tonsil Stones Developed by Dr. Chang

Dr. Chang developed an innovative minimally invasive technique to treat tonsil stones using coblation technology. His findings have been published in this month's ENT Journal. In fact, his research made the front cover of the journal! Dr. Richard Thrasher of ENT Centers of Texas was a co-author in the study.

This technique called coblation tonsil cryptolysis is unique in that it can be performed in adult patients without sedation using only local anesthesia, much like laser tonsil cryptolysis. As with laser cryptolysis, pain is significant for only a few days and most adults can resume normal diet and activity within 1 week. In contrast, tonsillectomy entails significant morbidity for several weeks. However, coblation avoids the significant disadvantages of laser use, including the potential for airway fire, retinal damage from reflected scatter, dealing with plume from vaporized tissues, oral/facial burns, and the high cost of purchasing and maintaining laser equipment. After a single session of coblation tonsil cryptolysis, a significant decrease and even elimination of tonsil stones can potentially be achieved.

Read more about this mode of treatment here.

Read the research article here.