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Bacteremia during adenoidectomy
International Journal of Pediatric Otorhinolaryngology 66 (2002) 149 /153 www.elsevier.com/locate/ijporl
Bacteremia during adenoidectomy Erdog˘an Okur a,*, Murat Aral b, I˙lhami Yildirim a, M. Akif Kılıc¸ a, Pınar C ¸ iragil b a
Department of Otorhinolaryngology, School of Medicine, Kahramanmaras Sutcu Imam University, Yorukselim mah. Hastane Cad. No. 32, 46050 Kahramanmaras, Turkey b Department of Microbiology and Clinical Microbiology, School of Medicine, Kahramanmaras Sutcu Imam University, 46050 Kahramanmaras, Turkey Received 5 February 2002; received in revised form 8 July 2002; accepted 9 July 2002
Abstract Objective : Although adenoidectomy is one of the most commonly performed surgical procedures in children, there is no satisfactory information about the risk of bacteremia during adenoidectomy and necessity of antibiotic use. The aim of this study was to determine the incidence of bacteremia during adenoidectomy and identify the organisms leading to bacteremia. Methods: Thirty two patients who had undergone adenoidectomy at ENT Clinic of Sutcu Imam University were included in the study. They had received no antimicrobial therapy for at least 20 days before surgery. Adenoidal surface and deep tissue cultures were taken and venous blood samples were obtained for cultures before and immediately after adenoidectomy in which adenoid was removed with a curette. Results : While none of the blood cultures taken preoperatively was positive for any organisms, the cultures obtained postoperatively were positive in only two of 32 patients included in the study. Conclusion: The results of this study suggest that there is an extremely low incidence of bacteremia during adenoidectomy. As a result, it may be concluded that the use of prophylactic antibiotics to prevent bacteremia or its complications is unnecessary unless the patient has a predisposing factor for cardiac infection like prosthetic valve replacement. # 2002 Published by Elsevier Science Ireland Ltd. Keywords: Adenoidectomy; Bacteremia; Complications; Children
1. Introduction The human nasopharynx is a natural reservoir for several bacterial species, including Streptococcus pneumoniae (S. pneumoniae ), Haemophilus
* Corresponding author. Tel.: /90-344-221-23-37x359; fax: /90-344-221-23-71 E-mail address: [email protected] (E. Okur).
influenzae (H. influenzae) and Moraxella catarrhalis (M. catarrhalis ). The adenoids in children with obstructive adenoidal hyperplasia and chronic adenoid infection are especially associated with some possible pathogens, particularly H . influenzae [1]. Adenoidectomy is one of the most common surgical procedures performed by otolaryngologists. Although it is most often simultaneously performed with tonsillectomy, it may also be conducted as a separate individual procedure.
0165-5876/02/$ - see front matter # 2002 Published by Elsevier Science Ireland Ltd. PII: S 0 1 6 5 - 5 8 7 6 ( 0 2 ) 0 0 2 3 9 - 2
150
E. Okur et al. / Int. J. Pediatr. Otorhinolaryngol. 66 (2002) 149 /153
Indications for adenoidectomy range from otitis media with effusion to nasal obstruction and sleep apnea. During this operation, the integrity of nasopharyngeal mucosa is broken and a fresh wound is formed in a field with a rich vascular supply and full of bacteria, some of which are pathogenic. As the wound surfaces remain open in this operation, it might be expected that bacterial migration into systemic circulation could readily occur. The risk of bacteremia changes from one operation to the other. For example, it has been reported that bacteremia is virtually nil during tympanostomy tube placement and occurs only infrequently during septoplasty, rhinoplasty and endoscopic sinus surgery [2 /6]. The reported incidence of bacteremia during tonsillectomy ranges from 22 to 40% [7 /11]. Bacteremia may lead to dramatic results in patients who have cardiovascular risk factors. Hence, antibiotic prophylaxis is offered by some authors before tonsillectomy [8,9]. Although adenoidectomy is one of the most common surgical procedures performed in children, there is no satisfactory information about the risk of bacteremia during adenoidectomy. The purpose of this study was to determine the incidence of bacteremia during adenoidectomy and to identify the organisms associated with it.
