Paraganglioma of the palatine tonsil

August 10, 2012     Joshua I. Warrick, MD; David S. Brink, MD; Ronald B. Mitchell, MD


Paragangliomas of the head and neck are rare. We describe the case of an 11-year-old girl who presented with an enlarged right palatine tonsil (grade 4). After a bilateral tonsillectomy, microscopic examination of the right tonsillar tissue revealed well-formed nests of polygonal epithelial cells separated by a collagenous stroma. The tumor cell nuclei were centrally placed and featured finely clumped chromatin and moderate anisonucleosis. Occasional mitotic figures were present. No necrosis was seen. An immunohistochemical staining panel showed no label for keratin, epithelial membrane antigen, HMB-45, or Melan-A; there was a strong label of tumor cells with chromogranin A, synaptophysin, and neuron-specific enolase. The S-100 protein label was strongly positive in the surrounding stromal cells and weakly positive in the polygonal tumor cells. Given the classic histology and the immunohistochemical staining profile, the diagnosis of paraganglioma was made. At 7 months postoperatively, the patient exhibited no evidence of recurrence or metastasis. To the best of our knowledge, no case of a paraganglioma of the palatine tonsil has been previously described in the literature.

Utility of preoperative hematologic screening for pediatric adenotonsillectomy

August 10, 2012     Yekaterina A. Koshkareva, MD; Michael Cohen, MD; John P. Gaughan, PhD; Vincent Callanan, MD; Wasyl Szeremeta, MD


We conducted a 3-year retrospective study to examine the results of preoperative 
hematologic screening, the incidence of postoperative bleeding, and the possible 
relationship between the two factors in patients who had undergone tonsillectomy 
with or without adenoidectomy. Our study population was made up of 875 patients—441 
boys and 434 girls, aged 2 to 18 years (mean: 7.52 ± 4.25)—who had been treated at 
our institution from January 2004 through December 2006. In addition to demographic 
data, we compiled information on each patient’s medical and surgical history, personal 
and family history of abnormal bleeding, indication for tonsillectomy, and preoperative 
hematologic screening results. The latter included determinations of the prothrombin 
time, activated partial thromboplastin time, international normalized ratio (INR), and 
platelet count. A total of 748 patients (85.5%) had normal findings on preoperative 
hematologic screening, and 127 (14.5%) had at least one abnormality. Postoperatively, 
hemorrhagic complications occurred in 31 children (3.5%)—in 22 of the 748 patients 
with normal screening results (2.9%) and in 9 of the 127 with a screening abnormality 
(7.1%); the difference between the two groups was statistically significant (p = 0.041). 
The abnormalities in the latter group consisted of an elevated INR but no otherwise 
identifiable coagulopathy. Another 14 patients with an abnormal screening result 
(11.0%) were found to have at least one coagulopathy that was newly diagnosed during 
our preoperative evaluation; they were treated perioperatively, and none bled 
postoperatively. Of 21 patients who had a personal or family history of abnormal 
bleeding, 5 (23.8%) were found to have a coagulopathy, but none bled following surgery. 
In conclusion, we found that preoperative hematologic screening identified patients 
with undiagnosed coagulopathies, and with appropriate treatment our surgeons were able 
to prevent some bleeding events in these patients. Our finding that patients with a 
mildly elevated INR had a higher incidence of postoperative hemorrhage warrants 
further study.

Coblation cryptolysis to treat tonsil stones: A retrospective case series

June 4, 2012     Christopher Y. Chang, MD; Richard Thrasher, MD


We introduce a novel and potentially effective approach in the treatment of tonsil stones using Coblation technology. A retrospective pilot case series was performed demonstrating the effectiveness of a technique that we call Coblation tonsil cryptolysis. This technique 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.

Is routine analysis of pediatric tonsillectomy specimens worth the money?

April 30, 2012     Marc C. Thorne, MD, MPH, Assistant Professor, Associate Program Director

Although gross pathologic analysis may seem like a good alternative to examining every specimen microscopically, from the point of view of cost-effectiveness, it is the worst option and is quite unlikely to identify significant pathology.

Palatoglossal flap: A novel approach to cover herniated fat during tonsillectomy

March 31, 2012     Parker A. Velargo, MD and Jerome W. Thompson, MD

Although herniation of parapharyngeal fat into the tonsillar fossa during a tonsillectomy is uncommon, such deftects need to be closed when they occur. One approach is to use a local flap for repair.

Giant retropharyngeal abscess in an adult as a complication of acute tonsillitis: Case report

October 31, 2009     Cem Ozbek, MD, Safak Dagli, MD, E. Evrim Unsal Tuna, MD, Onur Ciftci, MD, and Cafer Ozdem, MD


Retropharyngeal abscess is an uncommon entity that can have severe and even fatal complications if it is not identified and treated early. Clinical and radiologic findings must be considered together prior to surgical drainage of a suspected retropharyngeal abscess. Airway obstruction may require emergent surgical management with tracheotomy. We describe the case of a 22-year-old man with a massive retropharyngeal abscess that was caused by inadequate treatment of acute tonsillitis. He responded well to surgical drainage and empiric antibiotic therapy.

Intraoperative bupivacaine for reduction of post-tonsillectomy pain: A randomized, placebo-controlled, double-blind study of 26 patients

August 31, 2009     Tammara L. Watts, MD, PhD and Stilianos E. Kountakis, MD, PhD


We conducted a randomized, controlled, double-blind, prospective study to evaluate the effect of intraoperative bupivacaine injection on postoperative pain control following Bovie cautery-assisted tonsillectomy in 26 adults. Sixteen patients were injected with 10 ml of 0.5% bupivacaine with 1:200,000 epinephrine, and 10 were injected with 10 ml of normal saline solution. For 10 days after surgery, patients completed a questionnaire to rate their overall pain and to record their narcotic consumption and oral intake. At study's end, there was no statistically significant difference in pain scores, narcotic use, and oral intake between the bupivacaine group and the controls (p = 0.13, 0.37, and 0.35, respectively). We conclude that the effects of perioperative bupivacaine on postoperative pain control in tonsillectomy patients are similar to those of placebo.

