Aim: The aim of the study was to evaluate the differences in postoperative pain, nausea and time of discharge in children 3-12 years old after undergoing Tonsillectomy (TE) or Tonsillotomy (TT) at the post anaesthetic care unit (PACU), children’s ward and at home.  Background: TE involves risk of bleeding, severe postoperative pain and nausea. TT is a less invasive method with lower risk of bleeding and postoperative pain and nausea according to performed studies. Method: A prospective, comparative follow-up study design. Eighty-seven children from December 2008 until April 2009 in the ages 3-12 undergoing TE or TT participated. Visual analogue scale (VAS) was used for children’s pain and nausea assessments. Result/Findings: Significantly fewer children operated on by the TT assessed postoperative pain ≥ 3 according to the VAS than children operated on by the TE in both the PACU and the children’s ward. A significant difference of postoperative nausea was only present during the care at the PACU and children’s ward with fewer TT children that assessed nausea VAS ≥ 3. The time of postoperative care was shorter among the TT children in both the PACU and the children’s ward. Postoperative pain and pain related difficulties in eating after discharge was significantly more present among the TE children compared to the TT children. Conclusion: The results of our study indicated that TT is a more favourable alternative than TE in children.

Tonsillectomy, adenoidectomy and myringotomy are the most common surgical procedures undergone by children. Medical opinion regarding the appropriateness of these procedures remains contentious, and considerable resources have been expended in the formulation and distribution of relevant practice guidelines. The impact of this surgery on the child, community and private and public health resources is considerable, yet there has been little examination of surgery rates and trends, or of the characteristics of children who undergo surgery. This thesis addressed five major questions regarding this surgery in New South Wales, Australia. The first three related to population rates: the level of surgery among NSW children, comparability with international rates, trends over time and the effect of guidelines. Comprehensive hospital data between 1981 and 1999 were analysed. Major findings were a higher myringotomy rate in NSW than reported internationally, the short-term effect of guidelines, and a major shift towards children having surgery at a younger age. The remaining questions asked whether children who had surgery differed from other children in their use of health services prior to surgery, and if so, whether their utilization reverted to the norm following surgery. Matched records of a population cohort of 6239 NSW children, born during January 1990, were extracted from Health Insurance Commission data, and their claims for medical services followed retrospectively from birth to 8 years. Children who had privately funded surgery were found to use more medical services than other children, and, most unexpectedly, this did not change following surgery. The results suggest potential non-clinical factors influencing this excess utilization. This is the first population study to examine health service utilisation by these children and it has identified an important new risk factor for surgery.

Tonsillectomy is one of the most frequently performed surgical procedures in children and youths. The aim of this thesis was to study children and youths in relation to tonsil surgery with the goal of improving the care, and to describe partial tonsillectomy/tonsillotomy (TT) using radiofrequency technique (RF) (Ellman International) in comparison with the more commonly used total tonsillectomy (TE). The thesis covers studies of wo age-groups with obstructive problems, with or without recurrent tonsillitis. Randomization to surgery was done from the existing waiting list; 92 children, 5-15 years old to 49/TT and 43/TE, (I-III) and 76 youths, 16-25 years old to 32/TT and 44/TE (IV-V). The first purpose (I, IV) was to compare the two surgical techniques with respect to pain and postoperative morbidity. Pain measures were for the children the Face Pain Scale and for the youths and parents and staff a verbal-pain-rating-scale. From the first day, the TT-groups scored significantly less pain than the TE-groups. The doses of pain-killing drugs (paracetamol and diclofenac) taken were significantly less for the children and youths receiving the TT-surgery, they could stop taking pain-killers sooner, and were back to normal activity three (5-15yrs) or four (16-25yrs) days earlier compared with TE-groups. Paper II focused on the child’s behavior (Child Behavior Checklist/CBCL), experience of pain, anxiety (State-Trait-Anxiety Inventory for Children /STAIC), previous experiences of surgery/tonsillitis, and the management of pain. The children scored higher on CBCL than a normative group before surgery, but no connection was observed between CBCL rating and experience of pain reported post surgically. There was no relation between preoperative anxiety and reported pain, but the postoperative anxiety level correlated with pain. The Egroup scored higher anxiety after surgery. Previous experience of surgery or tonsillitis did not influence the postoperative pain. The nurses scored pain lower than the parents/children and under-medicated. The second purpose was to compare the long-term effects of TT and TE-surgery after one and three years (5-15yrs) and one year (16-25yrs) (III, IV). The effect on snoring was the same for both TT and TE-groups and the rate of recurrence of throat infections was low after both surgical techniques. After one year, all children (TT/TE) showed improvements on CBCL to the same degree and there was no longer a difference between total behavior and normative values. They also scored improvements in health-related quality of life (HRQL) with Glasgow-Children-Benefit-Inventory. For both TT and TE, the older group reported lower HRQL preoperatively on all dimensions of Study-Short-Form (SF-36) compared with a normal population. After one year, a large improvement was found in HRQL in both groups and there were no differences compared with a normal population. Conclusion: Preoperative obstructive problems, in combination with recurrent tonsillitis have a negative impact on HRQL. Both after TE and TT there are large improvements in HRQL, infections, obstructive, and behavior problems one to three years after surgery, indicating that both surgical methods are equally effective. With fewer postoperative complications, less pain, shorter recovery time, and lower cost, TT with RF should be considered as method of choice.