2. Materials and methods Thirty-two consecutive patients who had an indication for adenoidectomy were included in this study. The indications for adenoidectomy were either obstructive nasal symptoms attributable to adenoidal hypertrophy which was confirmed by endoscopic examination and by finger palpation before surgery, or otitis media with effusion which did not respond to antibiotic therapy for at least 2 months during the follow-up. The ages of patients ranged from 3 to 20 years with a mean age of 7.5 years. Seventeen of them were males. The patients did not have any cardiovascular risk factors nor did they receive any antibiotic therapy, for at least 20 days before the operation. The study was approved by the Medical Ethics Committee,
Faculty of Medicine, Sutcu Imam University, and informed consent was obtained from all of children’s parents or guardians. All patients underwent adenoidectomy, with or without tympanostomy tube placement (which if performed, followed adenoidectomy), under general anaesthesia within operating room conditions at Sutcu Imam University Hospital between December 2000 and November 2001. They were all discharged from the hospital on the morning of the first postoperative day without problem. Under aseptic conditions, 6 ml of blood for patients under 10 years of age and 15/18 ml of blood for those over 10 years of age was taken from a peripheral vein during preoperative and postoperative periods (within 5 min after adenoidectomy). Half of the sample was inoculated into an aerobic blood culture bottle (BACTECTM 40 or 25 ml, Lytic/10) and the other half into an anaerobic blood culture bottle (BACTECTM 40 ml, Lytic/10, Anaerobic /F blood bottle). The adenoidal surface cultures were taken transorally under direct vision using a sterile cotton tipped applicator for aerobic and anaerobic microorganisms after the uvula was retracted. Each swab was placed in a transport medium. The adenoids were removed with a curette and placed in a sterile container. The adenoid tissue specimen was rinsed in sterile conditions with physiological saline and cut into two pieces with a sterile scalpel. The core was swabbed with a sterile cotton tipped-applicator and placed into aerobic and anaerobic transport media. All of the samples were taken to the microbiology laboratory within half an hour. For the aerobic cultures, the samples obtained by swabbing were inoculated onto 5% sheep blood agar, chocolate agar and MacConkey’s agar and incubated for 24 /48 h at 35 8C. For the anaerobic cultures, the samples were inoculated onto chocolate agar, MacConkey’s agar and 5% anaerobic sheep blood agar containing kanamycin and vancomycin, and incubated for 48 /72 h at 35 8C in a GasPak anaerobic system (AnaeroGenTM, OXOID Ltd, Basingstoke, Hampshire, England). In addition to these anaerobic cultures, the same samples were taken into the enriched thioglycolate broth to facilitate and improve the growth of the
E. Okur et al. / Int. J. Pediatr. Otorhinolaryngol. 66 (2002) 149 /153
anaerobes, and were incubated for 4 /7 days at 35 8C in a GasPak anaerobic system. The venous blood samples collected in blood culture bottles were incubated within the BACTEC 9050 automatic blood culture system (Becton, Dickinson and Company Sparks MD 21152, Ireland). Routine bacteriologic inoculations were performed from the bottles in which bacterial growth took place. Aerobic microorganisms were identified by standart laboratory methods [12]. Anaerobic microorganisms were identified by using OXOID An-ident discs (Oxoid Limited).
3. Findings Thirty-two patients were included in the study. All the preoperative blood culture specimens were negative. Bacterial growth was observed in only two blood cultures (6.25%) prepared immediately after adenoidectomy. One of the organisms isolated from postoperative blood culture was H. influenzae , which was also isolated from the core of adenoid tissue specimen but not from the adenoidal surface. The other organism isolated from postoperative blood nature was Group A beta-haemolytic streptococcus (GABHS), which was recovered from both the adenoidal surface and core. The organisms isolated from the adenoidal surface did not always show correspondence with the organisms isolated from the deep tissue specimens. The organisms isolated from the adenoidal surface swabs and tissue specimens are presented in Table 1. GABHS was the most commonly grown organism in the core of the adenoidal tissue and/or adenoidal surface culture (seven patients), followed by S . pneumoniae (five patients), Staphylococcus aureus (four patients) and H. influenzae (four patients). M. catarrhalis was identified in only one culture (the core of the adenoidal tissue). Three anaerobic bacteria were isolated from the core of the adenoidal tissue cultures but not from those of adenoidal surface.