Lymphoma in the Waldeyer ring: A great masquerader

May 31, 2009     Ryan F. Osborne, MD, FACS, Jason S. Hamilton, MD, FACS, and Sofia Avitiaz, MD

Avoiding oral burns during electrocautery tonsillectomy

February 1, 2009     Thomas R. Lowry, MD, FACS and Jonathon R. Workman, MD, FACS


Electrocautery tonsillectomy is a common method of tonsil removal, and electrocautery devices are widely available. Although these devices are relatively safe, inadvertent patient injury may occur with their use, such as oral cavity burns. We describe a simple surgical technique that reduces the risk of oral burns during electrocautery tonsillectomy and review additional safety considerations.

Intratonsillar abscess: A rare cause for a common clinical presentation

December 1, 2008     Eng Cern Gan, MBBS, MRCS, Yuk Hui Ng, MBBS, MRCS, Siew Yoong Hwang, MBBS, FRCS, and Peter Kuo San Lu, MBBS, FRCS


Intratonsillar abscess is a rare clinical condition in patients who present with odynophagia. We report the case of a 33-year-old man who presented with odynophagia, unilateral tonsillar enlargement with palatal fullness, and deviation of the uvula. Failed attempts at drainage of a presumptive peritonsillar abscess and a worsening of signs and symptoms led to a clinical suspicion of a parapharyngeal abscess. Computed tomography of the neck detected a 2.6 x 2.3-cm intratonsillar abscess. The abscess was drained, and the patient's signs and symptoms resolved. Our review of the current English-language literature revealed that only 8 such cases have been previously reported. We report this new case to increase awareness of this condition, to demonstrate the diagnostic difficulty in such cases, and to discuss the pathophysiology of intratonsillar abscess formation.

Harmonic scalpel tonsillectomy versus monopolar diathermy tonsillectomy: A prospective study

May 31, 2008     Jason A. Roth, BSc(Med), MBBS, Tobias Pincock, MBBS, FRACS;, Raymond Sacks, MBBCh, FCS(SA)ORL, Martin Forer, MBBCh, FRACS;, Neil Boustred, MBBCh, FCS(SA)ORL, William Johnston, MBBS, FRACS;, and Michael Bailey, PhD, MSc


For tonsillectomy, the ultrasonic harmonic scalpel has been purported to cause less tissue injury and postoperative morbidity while providing adequate levels of hemostasis. We undertook a prospective study to compare outcomes in 162 patients who had undergone harmonic scalpel tonsillectomy and 40 patients who had undergone monopolar diathermy tonsillectomy over a 33-month period. We found that patients in the harmonic scalpel group experienced significantly less intraoperative bleeding (5.0 vs. 16.5 ml; p < 0.0001). There was no clinically significant difference between the groups with respect to (1) the amount of operating time, (2) the incidence of postoperative nausea and vomiting, dysphonia, and primary or secondary bleeding, and (3) the amount of time patients needed to resume normal diet and activities.

Safety and efficacy of pressure-assisted tissue-welding tonsillectomy: A preliminary evaluation

February 1, 2008     Randall G. Michel, MD, FACS, Bernard I. Weinstock, MD, and Kang Tsau, MD


We conducted a retrospective study of the safety and efficacy of a new pressure-assisted tissue-welding technology (ENTceps; Starion Instruments Corp.; Sunnyvale, Calif.) for total tonsillectomy, either alone or with adenoidectomy. The use of this instrument was compared in two groups of patients categorized by age. The younger group was made up of 50 patients aged 2 to 12 years who had undergone total tonsillectomy and adenoidectomy (T&A), and the older group was made up of 50 patients aged 13 to 47 years who had undergone either T&A or isolated total tonsillectomy. The primary safety endpoint was the presence or absence of intra- or postoperative complications—particularly the amount of intraoperative blood loss and the incidence of delayed postoperative bleeding. In each group, the mean amount of intraoperative blood loss was no more than 30 ml, and only 2 of the 100 patients experienced postoperative hemorrhage. Among the efficacy parameters were the amount of operating and recovery time and the postoperative appearance of the tonsillar fossae. The mean operating time was 13.0 minutes in the younger group and 19.5 minutes in the older group, and the mean total recovery times were 120.0 and 130.4 minutes, respectively; all tonsillar fossae were well epithelialized by 2 weeks after surgery. Finally, surgical morbidity was determined on the basis of the amount of perioperative pain medication administered, the number of unscheduled patient telephone contacts and clinic visits, and the amount of time needed to return to a normal diet and activities. Nine patients in the younger group and 6 in the older group required no pain medications during recovery; overall, pain was not a significant issue for most patients. Sixteen patients made a total of 20 telephone calls and 8 clinic visits prior to their scheduled postoperative appointment; almost all of these encounters dealt with postoperative pain. Only 1 patient, who had previously undiagnosed von Willebrand disease, had not returned to a normal diet and activities by the end of 1 week. Based on our preliminary findings—and a comparison of our results with those of other studies published in the literature relative to the amount of intraoperative bleeding, the incidence of postoperative bleeding, and operating times—we conclude that pressure-assisted tissue-welding technology is safe and compares favorably with other tonsillectomy techniques. This method of electrocautery is straightforward and relatively easy to learn.

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