Orientador: Silke Anna Thereza Weber / Resumo: Objetivo: Identificar preditores de risco para complicações respiratórias após adenotonsilectomia (AT) em crianças menores que 12 anos com AOS que aguardam cirurgia, bem como a prevalência e gravidade da AOS. Métodos: Estudo prospectivo em hospital escola da Faculdade de Medicina de Botucatu. Foram incluídas crianças de ambos os gêneros, 2 a 12 anos de idade, com AOS e indicação de AT. Todos realizaram polissonografia de noite inteira no pré- e pós-operatório. Foram utilizados o teste t independente, teste t dependente, Mann-Whitney, Kruskal-Wallis e Qui-quadrado para identificação de fatores de risco para morbidade respiratória após AT e estratificação da AOS. Resultados: As 82 crianças que realizaram AT foram divididas em 2 grupos de acordo com presença ou ausência de complicações respiratórias. Dezesseis crianças (20%), com idade média de 8,2 + 2,4 anos, apresentaram complicações respiratórias, sendo 9 gênero masculino. Foram observadas complicações respiratórias menores (SpO2 80 - 90%) e maiores (SpO2 < 80%, broncoespasmos intra- e pós-operatório e depressão respiratória). Asma, rinopatia e déficit de atenção foram preditores independentes de complicações respiratórias após AT. Entre as intervenções médicas, 1 criança realizou NBZ contínuas com broncodilatador, 6 necessitaram de reposicionamento de via aérea e NBZ com O2 suplementar e 1 fez uso de Narcan para reverter depressão respiratória. A prevalência de AOS em crianças de 2 a 12 anos foi de 93% (76 crianças), sendo 3... (Resumo completo, clicar acesso eletrônico abaixo) / Doutor

Submitted by RENATO OLIVEIRA MARTINS null (renatoceres@yahoo.com.br) on 2017-10-31T05:14:35Z No. of bitstreams: 1 TESE FINAL Renato Oliveira Martins.pdf: 2247703 bytes, checksum: 106afd1687efe2ab88182bfadfa76408 (MD5) / Approved for entry into archive by LUIZA DE MENEZES ROMANETTO (luizamenezes@reitoria.unesp.br) on 2017-11-09T19:23:40Z (GMT) No. of bitstreams: 1 martins_ro_dr_bot.pdf: 2247703 bytes, checksum: 106afd1687efe2ab88182bfadfa76408 (MD5) / Made available in DSpace on 2017-11-09T19:23:40Z (GMT). No. of bitstreams: 1 martins_ro_dr_bot.pdf: 2247703 bytes, checksum: 106afd1687efe2ab88182bfadfa76408 (MD5) Previous issue date: 2017-05-25 / Objetivo: Identificar preditores de risco para complicações respiratórias após adenotonsilectomia (AT) em crianças menores que 12 anos com AOS que aguardam cirurgia, bem como a prevalência e gravidade da AOS. Métodos: Estudo prospectivo em hospital escola da Faculdade de Medicina de Botucatu. Foram incluídas crianças de ambos os gêneros, 2 a 12 anos de idade, com AOS e indicação de AT. Todos realizaram polissonografia de noite inteira no pré- e pós-operatório. Foram utilizados o teste t independente, teste t dependente, Mann-Whitney, Kruskal-Wallis e Qui-quadrado para identificação de fatores de risco para morbidade respiratória após AT e estratificação da AOS. Resultados: As 82 crianças que realizaram AT foram divididas em 2 grupos de acordo com presença ou ausência de complicações respiratórias. Dezesseis crianças (20%), com idade média de 8,2 + 2,4 anos, apresentaram complicações respiratórias, sendo 9 gênero masculino. Foram observadas complicações respiratórias menores (SpO2 80 - 90%) e maiores (SpO2 < 80%, broncoespasmos intra- e pós-operatório e depressão respiratória). Asma, rinopatia e déficit de atenção foram preditores independentes de complicações respiratórias após AT. Entre as intervenções médicas, 1 criança realizou NBZ contínuas com broncodilatador, 6 necessitaram de reposicionamento de via aérea e NBZ com O2 suplementar e 1 fez uso de Narcan para reverter depressão respiratória. A prevalência de AOS em crianças de 2 a 12 anos foi de 93% (76 crianças), sendo 35% com AOS leve (26 crianças), 41% AOS moderada (34 crianças) e 20% AOS grave (16 crianças). Apenas 7% (6 crianças) não apresentavam AOS. A avaliação clínica por questionário e o exame otorrinolaringológico não foram capaz de estratificar clinicamente as crianças de acordo com sua gravidade, com exceção da DRGE. Conclusão: Crianças com idade entre 2 a 12 anos diagnosticadas com AOS que apresentam déficit de atenção, asma e rinopatia desenvolveram maiores complicações respiratórias após AT. A prevalência de AOS em crianças que aguardam o procedimento de AT foi de 93%. / Objective: To identify risk factors for respiratory complications after adenotonsillectomy in children ≤ 12 years of age with OSA awaiting AT surgery, as well as identify the prevalence and severity of OSA. Methods: Prospective study in a tertiary level Hospital of Botucatu Medical School. Children of both genders, aged 2 to 12 years old, with complaints of respiratory disorders and indication for adenotonsillectomy were included. All children underwent full-night PSG in the pre- and pos-operative. Independent t-test, t-dependent test, Mann-Whitney, Kruskal-Wallis and Chi-square tests were used to identify risk factors for respiratory morbidity after AT and severity of OSA. Results: Eighty-two children who performed AT were divided into 2 groups according to the presence or absence of respiratory complications. Sixteen children (20%) mean age 8.2 ± 2.4 years presented respiratory complications, (9 male). Minor (SpO2 80-90%) and major respiratory complication (SpO2 < 80%, intra and postoperative bronchospasm and respiratory depression) were observed. Asthma, rhinopathy and attention-deficit were independent predictors of respiratory complications after TA. Among the medical interventions, 1 child performed continuous NBZ with a bronchodilator, 6 required airway repositioning and NBZ with supplemental O2, and 1 used narcan to reverse respiratory depression. The prevalence of OSA in children aged 2 to 12 years was 93% (76 children). Out of these, 35% (26 children) were mild, 41% (34 children) moderate and 20% (16 children) severe OSA. Only 7% (6 children) did not present OSA. Clinical evaluation by questionnaire and otorhinolaryngological examination were not able to clinically stratify children according to their severity, with the exception of GER. Conclusion: Children up to 12 years of age diagnosed with OSA who present attention-deficit, asthma and rhinopathy developed greater respiratory complications after AT. The prevalence rate of OSA in children waiting in the surgical row for the AT procedure was 93%.

