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Dr Yolene Lacroix, MD FRCSC OTL-HNS MUHC-MCH November 29th 2017
Clinical Practice Guideline: Tonsillectomy and Tympanostomy Tubes in Children Dr Yolene Lacroix, MD FRCSC OTL-HNS MUHC-MCH November 29th 2017
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Conflicts of interest None
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Objectives Review and discuss the Clinical Practice Guidelines published by the AAO-HNS on Tonsillectomy in 2011 and Tympanostomy tubes in 2013 in children population Review the algorithm regarding the indications of tonsillectomy published by the CMQ « Clinical Practice Guideline: Tonsillectomy in Children - American Academy of OTL-HNS » 17 auteurs provenant de différentes spécialités et centres américains (ORL, pédiatres, anesthésistes, pneumologues, infectiologues, infirmières). Repose dur 229 articles de références
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Introduction Rapport public en 2009 - Dr Jacques Ramsay
Tympanostomy tube most common ambulatory surgical procedure USA procedures < 15 yo 20% of all ambulatory surgery Tonsillectomy second most common ambulatory surgical procedure 2006 USA, procedures < 15 yo 16% of all ambulatory surgery Quebec, around 12 000 T&A /year Between 2002 and 2017, death of at least 7 children Rapport public en Dr Jacques Ramsay « l’importance de bien identifier les différents éléments cliniques supportant l’indication chirurgicale de l’amygdalectomie chez l’enfant » Recommandation au Collège des médecins, de concert avec l’Association ORL et des pédiatres du Québec « développer des directives avec des critères clairs pour déterminer quand une amygdalectomie est requise »
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Tonsillectomy
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Indications Sleep-disordered breathing Recurrent throat infections
Chronic tonsillitis Cryptoliths (cryptic tonsillitis) and halitosis Hyponasal voice and orthodontic concerns Dysphagia Complicated tonsillitis Suspected neoplasm Specific syndroms Significant school absenteeism Costs: Direct: outpatient visits + medications prescribed Indirect: missed school and loss of time from work for caregivers compared with controls, SDB pts: significantly higher rate of antibiotic use, 40% more hospital visits, and an overall elevation of 215% in health care usage mostly from increased respiratory tract infections.
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STATEMENT 1 WATCHFUL WAITING FOR RECURRENT THROAT INFECTION: Clinicians should recommend watchful waiting for recurrent throat infection if there have been: < 7 episodes in the past year or < 5 episodes per year in the past 2 years or < 3 episodes per year in the past 3 years. Recommendation Caregivers should be educated on the likelihood of spontaneous improvement and the magnitude of benefit conferred by tonsillectomy for 2 years after surgery. Watchful waiting does not imply inaction; rather, patients should be closely monitored and episodes of pharyngotonsillitis accurately documented. Educate the caregiver on acquiring and maintaining an at-home record of the child’s throat infection and health history.
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Definition of throat infection
Sore throat + 1 or more of the following: Temperature >38.3° C, Cervical adenopathy (painful or >2cm), Tonsillar exudate, or Positive test for GABHS. Include: strep throat, tonsillitis, pharyngitis, adenotonsillitis or tonsillopharyngitis
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STATEMENT 2 RECURRENT THROAT INFECTION WITH DOCUMENTATION: Clinicians may recommend tonsillectomy for recurrent throat infection with a frequency of: ≥ 7 episodes in the past year or ≥ 5 episodes per year for 2 years or ≥ 3 episodes per year for 3 years with documentation in the medical record for each episode Option Although tonsillectomy for recurrent throat infections in severely affected children has been shown in a randomized controlled trial to reduce the frequency and severity of infections in the 2 years following surgery, the same cannot be shown for less severe cases or for a period greater than 2 years after surgery.
