2.  Indications for tonsillectomy are recurrent tonsillitis, peritonsillar abscess and airway obstruction.  Indications for adenoidectomy include:  Airway obstruction, and chronic serous otitis media  and/or sinusitis associated with airway obstruction.  

3.  Scarring of tonsillar crypts, bacterial synergism in tonsillar crypts or multiple reinfections can cause chronic tonsillitis.  Tonsillectomy is designed to treat the first indication.  If a patient has had only a few episodes a trial of a penicillinase resistant antibiotic should be considered.

4.  Complications from tonsillectomy include:  bleeding, death and infection.  Complications from adenoidectomy include:  bleeding (usually minor), death, superficial infection, hypernasality and nasopharyngeal stenosis.

Adenoidectomy and tonsillectomy were the most common major operations performed in children 5 years ago.  The indications for tonsillectomy in certain clinical situations are constantly being debated in the literature and among professionals.  The efficacy (or lack of) of adenotonsillectomy for the following circumstances will be discussed:  Chronic tonsillitis (recurrent throat infections), oral nasal obstruction, peritonsillar abscess, elimination of a bacterial carrier state, biopsy and prevention of tongue thrusting with resultant anterior open bite.  Adenoidectomy has been advocated in the literature for the treatment of nasal obstruction, sinusitis and chronic serous otitis media.  Questions regarding the use of this operation in the aforementioned situations will be addressed.

Complications of tonsillectomy and adenoidectomy include hemorrhage, anesthetic death, infection, nasopharyngeal stenosis, patulous eustachian tube, and hypernasality.  Children at risk for hypernasality are those with mental retardation, cerebral palsy, neuromuscular disorders and submucous cleft of the soft palate.  Pre-operative evaluation to detect the child at risk for complications will be discussed.

Because of the severity of the complications that can be encountered, medical and conservative therapy should be attempted before operative intervention is performed.  Proper antibiotic therapy will control many children with chronic serous otitis, sinusitis and chronic, recurrent tonsillitis.  Bacterial synergy is important to consider when selecting antibiotic therapy since B-Lactamase producing organisms may protect pathogens, which are commonly considered susceptible to standard antibiotic therapy.

Adenotonsillectomy in the past was the most commonly performed major surgery in children.  It's incidence has dropped in the United States from a high of 959,773 (4.7/1000 persons)1 in 1972 to 616,076 in 19772  and 496,000 in 19833 and now estimated to be only 280,000 a year.  this decrease is associated with a growing awareness in the medical community of the appropriate indications for this procedure.  The practice of removing tonsils just because they are enlarged or because a sibling is having theirs removed is antiquated and is mentioned only to be condemned.  In addition, the increasing litigious nature of our society make it prudent to be able to justify any recommended therapy without equivocation.

In this report we will discuss our indications for tonsillectomy and adenoidectomy.  These two procedures should be considered separately, realizing that a blanket policy of performing a tonsillectomy and adenoidectomy on all children requiring one or the other  does not meet with modern practice standards.

Indications for Tonsillectomy:
Recurrent pharyngitis is by far the most devated indication for tonsillectomy.  Paradise and Bluestone4 have shown this procedure to be effective in preventing recurrent tonsillitis and/or pharyngitis in severely affected children.  Entrance into their study required at least 7 episodes for one year, 5 for two years or 3 for three years.  They found that if a child undergoes tonsillectomy there is a fifty- percent chance of another episode of pharyngitis/tonsillitis in the first post-operative year.  If surgery is not performed there is a ninety percent chance of another episode.  They also observed that a substantial proportion of subjects who did not undergo tonsillectomy had a relatively low incidence of subsequent throat infections.

Their study did not address the risks vs. benefits to the patients.  As guidelines we consider surgical intervention when the frequency and severity of these episodes has a significant effect on the functioning of the child or family (days missed from work or school).  For example, one to two episodes of adenotonisllitis per year that cause a child to miss a total of five or less days from school can be treated adequately with antibiotic therapy.  The child suffering from four or more episodes per year is a different story.  Such a child will usually miss greater than two and one-half weeks from school, require multiple visits to his/her physician, and be prescribed numerous courses of antibiotic therapy.  In addition, the morbidity that the child will incur during these episodes can be great, not to mention that of the parents.  In these situations, a tonsillectomy is recommended.

It should be remembered that recurrent tonsillitis can be a synergistic infection between B-Hemolytic Streptococcus and a B-Lactamase producing organism (S. aureus, Bacteroides fragilis, Bacteroides melaninogenicus and Bacteroides oralis).5  Multiple organisms are found in the tonsillar crypts of patients with recurrent tonsillitis.6  In these cases treatment with clindamycin, 5,7 lincomycin,8 or rifampin has been reported effective.  If this treatment modality is attempted the entire family should be cultured for asymptomatic carriers and treated if positive results are obtained.