Submitted by Liliane Ferreira (ljuvencia30@gmail.com) on 2018-07-09T15:05:50Z No. of bitstreams: 2 Dissertação - Cristiane Barbosa dos Santos - 2018.pdf: 4688835 bytes, checksum: 602178d58980b72a2d89f36e87f53f8d (MD5) license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) / Approved for entry into archive by Luciana Ferreira (lucgeral@gmail.com) on 2018-07-10T11:01:34Z (GMT) No. of bitstreams: 2 Dissertação - Cristiane Barbosa dos Santos - 2018.pdf: 4688835 bytes, checksum: 602178d58980b72a2d89f36e87f53f8d (MD5) license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) / Made available in DSpace on 2018-07-10T11:01:34Z (GMT). No. of bitstreams: 2 Dissertação - Cristiane Barbosa dos Santos - 2018.pdf: 4688835 bytes, checksum: 602178d58980b72a2d89f36e87f53f8d (MD5) license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) Previous issue date: 2018-06-23 / The pharynx is an organ that participates in the respiratory and digestive systems. Its peculiar tubular anatomy may be mechanically obstructed, especially due to adenotonsillar hyperplasia. This hyperplasia, when chronic, results in changes in craniofacial growth and development. The present study aimed to perform the threedimensional evaluation, using cone beam computed tomography (CBCT), of 4- to 9- year-old children, with and without indication for adenotonsillectomy (AT) and with maxillary atresia, comparing the measurements and the location of the minimum area of the pharynx, as well as the total pharyngeal volume and the volume of the subregions of the palatine tonsils and adenoids and, additionally, locating the position of the hyoid bone (H) and correlating it with the total pharynx volume and the volume of the subregions of the palatine tonsils and adenoids. For the selection of the nonprobabilistic consecutive sampling, 487 children were screened at the Otorhinolaryngology Outpatient Clinic of the Hospital das Clínicas, School of Medicine of the Universidade Federal de Goiás, from March to December 2017. Inclusion criteria were: age group between 4 and 9 years, presence of maxillary atresia, and balanced face (evaluated by the S line) using facial analysis. Exclusion criteria were: obesity, extensive caries, previous AT, presence of craniofacial syndromes or congenital anomalies, history of traumas or surgeries in the region of head, neck, or face, previous orthopedic/orthodontic treatment, early tooth loss, and dental Class II or III. The diagnosis of maxillary atresia and the other oral conditions were performed by two orthodontists. After selection, the patients were evaluated by an otorhinolaryngologist, who conducted anamnesis, physical examination and flexible nasal endoscopy to diagnose the obstruction due to adenotonsillar hyperplasia. The sample size calculation, considering the minimum area of the pharynx as the primary variable, defined 30 patients in each of the two study groups, the surgical and the non-surgical groups, who underwent the Prick test. Posteriorly, they underwent CBCT exams to evaluate the airflow and position of H. CBCTs were analyzed using the Invivo Dental software to obtain the three-dimensional and two-dimensional measurements of the pharyngeal airway space and the position of H. The age did not show statistical difference between groups (p = 0.111). The surgical group had a higher frequency of male participants. The measurements of total pharyngeal volume (p = 0.038), volume of the adenoid region (p = 0.001), and minimum area of the pharynx (p = 0.011) showed significant statistical differences between the grupos. In the surgical group, the highest frequency of the minimum area of the pharynx was in the adenoid region (60.0%), while in the non-surgical group the highest frequency was in the palatine tonsil region (73.3%). The correlation coefficient between H-Tweed mandibular plane (MP) and the volume of the palatine tonsil region was moderate in the surgical group (r = 0.408; p = 0.025). In conclusion, in this study: the pharyngeal volumes and the volume in the adenoid region were signifcantly reduced in the patients of the surgical group compared to the non-surgical group; the volume corresponding to the palatine tonsil region was similar