Recent changes in reimbursement for tonsillectomy and adenoidectomy have resulted in a large number of these procedures being done on an outpatient basis. There is still considerable controversy, however, as to the safety of this concept. We reviewed the charts of 1000 consecutive patients who underwent these procedures. Three hundred ninety-six procedures were performed as inpatient surgery and 604 were performed as outpatient surgery. Patients were considered as candidates for outpatient surgery if they met specific criteria, such as good overall medical health, no central apnea, normal bleeding history and profile, and had adequate social considerations. The inpatient group included those patients who did not meet the criteria to be outpatients. We compared the complication rates of these two groups with regard to age, type of procedure performed (tonsillectomy, adenoidectomy, adenotonsillectomy), and indication for surgery in order to determine if there was any increased risk of outpatient surgery, despite strict selection criteria. The two groups were similar in their distribution with regards to age, sex, type of procedure, and indication for surgery. The overall complication rate for the entire group was 7.9%, with an 11.8% complication rate for inpatients and 4.1% complications for outpatients. The higher complication rate among the inpatient group is probably a direct result of the selection process because this group included the higher-risk patients. On the basis of these findings, we believe that surgery of the tonsils and adenoids can be performed safely as an outpatient procedure, regardless of age, indication, or procedure, if the candidates for ambulatory surgery are carefully selected by the surgeon.

Background 13-Cisretinoic acid (13-CRA) is a synthetic Vitamin A derivative. High-dose 13-CRA in patients with squamous cell cancers of the head and neck (SCCHN) reduces the incidence of second primary tumors (SPT). We report long-term results of a Phase III randomized trial that compared low-dose 13-CRA versus placebo, among patients with early-stage SCCHN in development of SPT and overall survival (OS). Methods 176 patients treated for Stage I/II SCCHN were randomized to low-dose 13-CRA (weight-based dose of 7.5 mg or 10 mg) or placebo for two years. Competing-risk approach and log-rank test were used, respectively, to compare time to SPT and OS between groups. Results 13-CRA neither significantly reduced cumulative incidence of SPT (p = 0.61) nor improved time to SPT (Hazard ratio (HR, 13-CRA/placebo) 0.86, p= 0.61). Despite limited power, there was a trend to improved OS for the 13-CRA arm (HR 0.75, p = 0.14) particularly among patients whose index tumor was surgically excised (N = 26, HR 0.50, p = 0.057), female patients (N= 39, HR 0.44, p = 0.065) and never/former smokers (N= 129, HR 0.61, p = 0.055), with a median follow-up of 16 years. Main 13-CRA related toxicities were dry skin and cheilitis. Conclusions Low-dose 13-CRA for 2 years did not decrease the incidence of SPT; subset analysis indicates a potential survival advantage among female patients and never/former smokers. More targeted interventions based on clinical risk factors and molecular characterization of tumors may yield greater success in future prevention trials.

Streptococcus pneumoniae is the predominant bacterial pathogen associated with acute otitis media (AOM), causing an estimated 7 million cases annually in the United States. Bacterial resistance should be considered when selecting an antimicrobial agent for otitis media. Significant increases in drug-resistant S pneumoniae are documented worldwide, and less than 50% oî S pneumoniae strains are fully susceptible to penicillin in some regions of the United States. Although amoxicillin is recommended for uncomplicated AOM, treatment guidelines should be flexible and adaptable, taking into consideration local and regional susceptibility patterns, the age of the patient, the frequency of prior infections, and the response to prior therapy. Resistant organisms are more prevalent in children younger than 2 years of age and in those who have recurrent or persistent AOM. Overdiagnosing AOM, selecting inappropriate empiric therapy, or both, leads to overuse and misuse of antibiotics and causes increased drug resistance. This article reviews persistent and recurrent AOM and discusses the pitfalls of diagnosis and the practical limitations of current treatment recommendations. KEY WORDS-cephalosporin, drug-resistant Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, otitis media, penicillin.

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