151
Table 1 Organisms isolated from adenoidal swabs and deep tissue specimens obtained during adenoidectomy Organism
Surface only (n )
Surface and core Core only (n ) (n )
GABHS S . pneumoniae H . influenzae S . aureus a M . catarrhalis E . coli b Anaerobes** Normal flora AHSc GFSd CNSe Diphteroid spp. Neisseria spp.
2 0 0 0 0 1 0 3 1 0 1 1
5* 1 1 2 0 0 0 23 10 4 1 6
0 4 3* 2 1 0 3 0 0 0 0 0
0
2
0
n , Number of patients from whose cultures each individual species was isolated. a Staphylococcus aureus . b Escherichia coli . c Alfa-haemolytic streptococci. d Group F streptococci. e Coagulase negative staphylococci. * Bacteremia was observed in one patient. ** Bacteroides fragilis (n /2), Gram positive cocci (n /1).
4. Discussion Our study, like others, has demonstrated the presence of pathogenic bacteria in adenoids of patients with otitis media with effusion and in hypertrophied adenoids. During adenoidectomy, the nasopharyngeal mucosa is torn and a fresh wound generates in a field with a rich vascular supply, and full of bacteria, some of which are pathogenic. As a result, it can be presumed that the resection of such heavily colonized tissue may lead to bacteremia by the venous route within the tissues nasopharyngeal mucous membranes. In the literature, there are a lot of reports related to blood cultures taken directly after tonsillectomy [7 /11], but there is not enough information as to whether any bacteremia during adenoidectomy takes place or not. As far as we know, there is only one report related to this [11]. In that study including 100 patients with adenoidectomy and/or
152
E. Okur et al. / Int. J. Pediatr. Otorhinolaryngol. 66 (2002) 149 /153
tonsillectomy, 2 of the 5 pure adenoidectomy cases (40%) had positive blood cultures. The incidence of bacteremia during adenoidectomy in our study was 6.25% (2 out of 32 cases), which was lower than those reported after tonsillectomy and adenoidectomy. Although the type of the operation is different, we have referred to the literature about post-tonsillectomy bacteremia, because, from the point of possible causes of bacteremia, both tonsils and adenoids share some features in common, like a rich vascular supply, similar bacterial flora. Also as previously mentioned, during the operation, the integrity of the related mucosal surface is broken down and a fresh wound is formed. It has been reported that the incidence of bacteremia is close to zero during septoplasty and rhinoplasty, and it also occurs rarely during endoscopic sinus surgery although there is bacterial colonization in these operative sites as well. Nevertheless bacteremia occurs in a significant percentage of tonsillectomies. Although there are many reports associated with post-tonsillectomy bacteremia, the pathophysiology of the bacteremia following tonsillectomy still remains controversial. Some authors have proposed a model of retrograde flow of bacteria through the exposed vessels [13], while others have suggested the traction of tonsil before dissection as the route of entry of microorganisms [9]. From the results of our study and other studies associated with nasal surgery, it may be concluded that the occurrence of bacteremia is not related to the presence of bacterial colonization in the operative site. Bacteremia may be related to traction of the tonsil before dissection rather than direct spread of bacteria into the exposed and traumatized vessels. Isaacson and Parke reported two cases of meningitis after adenoidectomy [13]. They suggested that the occurrence of meningitis was due to retrograde flow of bacteria secondary to retropharyngeal lidocaine and epinephrine injection. We did not perform any injection to the adenoid bed before or during adenoidectomy. By presuming that the bacteremia may be related to some procedural factors varying with the operation in concern, we suggest that bacteremia during adenoidectomy is a result of the manipulation of the operational site (i.e. digital examination of the operation site
before the procedure, digital compression of the remnant of adenoidal tissue which cannot be achieved and removed with a curette, and application of gauze tamponade). However, there obviously is a need for larger controlled studies to confirm this presumption. Transient post-tonsillectomy bacteremia is well recognized with reported incidence of 22/40% [7 / 11]. Transient bacteremia is generally harmless in healthy subjects and resolves spontaneously without complication. However it may lead to dramatic results in patients at a high risk of cardiovascular infections. Bacteremia had no clinical consequences in our two patients. In conclusion, bacteremia occurs infrequently in association with adenoidectomy, so it seems unnecessary to use prophylactic antibiotics routinely to prevent bacteremia on its complications unless the patient carries a high risk for a metastatic infection (e.g. having cardiac valvular disease).