in both groups; the narrowest pharynx area was located at a higher frequency in the region near the adenoid hyperplasia in the surgical group, whereas in the non-surgical group it was located at a higher frequency in the palatine tonsil region; no significant statistical difference was found for the position of H between the groups, and the correlation between its position and the sagital and vertical cephalometric patterns was weak. / A faringe é um órgão que participa dos sistemas respiratório e digestório. Sua peculiar anatomia tubular pode sofrer obstrução mecânica, em especial por hiperplasia adenotonsilar. Quando de caráter crônico, essa hiperplasia resulta em alterações no crescimento e no desenvolvimento craniofacial. O presente estudo teve como objetivo realizar a avaliação tridimensional, por meio de tomografia computadorizada de feixe cônico (TCFC), de crianças de 4 a 9 anos, com e sem indicação de adenotonsilectomia (AT) e com atresia de maxila, comparando as medidas e a localização da área mínima da faringe, assim como o volume total da faringe e das sub-regiões das tonsilas palatinas e adenoides e, adicionalmente, localizando a posição do osso hioide (H) e correlacionando-a com o volume total da faringe e das sub-regiões das tonsilas palatinas e adenoides. Para a seleção da amostra não probabilística consecutiva, foram triadas 487 crianças atendidas no Ambulatório de Otorrinolaringologia do Hospital das Clínicas da Faculdade de Medicina da Universidade Federal de Goiás entre março e dezembro de 2017. Os critérios de inclusão compreenderam faixa etária entre 4 e 9 anos, presença de atresia maxilar e face balanceada (avaliada pela linha S) por análise facial. Os critérios de exclusão foram: obesidade, cáries extensas, AT prévia, presença de síndromes craniofaciais ou anomalias congênitas, histórico de traumas ou cirurgias na região da cabeça, pescoço ou face, tratamento ortopédico/ortodôntico prévio, perda precoce de dentes e Classe II ou III dentária. O diagnóstico de atresia maxilar e das demais condições bucais foi feito por duas ortodontistas. Após a seleção, os pacientes foram avaliados por otorrinolaringologista, que procedeu a anamnese, exame físico e endoscopia nasal flexível para diagnóstico de obstrução por hiperplasia adenotonsilar. Pelo cálculo amostral, considerando como variável de desfecho primário a área mínima da faringe, definiu-se o número de 30 sujeitos em cada um dos dois grupos de estudo, o cirúrgico e o não cirúrgico, os quais foram submetidos ao Prick test. Posteriormente, passaram por exame de TCFC para avaliação da via aerífera e da posição do H. As TCFCs foram analisadas usando o software Invivo Dental para obtenção das medidas tridimensionais e bidimensionais do espaço aéreo faríngeo (EAF) e do posicionamento do H. A idade não apresentou diferença estatística entre os grupos (p = 0,111). O grupo cirúrgico apresentou maior frequência de indivíduos do sexo masculino. As medidas de volume total (p = 0,038), volume da região das adenoides (p = 0,001) e área mínima da faringe (p = 0,011) apresentaram diferenças estatisticamente significativas entre os grupos. No grupo cirúrgico, houve maior frequência de área mínima na região das adenoides (60,0%) enquanto no grupo não cirúrgico houve maior frequência na região das tonsilas palatinas (73,3%). O coeficiente de correlação entre H-plano mandibular de Tweed (MP) e o volume da região das tonsilas palatinas foi moderado no grupo cirúrgico (r = 0,408; p = 0,025). Conclui-se que, neste estudo: os volumes aéreos faríngeos e da região das adenoides foram significativamente reduzidos nos pacientes do grupo cirúrgico em comparação com os do grupo não cirúrgico; o volume correspondente à região das tonsilas palatinas se apresentou semelhante para os dois grupos; a área de maior estreitamento faríngeo se localizou com maior frequência na região próxima à hiperplasia das adenoides no grupo cirúrgico, enquanto no não cirúrgico se localizou com mais frequência na região próxima às tonsilas palatinas; não houve diferença estatisticamente significativa na posição do H entre os grupos, e a correlação entre a sua posição e os padrões cefalométricos sagital e vertical foi fraca.

