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 /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? Sinusitis – 31 million cases per year 4 days off work 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?