References [1] L. Brodsky, R.J. Koch, Bacteriology and immunology of normal and diseased adenoids in children, Arch. Otolaryngol. Head Neck Surg. 119 (8) (1993) 821 /829. [2] J.A. Lohr, F.B. Sloop, A. Sydnor, Jr., L.G. Donowitz, Bacteremia associated with tympanostomy tube insertion, J. Infect. Dis. 159 (3) (1989) 594 /595. [3] O.E. Brown, S.C. Manning, D.L. Phillips, Lack of bacteremia in children undergoing myringotomy and tympanostomy tube placement, Pediatr. Infect. Dis. J. 14 (12) (1995) 1101 /1102. [4] K.L. Silk, M.B. Ali, B.J. Cohen, J.T. Summersgill, M.J. Raff, Absence of bacteremia during nasal septoplasty, Arch. Otolaryngol. Head Neck Surg. 117 (1) (1991) 54 /55. [5] S.A. Slavin, T.D. Rees, C.L. Gay, R.M. Goldwyn, An investigation of bacteremia during rhinoplasty, Plast. Reconstr. Surg. 71 (2) (1983) 196 /198. [6] M. Rontal, J.M. Bernstein, E. Rontal, J. Anon, Bacteriologic findings from the nose, ethmoid, and bloodstream during endoscopic surgery for chronic rhinosinusitis: implications for antibiotic therapy, Am. J. Rhinol. 13 (2) (1999) 91 /96. [7] V.T. Anand, J.J. Phillipps, D. Allen, D.H. Joynson, H.M. Fielder, A study of postoperative fever following paediatric tonsillectomy, Clin. Otolaryngol. 24 (4) (1999) 360 / 364. [8] I. Kaygusuz, U. Gok, S. Yalcin, E. Keles, A. Kizirgil, E. Demirbag, Bacteremia during tonsillectomy, Int. J. Pediatr. Otorhinolaryngol. 58 (1) (2001) 69 /73.
E. Okur et al. / Int. J. Pediatr. Otorhinolaryngol. 66 (2002) 149 /153 [9] M. Francois, E.H. Bingen, N.Y. Lambert-Zechovsky, P. Mariana-Kurkdjian, J.B. Nottet, P. Narcy, Bacteremia during tonsillectomy, Arch. Otolaryngol. Head Neck Surg. 118 (11) (1992) 1229 /1231. [10] L. Soldado, F. Esteban, M. Delgado-Rodriguez, J. Solanellas, C. Florez, E. Martin, Bacteraemia during tonsillectomy: a study of the factors involved and clinical implications, Clin. Otolaryngol. 23 (1) (1998) 63 /66.
153
[11] M. Van Eyck, Bacteremia after tonsillectomy and adenectomy, Acta. Otolaryngol. 81 (3 /4) (1976) 242 /243. [12] E.W. Koneman, S.D. Allen, W.M. Janda, P.C. Schreckenberger, W.C. Winn, Diagnostic Microbiology, Fourth ed., JB Lippincott Company, Philadelphia, 1992. [13] G. Isaacson, W.W. Parke, Meningitis after adenoidectomy an anatomic explanation, Ann. Otol. Rhinol. Laryngol. 105 (9) (1996) 684 /688.
