The edition · ENT & Head and Neck Surgery
Adults bled after tonsillectomy nearly four times as often as children, mostly around day 7
A ten-year tonsillectomy cohort closes the edition. Before it: a European consensus on office-based laryngology, pembrolizumab with metformin in metastatic head and neck cancer, awake tympanostomy in children, and a link between vertigo and atrial fibrillation.
The edition in brief
In 945 tonsillectomies at a Lebanese tertiary centre over ten years, 2.65% bled; 92% of bleeds were secondary, typically around day 7, and a fifth of those who bled needed transfusion. Adults bled more than children (7.4% vs 1.9%), and adult age was the only independent predictor (adjusted OR 2.93, 1.17–7.36). Operative time, surgeon and routine preoperative blood tests did not predict bleeding. The practical message is counselling and a clear return plan for the second week, especially in adults. A European Delphi consensus of 25 laryngologists approved 60 statements on office-based laryngology, naming polyps, Reinke's oedema, varices, leukoplakia, biopsies, granulomas and recurrent respiratory papillomatosis as primary indications. In a 21-patient phase II study of pembrolizumab with extended-release metformin in recurrent or metastatic head and neck squamous cell carcinoma, the response rate was 50% (29–71%), with mild gastrointestinal toxicity; this needs a randomised trial. A meta-analysis of 11 studies of in-office tympanostomy tube placement in awake children found 97% procedural success, low pain scores and 95% parental satisfaction, from non-randomised data with high heterogeneity. A Taiwanese case-control study of 120,774 adults found peripheral vestibulopathy, especially BPPV, associated with prior atrial fibrillation (aOR 1.21). The pearl: diagnose and treat posterior canal BPPV at the first visit.
A European consensus sets out which laryngeal procedures belong in the office
Use this consensus to set indications and protocols before expanding office-based laryngeal procedures in your unit.
Pembrolizumab with metformin gave a 50% response rate in a small metastatic head and neck cancer study
Pembrolizumab with metformin is promising but unproven in metastatic head and neck cancer; do not add metformin outside a trial.
Awake in-office tympanostomy tube placement succeeded in 97% of children
Awake in-office tympanostomy is a reasonable option for selected children in experienced hands; train and audit before offering it.
Peripheral vertigo, particularly BPPV, was associated with previous atrial fibrillation
Feel the pulse in every dizzy adult, and get an ECG if it is irregular.
Diagnose and treat posterior canal BPPV at the first visit
Do a Dix–Hallpike test in positional vertigo and treat a positive result with an Epley manoeuvre in the same visit instead of prescribing vestibular sedatives.
Post-tonsillectomy bleeding was mostly late and nearly four times more common in adults
Counsel adults having tonsillectomy about a higher bleeding risk, and tell every patient to come in the same day for any bleeding in the second week.
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