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Documention of each episode
Symptoms Signs Swab results Days of school absence Impact on Quality of life (QoL) Minimum observation of 12 months Discussion on potential complications If not fully documented, subsequent observance by the clinician of 2 episodes of throat infection with patterns of frequency and clinical features consistent with the initial history
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« individual features »
STATEMENT 3 TONSILLECTOMY FOR RECURRENT INFECTION WITH MODIFYING FACTORS: « individual features » multiple antibiotic allergy/intolerance, sore throat episodes are very severe or tolerated poorly by the child, if illness-related absences interfere with school performance Recommendation (Periodic fever, apthous stomatitis, pharyngitis, adenitits) Généralement enfant de moins de 5 ans Fièvre ( degré) avec début soudain d'une durée max de 4 à 5 jours récidivant chaque 3 à 6 sem (périodique) 2. Ulcères buccaux (Stomatite aphteuse) 3. Pharyngo-amygdalite et culture négative pour step A et négative pour virus 4. Ganglions cervicaux Tx : Prednisone, Cimetidine PANDAS (pediatric autoimmune neuropsychiatric disorders associated with streptococccal infections) Lors d'infection strep A augmenterait tic ds Gilles LaTourette ou geste compulsif chez patient avec tb déjà compulsif - Études controversées
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« specific clinical syndromes »
STATEMENT 3 TONSILLECTOMY FOR RECURRENT INFECTION WITH MODIFYING FACTORS: « specific clinical syndromes » PFAPA (periodic fever, aphthous stomatitis, pharyngitis, and adenitis) Recommendation history of peritonsillar abscess Controversy PANDAS Unknown impact (Periodic fever, apthous stomatitis, pharyngitis, adenitits) Généralement enfant de moins de 5 ans Fièvre ( degré) avec début soudain d'une durée max de 4 à 5 jours récidivant chaque 3 à 6 sem (périodique) 2. Ulcères buccaux (Stomatite aphteuse) 3. Pharyngo-amygdalite et culture négative pour step A et négative pour virus 4. Ganglions cervicaux Tx : Prednisone, Cimetidine PANDAS (pediatric autoimmune neuropsychiatric disorders associated with streptococccal infections) Lors d'infection strep A augmenterait tic ds Gilles LaTourette ou geste compulsif chez patient avec tb déjà compulsif - Études controversées
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« poorly validated clinical indications »
STATEMENT 3 TONSILLECTOMY FOR RECURRENT INFECTION WITH MODIFYING FACTORS: « poorly validated clinical indications » Chronic or cryptic tonsillits Febrile seizures Muffled (« hot potato ») voice Halitosis, malocclusion of teeth Chronic pharygeal carriage of GABHS Tonsillar hypertrohpy Option (Periodic fever, apthous stomatitis, pharyngitis, adenitits) Généralement enfant de moins de 5 ans Fièvre ( degré) avec début soudain d'une durée max de 4 à 5 jours récidivant chaque 3 à 6 sem (périodique) 2. Ulcères buccaux (Stomatite aphteuse) 3. Pharyngo-amygdalite et culture négative pour step A et négative pour virus 4. Ganglions cervicaux Tx : Prednisone, Cimetidine PANDAS (pediatric autoimmune neuropsychiatric disorders associated with streptococccal infections) Lors d'infection strep A augmenterait tic ds Gilles LaTourette ou geste compulsif chez patient avec tb déjà compulsif - Études controversées
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Other modifying factors
Recurrent severe infections requiring hospitalization, Lemierre syndrome (thrombophlebitis of the internal jugular vein) Family history of rheumatic heart disease Numerous repeat infections in a single household (“pingpong spread”)
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STATEMENT 4 TONSILLECTOMY FOR SLEEP DISORDERED BREATHING:
Clinicians should ask caregivers of children with sleep-disordered breathing and tonsil hypertrophy about comorbid conditions that might improve after tonsillectomy, including: growth retardation, poor school performance, enuresis, and behavioral problems. Recommendation compared with controls, SDB pts: significantly higher rate of antibiotic use, 40% more hospital visits, and an overall elevation of 215% in health care usage mostly from increased respiratory tract infections. Children with tonsillar disease, also showed Significantly lower scores on several QoL subscales including general health, physical functioning, behavior, bodily pain, and caregiver impact when compared with healthy children.