Bacteremia during adenoidectomy Erdog˘an Okur a,*, Murat Aral b, I˙lhami Yildirim a, M. Akif Kılıc¸ a, Pınar C ¸ iragil b a
Department of Otorhinolaryngology, School of Medicine, Kahramanmaras Sutcu Imam University, Yorukselim mah. Hastane Cad. No. 32, 46050 Kahramanmaras, Turkey b Department of Microbiology and Clinical Microbiology, School of Medicine, Kahramanmaras Sutcu Imam University, 46050 Kahramanmaras, Turkey Received 5 February 2002; received in revised form 8 July 2002; accepted 9 July 2002
Abstract Objective : Although adenoidectomy is one of the most commonly performed surgical procedures in children, there is no satisfactory information about the risk of bacteremia during adenoidectomy and necessity of antibiotic use. The aim of this study was to determine the incidence of bacteremia during adenoidectomy and identify the organisms leading to bacteremia. Methods: Thirty two patients who had undergone adenoidectomy at ENT Clinic of Sutcu Imam University were included in the study. They had received no antimicrobial therapy for at least 20 days before surgery. Adenoidal surface and deep tissue cultures were taken and venous blood samples were obtained for cultures before and immediately after adenoidectomy in which adenoid was removed with a curette. Results : While none of the blood cultures taken preoperatively was positive for any organisms, the cultures obtained postoperatively were positive in only two of 32 patients included in the study. Conclusion: The results of this study suggest that there is an extremely low incidence of bacteremia during adenoidectomy. As a result, it may be concluded that the use of prophylactic antibiotics to prevent bacteremia or its complications is unnecessary unless the patient has a predisposing factor for cardiac infection like prosthetic valve replacement. # 2002 Published by Elsevier Science Ireland Ltd. Keywords: Adenoidectomy; Bacteremia; Complications; Children
1. Introduction The human nasopharynx is a natural reservoir for several bacterial species, including Streptococcus pneumoniae (S. pneumoniae ), Haemophilus
* Corresponding author. Tel.: /90-344-221-23-37x359; fax: /90-344-221-23-71 E-mail address: [email protected] (E. Okur).
influenzae (H. influenzae) and Moraxella catarrhalis (M. catarrhalis ). The adenoids in children with obstructive adenoidal hyperplasia and chronic adenoid infection are especially associated with some possible pathogens, particularly H . influenzae [1]. Adenoidectomy is one of the most common surgical procedures performed by otolaryngologists. Although it is most often simultaneously performed with tonsillectomy, it may also be conducted as a separate individual procedure.
0165-5876/02/$ - see front matter # 2002 Published by Elsevier Science Ireland Ltd. PII: S 0 1 6 5 - 5 8 7 6 ( 0 2 ) 0 0 2 3 9 - 2
150
E. Okur et al. / Int. J. Pediatr. Otorhinolaryngol. 66 (2002) 149 /153
Indications for adenoidectomy range from otitis media with effusion to nasal obstruction and sleep apnea. During this operation, the integrity of nasopharyngeal mucosa is broken and a fresh wound is formed in a field with a rich vascular supply and full of bacteria, some of which are pathogenic. As the wound surfaces remain open in this operation, it might be expected that bacterial migration into systemic circulation could readily occur. The risk of bacteremia changes from one operation to the other. For example, it has been reported that bacteremia is virtually nil during tympanostomy tube placement and occurs only infrequently during septoplasty, rhinoplasty and endoscopic sinus surgery [2 /6]. The reported incidence of bacteremia during tonsillectomy ranges from 22 to 40% [7 /11]. Bacteremia may lead to dramatic results in patients who have cardiovascular risk factors. Hence, antibiotic prophylaxis is offered by some authors before tonsillectomy [8,9]. Although adenoidectomy is one of the most common surgical procedures performed in children, there is no satisfactory information about the risk of bacteremia during adenoidectomy. The purpose of this study was to determine the incidence of bacteremia during adenoidectomy and to identify the organisms associated with it.