Submitted by JÚLIO HEBER SILVA (julioheber@yahoo.com.br) on 2017-08-25T17:44:39Z No. of bitstreams: 2 Dissertação - Marcus Cavalcante de Oliveira Araújo - 2017.pdf: 5070283 bytes, checksum: fe80dd4118b1b88c12a8af5c53335ff4 (MD5) license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) / Approved for entry into archive by Luciana Ferreira (lucgeral@gmail.com) on 2017-09-15T12:51:13Z (GMT) No. of bitstreams: 2 Dissertação - Marcus Cavalcante de Oliveira Araújo - 2017.pdf: 5070283 bytes, checksum: fe80dd4118b1b88c12a8af5c53335ff4 (MD5) license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) / Made available in DSpace on 2017-09-15T12:51:13Z (GMT). No. of bitstreams: 2 Dissertação - Marcus Cavalcante de Oliveira Araújo - 2017.pdf: 5070283 bytes, checksum: fe80dd4118b1b88c12a8af5c53335ff4 (MD5) license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) Previous issue date: 2017-08-16 / This dissertation was carried out in the form of two articles. The first one had the objective conduct a systematic reviewof about intravenous and intraoperative administration of morphine for the analgesia of children submitted to palatine tonsillectomy. These surgeries may have significant perioperative morbidity, with the possibility of nausea, vomiting and respiratory events such as hypoxia, especially in pediatric patients, in addition to postoperative pain, which is considered intense and can be difficult to evaluate and treat. Morphine is an opioid drug that can be used as an analgesic in these patients, but it also has the potential to lead to some of these adverse events, which makes its use infrequent in these procedures. Thus, a bibliographic review was performed in the electronic databases Pubmed, Cochrane, Lilacs, Scielo and ClinicalKey, searching for studies written in English, Portuguese or Spanish, published until June 2017. The selected uniterms were "morphine", "opioid", "analgesia", "tonsillectomy" and "tonsillectomies" and the keyword "tonsillectomy", separated by the AND and OR interlocutors. Randomized, prospective clinical trials with patients up to the age of 18 years who underwent tonsillectomy and who used intravenous morphine administered intravenously with postoperative pain evaluation were included. The research was complemented by a review of the bibliographic references of each relevant article found. In the results found, the total number of children evaluated was 1076, with physical status ASA I to III, and the postoperative pain intensity evaluation was variable, being performed through numerical pain scales (NRS), behavioral (FLACC, Hannallah, CHEOPS and modified CHEOPS), by nursing assessment in the recovery room or by simple patient complaint. Only one of the studies was placebocontrolled and eight were double-blind. Pre-anesthetic medication was administered in 6 studies and the main one was paracetamol (acetaminophen). Morphine was used as the main analgesic, with pain reduction, as well as analgesia recovery, and there were adverse effects in the postoperative period, with variable incidence of nausea, vomiting, Abstract xxi pruritus, sedation and oxygen desaturation, but without reports of gravity. The conclusion was that intravenous morphine can be successfully used to treat pain in children after tonsillectomy, despite the need for rigorous postoperative monitoring, mainly breathing, and addition of prevention of nausea and vomiting. The second article was a prospective randomized clinical trial aimed at evaluating the use of intravenous morphine for postoperative analgesia in children submitted to tonsillectomy. It includes fifty-seven children 5 to 12 years old, ASA I, submitted to elective tonsillectomy, with or without adenoidectomy, under standardized general anesthesia and distributed in two groups to receive intraoperative analgesia. One group received 0.1mg / kg morphine intravenously shortly after intubation and another group did not. Postoperative pain was assessed independently by parents / guardians and children through the Face Pain Scale at 30, 60, 120, 180 and 240 minutes. In addition, the time of awakening of the anesthesia, the need for rescue analgesics and the possible adverse effects were observed. The results showed that the group that used morphine had a lower level of pain both in the evaluation by the children, at the moment of 30 min after awakening, and by the parents / guardians, in the moments of 30, 60 and 180 minutes in relation to the other group, without increase the awakening time of anesthesia and without significant adverse effects. There was a greater need for rescue analgesics in the group that did not use morphine. The conclusion was that administration of intravenous morphine during surgery reduced the intensity of pain in the immediate postoperative period, both in the reports of the children and the parents / guardians, without increasing the time of awakening from general anesthesia or adverse effects. / Esta dissertação foi realizada sob a forma de dois artigos. O primeiro teve como objetivo realizar uma revisão sistemática sobre administração via endovenosa e intra-operatória de morfina para a analgesia de crianças submetidas à tonsilectomia palatina. Estas cirurgias podem ter significativa morbidade peri-operatória, com possibilidade de náuseas, vômitos e eventos respiratórios como hipóxia, especialmente em pacientes pediátricos, além da dor pós-operatória, considerada intensa e que pode ser de difícil avaliação e tratamento. A morfina é uma droga opioide que pode ser utilizada como analgésico nestes pacientes, mas também tem o potencial de levar a alguns destes eventos adversos, o que torna seu uso pouco frequente nestes procedimentos. Assim, foi realizada revisão bibliográfica nas bases de dados eletrônicas Pubmed, Cochrane, Lilacs, Scielo e ClinicalKey, com busca de estudos escritos em inglês, português ou espanhol, publicados até junho de 2017. Os unitermos selecionados foram “morphine”, “opioid”, “analgesia”, “tonsillectomy” e “tonsillectomies” e a palavra-chave “amigdalectomia”, separados pelos interlocutores AND e OR. Foram incluídos ensaios clínicos randomizados, prospectivos, com pacientes até 18 anos de idade, submetidos a tonsilectomia com utilização no intra-operatório de morfina administrada via endovenosa e com avaliação da dor pós-operatória. A pesquisa foi complementada pela revisão das referências bibliográficas de cada artigo relevante encontrado. Nos resultados encontrados, o total de crianças selecionadas foi de 1076, com estado físico ASA I a III, e a avaliação da intensidade da dor pós-operatório foi variável, sendo realizada através de escalas numérica de dor (NRS), comportamentais (FLACC, Hannallah, CHEOPS e CHEOPS modificada), por avaliação da enfermagem na sala de recuperação ou ainda pela simples queixa dolorosa do paciente. Apenas um dos