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Gradation of tonsils Grade Definition Description
0 Not visible Tonsils do not reach tonsillar pillars 1+ Less than 25% Tonsils fill less than 25% of the transverse oropharyngeal space measured between the anterior tonsillar pillars 2+ 25% to 49% Tonsils fill less than 50% %-74% Tonsils fill less than 75% 4+ 75% or more Tonsils fill 75% or more
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Tonsillar asymmetry Alone, is not an indication for tonsillectomy
History PMHx cancer Immunosuppression Systemic symptoms Progressive increase of volume Chronic pain +- dysphagia Physical exam Suspect appearence, cervical lymphadenopathy Labs
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STATEMENT 5 TONSILLECTOMY AND POLYSOMNOGRAPHY:
Clinicians should counsel caregivers about tonsillectomy as a means to improve health in children with: abnormal polysomnography + tonsil hypertrophy sleep-disordered breathing. Recommendation
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STATEMENT 6 Recommendation
OUTCOME ASSESSMENT FOR SLEEP-DISORDERED BREATHING: Clinicians should counsel caregivers and explain that SDB may persist or recur after tonsillectomy and may require further management. Recommendation
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STATEMENT 7 INTRAOPERATIVE STEROIDS: Clinicians should administer a single, intraoperative dose of intravenous dexamethasone to children undergoing tonsillectomy. Strong recommendation Nausées et vomissements post-opératoires Mécanisme inconnu Dose recommandée 0.5mg/kg NNT = 4 Douleur Délai pour reprise de l’alimentation Hémorragies post-opératoires Exclusions Patients: Avec désordres endocriniens nécessitant prise exogène de stéroïdes Chez lesquels l’administration de stéroïdes pourrait interférer avec la régulation normale de l’insuline et du glucose (diabète)
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STATEMENT 8 PERIOPERATIVE ANTIBIOTICS: Clinicians should not routinely administer or prescribe perioperative antibiotics to children undergoing tonsillectomy. Strong recommendation against Revue Cochrane de 10 essais randomisés contrôlés Conclusion: Absence d’évidence pour supporter un impact clinique important et constant Exclusions Conditions cardiaques nécessitant une antibiothérapie prophylactique péri-opératoire Abcès péri-amygdalien concomitant
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STATEMENT 9 POSTOPERATIVE PAIN CONTROL: The clinician should advocate for pain management after tonsillectomy and educate caregivers about the importance of managing and reassessing pain. Recommendation Éducation: -Prise en charge de la douleur des parents/tuteurs des enfants -Hydratation Codéine: Combinaison Acétaminophène/Codéine pas supérieure à Acétaminophène seule Variabilité Non métabolisateur avec effets secondaires Métabolisateur rapide AINS: N’augmente pas de façon significative les hémorragies post-opératoire Exception: Ketorolac Augmentation de 4.4 à 18% Régime d’administration: Fixe n’a pas été démontrée supérieure à PRN Inconfort est plus important le matin peu importe le régime d’administration
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Good hydratation is associate with less pain
Ibuprofen can be used safely Codeine is not used anymore post T&A at the MCH Halitosis Cicatrice grisatre Hygiene buccale Prendre médication régulièrement
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STATEMENT 10 POSTTONSILLECTOMY HEMORRHAGE: Clinicians who perform tonsillectomy should determine their rate of primary and secondary posttonsillectomy hemorrhage at least annually. Recommendation Approche préférable à une recommandation spécifique en regard de la technique chirurgicale Lors du suivi, s’informer des saignements post-opératoires et de la nécessité de traitement Hémorragie primaire (≤ 24H post-op) Taux % Hémorragie secondaire (> 24H post-op) Taux 0.1-3%
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L’amygdalectomie… Une chirurgie courante mais non banale. , P
L’amygdalectomie… Une chirurgie courante mais non banale!, P. Greff, Le Collège, :1, pp
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Tympanostomy tubes
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Indications Chronic otitis media with effusion (OME)
Recurrent acute otits media (AOM) AOM that persist after antibiotic therapy Hearing loss caused by middle ear effusion (MEE) Retraction-type ear disease (atelectasis or adhesive otitis media), Complications of AOM
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Benefits Significantly improves hearing, Reduces effusion prevalence,
May reduce the incidence of recurrent acute otitis media (AOM), and Provides a mechanism for drainage and administration of topical antibiotic therapy for persistent AOM Can improve disease-specific quality of life (QOL) for children with chronic OME, recurrent AOM, or both. Table 8. Comparison of acute otitis media with and without a tympanostomy tube.a Issue AOM without a Tube AOM with a Tube Ear pain Mild to severe None, unless skin irritated or tube occluded Drainage from the ear canal (otorrhea) No, unless eardrum ruptures Yes, unless tube obstructed Duration of middle ear effusion after infection Can last weeks or months Usually resolves promptly Needs oral antibiotics Often Rarely Needs antibiotic eardrops No benefit Often Risk of eardrum rupture Yes No, unless tube obstructed Risk of suppurative complications Rare Exceedingly rare Abbreviation: AOM, acute otitis media. aAdapted.3
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STATEMENT 1 OME OF SHORT DURATION: Clinicians should not perform tympanostomy tube insertion in children with a single episode of OME of less than 3 months’ duration. Recommendation (against)
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STATEMENT 2 HEARING TESTING:
Clinicians should obtain an age-appropriate hearing test if OME persists for 3 months or longer (chronic OME) OR prior to surgery when a child becomes a candidate for tympanostomy tube insertion. Recommendation