2. Materials and methods Thirty-two consecutive patients who had an indication for adenoidectomy were included in this study. The indications for adenoidectomy were either obstructive nasal symptoms attributable to adenoidal hypertrophy which was confirmed by endoscopic examination and by finger palpation before surgery, or otitis media with effusion which did not respond to antibiotic therapy for at least 2 months during the follow-up. The ages of patients ranged from 3 to 20 years with a mean age of 7.5 years. Seventeen of them were males. The patients did not have any cardiovascular risk factors nor did they receive any antibiotic therapy, for at least 20 days before the operation. The study was approved by the Medical Ethics Committee,
Faculty of Medicine, Sutcu Imam University, and informed consent was obtained from all of children’s parents or guardians. All patients underwent adenoidectomy, with or without tympanostomy tube placement (which if performed, followed adenoidectomy), under general anaesthesia within operating room conditions at Sutcu Imam University Hospital between December 2000 and November 2001. They were all discharged from the hospital on the morning of the first postoperative day without problem. Under aseptic conditions, 6 ml of blood for patients under 10 years of age and 15/18 ml of blood for those over 10 years of age was taken from a peripheral vein during preoperative and postoperative periods (within 5 min after adenoidectomy). Half of the sample was inoculated into an aerobic blood culture bottle (BACTECTM 40 or 25 ml, Lytic/10) and the other half into an anaerobic blood culture bottle (BACTECTM 40 ml, Lytic/10, Anaerobic /F blood bottle). The adenoidal surface cultures were taken transorally under direct vision using a sterile cotton tipped applicator for aerobic and anaerobic microorganisms after the uvula was retracted. Each swab was placed in a transport medium. The adenoids were removed with a curette and placed in a sterile container. The adenoid tissue specimen was rinsed in sterile conditions with physiological saline and cut into two pieces with a sterile scalpel. The core was swabbed with a sterile cotton tipped-applicator and placed into aerobic and anaerobic transport media. All of the samples were taken to the microbiology laboratory within half an hour. For the aerobic cultures, the samples obtained by swabbing were inoculated onto 5% sheep blood agar, chocolate agar and MacConkey’s agar and incubated for 24 /48 h at 35 8C. For the anaerobic cultures, the samples were inoculated onto chocolate agar, MacConkey’s agar and 5% anaerobic sheep blood agar containing kanamycin and vancomycin, and incubated for 48 /72 h at 35 8C in a GasPak anaerobic system (AnaeroGenTM, OXOID Ltd, Basingstoke, Hampshire, England). In addition to these anaerobic cultures, the same samples were taken into the enriched thioglycolate broth to facilitate and improve the growth of the
E. Okur et al. / Int. J. Pediatr. Otorhinolaryngol. 66 (2002) 149 /153
anaerobes, and were incubated for 4 /7 days at 35 8C in a GasPak anaerobic system. The venous blood samples collected in blood culture bottles were incubated within the BACTEC 9050 automatic blood culture system (Becton, Dickinson and Company Sparks MD 21152, Ireland). Routine bacteriologic inoculations were performed from the bottles in which bacterial growth took place. Aerobic microorganisms were identified by standart laboratory methods [12]. Anaerobic microorganisms were identified by using OXOID An-ident discs (Oxoid Limited).
3. Findings Thirty-two patients were included in the study. All the preoperative blood culture specimens were negative. Bacterial growth was observed in only two blood cultures (6.25%) prepared immediately after adenoidectomy. One of the organisms isolated from postoperative blood culture was H. influenzae , which was also isolated from the core of adenoid tissue specimen but not from the adenoidal surface. The other organism isolated from postoperative blood nature was Group A beta-haemolytic streptococcus (GABHS), which was recovered from both the adenoidal surface and core. The organisms isolated from the adenoidal surface did not always show correspondence with the organisms isolated from the deep tissue specimens. The organisms isolated from the adenoidal surface swabs and tissue specimens are presented in Table 1. GABHS was the most commonly grown organism in the core of the adenoidal tissue and/or adenoidal surface culture (seven patients), followed by S . pneumoniae (five patients), Staphylococcus aureus (four patients) and H. influenzae (four patients). M. catarrhalis was identified in only one culture (the core of the adenoidal tissue). Three anaerobic bacteria were isolated from the core of the adenoidal tissue cultures but not from those of adenoidal surface.