estudos foi controlado com placebo e oito foram duplocegos. Medicação pré-anestésica foi administrada em 6 estudos, sendo a principal o paracetamol (acetaminofeno). A morfina foi utilizada como analgésico principal, com redução da dor, e também para resgate da analgesia, e houve presença de efeitos adversos no pós-operatório, com Resumo xix incidências variáveis de náuseas, vômitos, prurido, sedação e dessaturação do oxigênio, mas sem relatos de gravidade. A conclusão foi que a morfina via endovenosa administrada no intraoperatório pode ser utilizada com sucesso para tratamento de dor em crianças após tonsilectomia, apesar da necessidade de monitorização pós-operatória rigorosa, principalmente da respiração, além também da prevenção de náuseas e vômitos. Já o segundo artigo trata-se de um ensaio clínico randomizado prospectivo, com o objetivo de avaliar o uso de morfina endovenosa para analgesia pós-operatória de crianças submetidas à tonsilectomia. Ele inclui cinquenta e sete crianças de 5 a 12 anos, ASA I, submetidas à cirurgia eletiva de tonsilectomia, com ou sem adenoidectomia, sob anestesia geral padronizada e distribuídas em dois grupos para receberem analgesia intraoperatória. Um grupo recebeu morfina 0,1mg/kg via endovenosa logo após a intubação e outro grupo não. A dor pós-operatória foi avaliada de forma independente por pais/responsáveis e pelas crianças através da Escala de Dor pela Face nos momentos de 30, 60, 120, 180 e 240 minutos. Além disto, observou-se o tempo de despertar da anestesia, a necessidade de analgésicos de resgate e os possíveis efeitos adversos. Os resultados demostraram que o grupo que utilizou morfina apresentou menor nível de dor tanto na avaliação pelas crianças, no momento de 30 min após despertar, quanto pelos pais/responsáveis, nos momentos de 30, 60 e 180 minutos em relação ao outro grupo, sem aumentar o tempo de despertar da anestesia e sem efeitos adversos significativos. Houve maior necessidade de analgésico de resgate no grupo que não utilizou morfina. A conclusão foi que a administração de morfina via endovenosa durante a cirurgia reduziu a intensidade da dor no pós-operatório imediato, tanto no relato das crianças quanto no dos pais/responsáveis, sem aumentar o tempo de despertar da anestesia geral ou os efeitos adversos.

Crianças com aumento do volume de tonsilas palatinas e faríngeas, freqüentemente apresentam anormalidades respiratórias tais como roncar, respiração oral e apnéia do sono, assim como atraso no crescimento, alterações físicas e emocionais. Sabe-se que a obstrução de vias aéreas superiores e conseqüentemente a respiração oral podem resultar em problemas pulmonares. A obstrução de vias aéreas superiores também pode conduzir a alterações na mecânica respiratória e evoluir para alterações no equilíbrio das forças musculares, causando disfunções faciais, torácicas e dos eixos posturais. As alterações na função pulmonar (Pressão Inspiratória Máxima, Pressão Expiratória Máxima e Volume Pulmonar) foram avaliadas em 32 crianças (6-13 anos, M: F) com aumento do volume de tonsilas que seriam submetidas a cirurgia de Adenoamigdalectomia na Divisão de Otorrinolaringologia da Universidade de São Paulo. Todas as crianças foram avaliadas no pré e pósoperatório (3 e 6 meses) de adenotonsilectomia. A pressão Inspiratória e expiratória máxima foram medidas com o uso de um manovacuômetro. O volume pulmonar foi medido através do uso de um Inspirômetro de Incentivo infantil. Os perímetros torácicos e abdominais foram obtidos através de uma fita métrica comum. No pré-operatório os seguintes valores foram obtidos: pressão inspiratória máxima média de 24,72 cm/H2O, pressão expiratória máxima média de 37,50 cm/H2O, volume pulmonar médio de 682,81ml, perímetro torácico com média de 69,25cm e o perímetro abdominal com média de 67,50 cm. Todos os valores analisados apresentaram-se maiores no pós-operatório, sendo os resultados mais significantes a pressão inspiratória máxima com o valor de 28,62 cm/H2O no pós-operatório de 3 meses e 32,52 cm/H2O em seis meses. O volume pulmonar também apresentou um ganho de 265,47 ml no pós-operatório de seis meses em relação ao valor obtido no pré-operatório. Concluímos que a pressão inspiratória máxima apresentou um aumento significativo em seus valores no pós-operatório de 3 e 6 meses o que denota um ganho na força da musculatura respiratória inspiratória o que propiciou o aumento no volume pulmonar. Verificamos um aumento gradativo em todos os parâmetros estudados nos resultados obtidos no pós-operatório de 3 meses para os 6 meses. Os resultados comparativos entre os tamanhos das tonsilas (grau 3 e 4) não demonstraram diferença significativa. / Children with enlarged tonsils and pharynx, often exhibit respiratory abnormalities such as snoring, mouth breathing and sleep apnea, as well as delay in growth, physical and emotional changes. It is known that the upper airway obstruction and consequent mouth breathing may lead to lung problems. The obstruction of upper airway can also lead to changes in respiratory mechanics and evolve to changes in the balance of forces muscle, causing facial disorders, thoracic and axes posture. The changes in lung function (maximal inspiratory pressure, maximal expiratory pressure and lung volume) were evaluated in 32 children (6-13 years old, M: F) with enlarged tonsils who would be subjected to surgery for adenotonsillectomy at Division of Otorhinolaryngology, University of São Paulo. All children were evaluated in the preoperative and postoperative (3 and 6 months) of adenotonsillectomy. The maximal inspiratory and expiratory pressures were measured using a manometer. The lung volume was measured by using a volumetric incentive spirometer. The thoracic and abdominal perimeters were obtained through a common tape. Preoperatively the following values were obtained: mean maximal inspiratory pressure of 24.72 cm/H2O, mean maximal expiratory pressure of 37.50 cm/H2O, mean pulmonar volume of 682.81 ml. Mean girth of 69.25 cm and mean Abdominal Perimeter of 67.50 cm. All figures analyzed were higher in the postoperative period, and the more significant result was maximal inspiratory pressure with a value of 28.62 cm/H2O the postoperative 3-month and 32.52 cm/H2O in six months. The lung volume also showed a gain of 265.47 ml in the postoperative period of six months from the value obtained preoperatively. We conclude that the maximal inspiratory pressure showed a significant increase in their values in the postoperative period of 3 and 6 months which indicates a gain in respiratory muscle strength which allowed the increase in lung volume. Noticed a gradual increase in all parameters studied the results in the postoperative period of 3 months to 6 months. The comparative results between the size of tonsils (grade 3 and 4) showed no significant difference.