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STATEMENT 3 CHRONIC BILATERAL OME WITH HEARING DIFFICULTY:
Clinicians should offer bilateral tympanostomy tube insertion to children with bilateral OME for 3 months or longer (chronic OME) AND documented hearing difficulties. Recommendation
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STATEMENT 4 CHRONIC OME WITH SYMPTOMS: Clinicians may perform tympanostomy tube insertion in children with unilateral or bilateral OME for 3 months or longer (chronic OME) AND symptoms that are likely attributable to OME that include, but are not limited to, vestibular problems, poor school performance, behavioral problems, ear discomfort, or reduced quality of life. Option
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STATEMENT 5 SURVEILLANCE OF CHRONIC OME:
Clinicians should reevaluate, at 3- to 6-month intervals, children with chronic OME who did not receive tympanostomy tubes, until the effusion is no longer present, or significant hearing loss is detected, or structural abnormalities of the tympanic membrane or middle ear are suspected. Recommendation
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STATEMENT 6 RECURRENT AOM WITHOUT MEE:
Clinicians should not perform tympanostomy tube insertion in children with recurrent AOM who do not have middle ear effusion in either ear at the time of assessment for tube candidacy. Recommendation (against) Systematic reviews of tympanostomy tube insertion for recurrent AOM have shown either a transient benefit of questionable clinical significance,22 no additional benefit compared with antibiotic use,24 or no benefit at all.18,23
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Definition of recurrent AOM
≥ 3 well-documented and separate AOM episodes in the past 6 months or ≥ 4 well-documented and separate AOM episodes in the past 12 months with at least 1 in the past 6 months
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STATEMENT 7 RECURRENT AOM WITH MEE:
Clinicians should offer bilateral tympanostomy tube insertion to children with recurrent AOM who have unilateral or bilateral middle ear effusion at the time of assessment for tube candidacy. Recommendation
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STATEMENT 8 AT RISK CHILDREN:
Clinicians should determine if a child with recurrent AOM or with OME of any duration is at increased risk for speech, language, or learning problems from otitis media because of baseline sensory, physical, cognitive, or behavioral factors (see Table 2). Recommendation
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STATEMENT 9 TYMPANOSTOMY TUBES AND AT RISK CHILDREN:
Clinicians may perform tympanostomy tube insertion in at-risk children with unilateral or bilateral OME that is unlikely to resolve quickly as reflected by a type B (flat) tympanogram or persistence of effusion for 3 months or longer (chronic OME). Option Children with OME typically have mild hearing loss (about 25-28 dB HL), with 20% of affected ears having levels exceeding 35 dB HL.55
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Risk factors for developmental difficulties
Permanent hearing loss independent of otitis media with effusion Suspected or confirmed speech and language delay or disorder Autism-spectrum disorder and other pervasive developmental disorders Syndromes (eg, Down) or craniofacial disorders that include cognitive, speech, or language delays Blindness or uncorrectable visual impairment Cleft palate, with or without associated syndrome Developmental delay
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STATEMENT 10 PERIOPERATIVE EDUCATION:
In the perioperative period, clinicians should educate caregivers of children with tympanostomy tubes regarding the expected duration of tube function, recommended follow-up schedule, and detection of complications. Recommendation
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Primary care provider’s role
Referral to the otolaryngologist should be made if Tubes cannot be visualized or are occluded, Suspected change in hearing status, or Other complications: granuloma, persistent or recurrent otorrhea following treatment, culture perforation at the tube site, persistent tube for greater than 2-3 years, retraction pocket, or cholesteatoma
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STATEMENT 11 ACUTE TYMPANOSTOMY TUBE OTORRHEA:
Clinicians should prescribe topical antibiotic eardrops only, without oral antibiotics, for children with uncomplicated (fever < 38,5oC) acute (< 4 weeks) TTO. Strong recommendation
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TTO Responds to topical antibiotic ear drops
Pumping of the tragus following placement of the drops may help with penetration of the drops to the ear canal and middle ear space Aural toilet may be required prior to drop administration when otorrhea is filling the canal Does not usually require oral antibiotics Benefits from water precautions until the discharge is no longer present Rates of clinical cure upon completion of therapy after 7 to 10 days ranged from 77% to 96% with topical therapy and from 30% to 67% with systemic antibiotic therapy. Topical antibiotic therapy avoids adverse events associated with systemic antibiotics including dermatitis,123,124 allergic reactions, gastrointestinal upset,123,124 oral thrush,124 and increased antibiotic resistance.121 Aural toilet: by blotting the canal opening or using an infant nasal aspirator to gently suction away any visible secretions.3 Any dry crust or adherent discharge can be cleaned using a cotton-tipped swab and hydrogen peroxide, which can be used safely when a tympanostomy tube is present.130 OTL referral: -If the drops are not able to penetrate the canal because of debris or crusting, the child may require suctioning of the canal by the otolaryngologist. -When drainage is persistent following treatment, or recurs frequently, the child should be evaluated by an otolaryngologist.