151
Table 1 Organisms isolated from adenoidal swabs and deep tissue specimens obtained during adenoidectomy Organism
Surface only (n )
Surface and core Core only (n ) (n )
GABHS S . pneumoniae H . influenzae S . aureus a M . catarrhalis E . coli b Anaerobes** Normal flora AHSc GFSd CNSe Diphteroid spp. Neisseria spp.
2 0 0 0 0 1 0 3 1 0 1 1
5* 1 1 2 0 0 0 23 10 4 1 6
0 4 3* 2 1 0 3 0 0 0 0 0
0
2
0
n , Number of patients from whose cultures each individual species was isolated. a Staphylococcus aureus . b Escherichia coli . c Alfa-haemolytic streptococci. d Group F streptococci. e Coagulase negative staphylococci. * Bacteremia was observed in one patient. ** Bacteroides fragilis (n /2), Gram positive cocci (n /1).
4. Discussion Our study, like others, has demonstrated the presence of pathogenic bacteria in adenoids of patients with otitis media with effusion and in hypertrophied adenoids. During adenoidectomy, the nasopharyngeal mucosa is torn and a fresh wound generates in a field with a rich vascular supply, and full of bacteria, some of which are pathogenic. As a result, it can be presumed that the resection of such heavily colonized tissue may lead to bacteremia by the venous route within the tissues nasopharyngeal mucous membranes. In the literature, there are a lot of reports related to blood cultures taken directly after tonsillectomy [7 /11], but there is not enough information as to whether any bacteremia during adenoidectomy takes place or not. As far as we know, there is only one report related to this [11]. In that study including 100 patients with adenoidectomy and/or
152
E. Okur et al. / Int. J. Pediatr. Otorhinolaryngol. 66 (2002) 149 /153
tonsillectomy, 2 of the 5 pure adenoidectomy cases (40%) had positive blood cultures. The incidence of bacteremia during adenoidectomy in our study was 6.25% (2 out of 32 cases), which was lower than those reported after tonsillectomy and adenoidectomy. Although the type of the operation is different, we have referred to the literature about post-tonsillectomy bacteremia, because, from the point of possible causes of bacteremia, both tonsils and adenoids share some features in common, like a rich vascular supply, similar bacterial flora. Also as previously mentioned, during the operation, the integrity of the related mucosal surface is broken down and a fresh wound is formed. It has been reported that the incidence of bacteremia is close to zero during septoplasty and rhinoplasty, and it also occurs rarely during endoscopic sinus surgery although there is bacterial colonization in these operative sites as well. Nevertheless bacteremia occurs in a significant percentage of tonsillectomies. Although there are many reports associated with post-tonsillectomy bacteremia, the pathophysiology of the bacteremia following tonsillectomy still remains controversial. Some authors have proposed a model of retrograde flow of bacteria through the exposed vessels [13], while others have suggested the traction of tonsil before dissection as the route of entry of microorganisms [9]. From the results of our study and other studies associated with nasal surgery, it may be concluded that the occurrence of bacteremia is not related to the presence of bacterial colonization in the operative site. Bacteremia may be related to traction of the tonsil before dissection rather than direct spread of bacteria into the exposed and traumatized vessels. Isaacson and Parke reported two cases of meningitis after adenoidectomy [13]. They suggested that the occurrence of meningitis was due to retrograde flow of bacteria secondary to retropharyngeal lidocaine and epinephrine injection. We did not perform any injection to the adenoid bed before or during adenoidectomy. By presuming that the bacteremia may be related to some procedural factors varying with the operation in concern, we suggest that bacteremia during adenoidectomy is a result of the manipulation of the operational site (i.e. digital examination of the operation site
before the procedure, digital compression of the remnant of adenoidal tissue which cannot be achieved and removed with a curette, and application of gauze tamponade). However, there obviously is a need for larger controlled studies to confirm this presumption. Transient post-tonsillectomy bacteremia is well recognized with reported incidence of 22/40% [7 / 11]. Transient bacteremia is generally harmless in healthy subjects and resolves spontaneously without complication. However it may lead to dramatic results in patients at a high risk of cardiovascular infections. Bacteremia had no clinical consequences in our two patients. In conclusion, bacteremia occurs infrequently in association with adenoidectomy, so it seems unnecessary to use prophylactic antibiotics routinely to prevent bacteremia on its complications unless the patient carries a high risk for a metastatic infection (e.g. having cardiac valvular disease).