Abstract Recurrent pharyngitis causes doctor visits, antibiotics use and absences from school or work and thus worsens patients’ quality of life (QOL). Even though tonsillectomy is often performed for recurrent pharyngitis, there is limited evidence of the tonsillectomy benefit concerning both researcher- and patient-recorded outcomes. The intent of this work was to find out if tonsillectomy reduces numbers of pharyngitis episodes or symptom days, if tonsillectomy improves patients’ QOL and if there are any clinical factors predicting QOL benefit after tonsillectomy. Seventy adult patients with recurrent streptococcal pharyngitis (2001–2005) and 86 patients with recurrent pharyngitis of any origin (2007–2010) were enrolled for two randomised controlled trials. Patients with recurrent pharyngitis of any origin were followed up either before (control group, n=40) or after (tonsillectomy group, n=46) tonsillectomy. At five months of follow-up, 17 (43%) patients in the control group and 2 (4%) patients in the tonsillectomy group consulted a physician for pharyngitis. Thirty-two (80%) patients in the control group and 18 (39%) patients in the tonsillectomy group experienced any kind of pharyngitis episode. Only one episode was considered severe. The numbers of days with throat pain and fever were significantly lower in the tonsillectomy group. QOL of 142 responders measured by Glasgow Benefit Inventory (GBI) six months after tonsillectomy showed improvement: median GBI total score was +27. However, GBI total scores varied considerably between the patients (range −19 to +69). Only one patient reported declined QOL. The number of prior pharyngitis episodes, frequent throat pain, untreated dental caries and chronically infected tonsils were the best clinical factors predicting QOL improvement. The precision of these predictions was still quite low. The results of this work suggest that tonsillectomy reduces numbers of acute pharyngitis episodes and symptoms. Although most of the episodes are not severe, tonsillectomy still generally improves patients’ QOL. The distribution of QOL benefit is broad, however. Throat-related morbidity before tonsillectomy is the only clinical factor that was associated with patient satisfaction. / Tiivistelmä Toistuvat nielutulehdukset aiheuttavat paljon lääkärikäyntejä, antibioottihoitoja sekä poissaoloja töistä tai opinnoista ja huonontavat potilaiden elämänlaatua. Toistuvien nielutulehdusten vuoksi päädytään usein nielurisaleikkaukseen, vaikka tutkimusnäyttö leikkauksen hyödystä on vähäistä. Tämän väitöskirjatyön tavoitteena oli tutkia, vähentääkö nielurisaleikkaus nielutulehdusten määrää tai oireita sekä selvittää leikkauksenjälkeistä elämänlaatua ja siihen liittyviä ennustekijöitä. Tutkimusaineisto koostui kahta eri satunnaistettua kliinistä koetta varten rekrytoiduista potilaista: 70 potilasta, joiden toistuvien nielutulehdusten aiheuttaja oli A-ryhmän streptokokki (2001–2005) ja 86 potilasta, joiden toistuvien nielutulehdusten etiologialle ei asetettu vaatimuksia (2007–2010). Potilaat, joilla nielutulehdusten etiologia oli avoin, satunnaistettiin kahteen ryhmään: kontrolliryhmää (n=40) seurattiin ennen nielurisaleikkausta ja leikkausryhmää (n=46) sen jälkeen, molempia 5 kuukauden ajan. Seurannassa 17 (43&#160;%) kontrolliryhmän potilasta ja 2 (4&#160;%) leikkausryhmän potilasta hakeutui lääkäriin nielutulehduksen vuoksi. Kontrolliryhmän potilaista 32 (80&#160;%) ja leikkausryhmän potilaista 18 (39&#160;%) sairasti nielutulehduksen vähintään kerran. Vain yksi episodi luokiteltiin vaikeaksi. Nielukipu- ja kuumepäiviä oli merkittävästi vähemmän leikkausryhmässä. Nielurisaleikkauksen vaikutusta elämänlaatuun tutkittiin Glasgow Benefit Inventory (GBI) -kyselyllä kuusi kuukautta leikkauksen jälkeen. Yhteensä 142 potilasta vastasi kyselyyn. GBI:n mediaanitulos +27 osoitti leikkauksen parantavan elämänlaatua. GBI-tulokset kuitenkin vaihtelivat huomattavasti potilaiden välillä (−19 – +67), vaikkakin vain yksi potilas raportoi elämänlaatunsa heikentyneen. Aiempien nielutulehdusten määrä, usein toistuva nielukipu, hoitamaton karies ja kroonisesti tulehtuneet nielurisat ennustivat parhaiten potilastyytyväisyyttä leikkauksen jälkeen, mutta näidenkin tekijöiden ennustearvo oli melko heikko. Tulosten perusteella nielurisaleikkaus vähentää akuutteja nielutulehduksia sekä oirepäiviä. Vaikka sairastamisjaksot ovat harvoin vaikeaoireisia, leikkaus parantaa useimmiten elämänlaatua, mutta hyödyn määrä vaihtelee merkittävästi potilaiden välillä. Ainoastaan leikkausta edeltävä nielun oireilun määrä ennustaa leikkaushyötyä jossain määrin.

