Transcript A Yacht called Grommets

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
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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 > 3months 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?
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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?