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Aural toilet Blotting the canal opening or using an infant nasal aspirator to Dry crust or adherent discharge can be cleaned using a cotton-tipped swab and hydrogen peroxide Persistent debris despite these measures can often be removed by suctioning through an open otoscope head or by using a binocular microscope for visualization.
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Eardrops Use only eardrops that are specifically approved for use with tympanostomy tubes, because nonapproved ear drops may induce pain, infection, or even damage hearing. Over-the-counter otic drops are NOT SAFE for use with tympanostomy tubes, regardless of the indication (eg, earwax, swimmer’s ear, discomfort) Clinicians should also be aware that sensitivity results from otorrhea culture typically relate to serum drug levels achieved from systemic antibiotic therapy, but the antibiotic concentration at the site of infection with topical drops can be up to 1000-fold higher and will typically overcome this level of resistance.
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Systemic antibiotic therapy
1. Cellulitis of the pinna or adjacent skin 2. Concurrent bacterial infection (eg, sinusitis, pneumonia, or streptococcal pharyngitis) 3. Signs of severe infection (high fever, severe otalgia, toxic appearance) 4. Acute TTO persists, or worsens, despite topical antibiotic therapy (conversion rate 4-8%) 5. Administration of eardrops is not possible because of local discomfort or lack of tolerance by the child 6. Patient has an immune-compromised state 7. Cost considerations prevent access to non-ototoxic topical antibiotic drops
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Ciprodex substitute Ciloxan 0.3% + Maxidex 0.1% For economic reason
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Granuloma About 4% of pts
Persistent, usually painless, otorrhea pink or bloody NOT AN EMERGENCY Treatment of choice: topical quinolone drop, with or without dexamethasone systemic antibiotics should not be prescribed
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STATEMENT 12 WATER PRECAUTIONS:
Clinicians should not encourage routine, prophylactic water precautions (use of ear plugs, headbands; avoidance of swimming or water sports) for children with tympanostomy tubes. Recommendation (against) A child would need to wear plugs for 2.8 years, on average, to prevent a single episode of TTO.
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A child would need to wear plugs for 2
A child would need to wear plugs for 2.8 years, to prevent a single episode of TTO. Water avoidance is at a minimum a social inconvenience and at worst a detriment to developing water safety skills for young children
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Water protection indications
Recurrent or persistent otorrhea Children with risk factors for infection and complications, such as immune dysfunction To avoid exposure to heavily contaminated water (eg, certain lakes), For children who experience ear discomfort during swimming.
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Conclusion Stay vigilant when chosing to perform tonsillectomy and PETubes as, despites being the most frequent surgeries performed in the world, they are not without risks.
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QUESTIONS ? MCH OTL-HNS Clinic Secretary: 514 412-4304
Appointment: Fax:
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References L’amygdalectomie… Une chirurgie courante mais non banale!, P. Greff, Le Collège, :1, pp Clinical Practice Guideline: Tonsillectomy in Children, R.F. Baugh et al., Otolaryngology-Head and Neck Surgery, : S1, pp. S1-S30 Clinical Practice Guideline: Tympanostomy Tubes in Children, R.M. Rosenfeld et al., Otolaryngology-Head and Neck Surgery, : S1, pp. S1-S35
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MERCI
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