Hitzschke, Maria: Der Einsatz von FloSeal® bei der Blutstillung im Rahmen der Tonsillektomie Universität Leipzig, Dissertation 76 S., 79 Lit., 14 Abb., 17 Tab. Referat: Die Tonsillektomie ist eine der häufigsten operativen Eingriffe in der HNO-Heilkunde in Deutschland. Trotz neuer Techniken der Präparation und Blutstillung kann es dabei zu teilweise lebensbedrohlichen Komplikationen kommen. Ziel der vorliegenden randomisierten, monozentrischen Einfachblindstudie, welche auf prospektiv erfassten Patientendaten beruht, war es zu prüfen, ob der Einsatz einer Gelatine-Thrombin-Matrix (FloSeal®) bei der Blutstillung im Rahmen der Tonsillektomie einen Einfluss auf die Operationsdauer, den postoperativen Schmerzverlauf, die Wundheilung oder auf die Nachblutungsrate im Vergleich zur konventionellen elektrischen Blutstillungstechnik aufweist. Im Ergebnis konnten die Operationszeiten, vor allem für erfahrene Operateure, durch FloSeal® nicht verkürzt werden. Die bessere Planbarkeit der Operationsdauer durch die vordefinierte Blutstillungszeit bei der FloSeal®-Anwendung ist aber vor allem für unerfahrene Operateure von Bedeutung. Die postoperativen Schmerzen ab dem 4. postoperativen Tag waren in der FloSeal®-Gruppe geringer, auch die Schmerzdauer konnte um knapp 3 Tage verkürzt werden. Dies ist am ehesten auf eine verbesserte Wundheilung bei den mittels FloSeal® behandelten Patienten zurückzuführen, die sich in den stets signifikant geringeren Wundbelägen widerspiegelte. Der verminderte Einsatz der bipolaren Koagulation durch die Anwendung von FloSeal® konnte jedoch nicht zu einer signifikanten Reduktion der Nachblutungsrate führen. Trotz ermittelter Vorteile des Einsatzes von FloSeal® im Rahmen der Tonsillektomie sollte FloSeal® aber aus unserer Sicht den Patienten mit diffusen flächigen Blutungen im Rahmen einer Tonsillektomie vorbehalten bleiben, bei denen eine großflächige bipolare Koagulation die postoperative Morbidität deutlich steigern würde.:Inhaltsverzeichnis 1. Einleitung 1 1.1. Anatomie der Tonsilla palatina 2 1.2. Indikationen zur Tonsillektomie 6 1.3. Tonsillektomie - Verfahren 8 1.4. Komplikationen der Tonsillektomie 9 1.5. Wirkmechanismus von FloSeal® und klinische Anwendung 13 2. Zielstellung 20 3. Material und Methoden 21 3.1. Studienablauf 21 3.1.1. Präoperative Parameter 26 3.1.2. Intraoperative Parameter 26 3.1.3. Postoperative Parameter 27 3.2. Statistische Auswertung der Daten 28 4. Ergebnisse 30 4.1. Präoperative Parameter 32 4.1.1. Epidemiologische Daten 32 4.1.2. Präoperative Labor- und Blutdruckwerte 33 4.2. Intraoperative Parameter 33 4.2.1. Erfahrung des Operateurs 33 4.2.2. Operationszeiten 34 4.2.3. Koagulation nach FloSeal® bzw. Tupfereinlage 37 4.2.4. Weitere Maßnahmen zur Blutstillung 38 4.2.5. Beurteilung von FloSeal® 38 4.3. Postoperative Parameter 39 4.3.1. Verlauf postoperativer Schmerzen 39 4.3.2. Postoperativer Schmerzmittelverbrauch 43 4.3.3. Verlauf der Wundheilung 44 4.3.4. Nachblutungen und unerwünschte Ereignisse 46 4.3.5. Postoperative Laborwerte 47 5. Diskussion 48 6. Zusammenfassung der Arbeit 60 7. Literaturverzeichnis 63 8. Erklärung über die eigenständige Abfassung der Arbeit 72 9. Lebenslauf 73 10. Publikationen 75 11. Danksagung 76