References [1] L. Brodsky, R.J. Koch, Bacteriology and immunology of normal and diseased adenoids in children, Arch. Otolaryngol. Head Neck Surg. 119 (8) (1993) 821 /829. [2] J.A. Lohr, F.B. Sloop, A. Sydnor, Jr., L.G. Donowitz, Bacteremia associated with tympanostomy tube insertion, J. Infect. Dis. 159 (3) (1989) 594 /595. [3] O.E. Brown, S.C. Manning, D.L. Phillips, Lack of bacteremia in children undergoing myringotomy and tympanostomy tube placement, Pediatr. Infect. Dis. J. 14 (12) (1995) 1101 /1102. [4] K.L. Silk, M.B. Ali, B.J. Cohen, J.T. Summersgill, M.J. Raff, Absence of bacteremia during nasal septoplasty, Arch. Otolaryngol. Head Neck Surg. 117 (1) (1991) 54 /55. [5] S.A. Slavin, T.D. Rees, C.L. Gay, R.M. Goldwyn, An investigation of bacteremia during rhinoplasty, Plast. Reconstr. Surg. 71 (2) (1983) 196 /198. [6] M. Rontal, J.M. Bernstein, E. Rontal, J. Anon, Bacteriologic findings from the nose, ethmoid, and bloodstream during endoscopic surgery for chronic rhinosinusitis: implications for antibiotic therapy, Am. J. Rhinol. 13 (2) (1999) 91 /96. [7] V.T. Anand, J.J. Phillipps, D. Allen, D.H. Joynson, H.M. Fielder, A study of postoperative fever following paediatric tonsillectomy, Clin. Otolaryngol. 24 (4) (1999) 360 / 364. [8] I. Kaygusuz, U. Gok, S. Yalcin, E. Keles, A. Kizirgil, E. Demirbag, Bacteremia during tonsillectomy, Int. J. Pediatr. Otorhinolaryngol. 58 (1) (2001) 69 /73.
E. Okur et al. / Int. J. Pediatr. Otorhinolaryngol. 66 (2002) 149 /153 [9] M. Francois, E.H. Bingen, N.Y. Lambert-Zechovsky, P. Mariana-Kurkdjian, J.B. Nottet, P. Narcy, Bacteremia during tonsillectomy, Arch. Otolaryngol. Head Neck Surg. 118 (11) (1992) 1229 /1231. [10] L. Soldado, F. Esteban, M. Delgado-Rodriguez, J. Solanellas, C. Florez, E. Martin, Bacteraemia during tonsillectomy: a study of the factors involved and clinical implications, Clin. Otolaryngol. 23 (1) (1998) 63 /66.
153
[11] M. Van Eyck, Bacteremia after tonsillectomy and adenectomy, Acta. Otolaryngol. 81 (3 /4) (1976) 242 /243. [12] E.W. Koneman, S.D. Allen, W.M. Janda, P.C. Schreckenberger, W.C. Winn, Diagnostic Microbiology, Fourth ed., JB Lippincott Company, Philadelphia, 1992. [13] G. Isaacson, W.W. Parke, Meningitis after adenoidectomy an anatomic explanation, Ann. Otol. Rhinol. Laryngol. 105 (9) (1996) 684 /688.