Peritonsillar abscess (Quency) is another debated indication for tonsillectomy.  Abscesses develop between the tonsil and superior constrictor muscle.  Clinically, they are associated with swelling of the peritonsillar tissue and palate with displacement of the uvula.  Often the patient complains of odynophagia, ipsilateral otalgia, tender cervical lymphadenopathy, and has a classic "hot potato" voice.  Many patients present with dehydration because of the  associated pain with swallowing and trismus.  Diagnosis is confirmed by the aspiration of purulent material from the tonsillar fossa.  The abscess cavity is usually located in the superior aspect of the tonsil (70%),9 and may contain aerobic organisms (streptococci, hemaphilius influenza, and diplococcus pneumonia) along with a variety of anaerobic organisms. 9,10  The treatment of choice has varied in the literature from aspiration with oral antibiotic therapy11 to I.V. antibiotics and emergency tonsillectomy.  A few treatment principles are important to antibiotics and emergency tonsillectomy.  A few treatment principles are important to remember.  The abscess must be thoroughly evacuated and the patient treated with an antibiotic effective against the expected pathogens (penicillin is the drug of choice).  Failure to aspirate purulent material from the superior pole area should encourage the clinician to explore the entire tonsil bed.  30%  of peritonsillar abscesses are located in the middle and inferior pole areas with 8% being multiloculated.  Inadequate drainage may result in persistence of symptoms or a rapid recurrence of symptoms after antimicrobial therapy is completed.  Possible injury to the carotid vasculature and pulmonary aspiration preclude draining peritonsillar abscesses in an awake, uncooperative child.  Children below the age of fifteen will usually require the use of a general anesthetic in order to drain the abscess adequately.12  Close patient observation is necessary until recovery.  Treatment may require hospitalization.  Protocols treating patients with oral antibiotics with frequent (daily) clinic visits have also been reported.11  Gargling with warm salt water, and taking analgesics are all to be encouraged in order to alleviate throat pain.

A history of recurrent tonsillitis or a previous peritonsillar abscess is an indication for immediate tonsillectomy when a child presents with a peritonsillar abscess.  The patient is usually admitted to the hospital and stabilized with intravenous hydration and antibiotic therapy.  After adequate hydration is established, the tonsils are then removed.  Younger patients are often treated initially  with immediate tonsillectomy.13  Many feel that since children have an significant risk of developing a recurrent abscess (7%), it would be prudent to remove the tonsils while the child is under the general anesthetic required to drain the abscess.  The obviates the need for an additional general anesthetic and its inherent risks should the child require a tonsillectomy in the future.  Patients over the age of 40, who do not have a significant tonsillar history, have a very small incidence of recurrent tonsillar abscess.14  In this patient group a conservative policy of watchful waiting should be strongly considered.

Other indications for tonsillectomy include airway obstruction.  Nasopharyngeal airway obstruction or sleep apnea will often have a significant oral pharyngeal obstructive component and is called obstruction sleep apnea.  Uncorrected, this can lead to severe cardiac and pulmonary problems in addition to cognitive abnormalities.  If performed early an adenotonsillectomy can reverse the majority of complications.  Severe cardiomegaly, cor pulmonale and right heart failure, unfortunately are usually irreversible.  Here, surgery will serve only to arrest the progression of these problems.  Swallowing difficulties sometimes may be helped by tonsillectomy.  Tonsillectomy can also be used as a method to biopsy tonsil tissue, e.g. non-Hodgkin’s lymphoma.  It is unlikely that tonsillectomy will have a significant effect on drooling or tongue thrusting if oral/nasal obstructive symptoms are not present.

Indications for Adenoidectomy:
The most common indication for adenoidectomy is nasal obstruction.   Mild nasal obstruction associated with chronic serous otitis or sinusitis may be treated with adenoidectomy alone.  However, significant oral airway obstruction from adenotonsillar hypertrophy associated with severe sleep disturbance and/or failure to thrive should be treated by adenotonsillectomy.15  In these cases there is still a two percent failure rate to relieve airway obstruction and snoring will persist in thirteen percent of cases.  If only the adenoids are removed sleep apnea will often recur from pharyngeal tonsillar obstruction.16

Airway obstruction in children with altered craniofacial structure is often a problem.  In this population, adenoidectomy and/or tonsillectomy may not decrease upper airway obstruction and may result in significant post-operative hypernasality.  Examples of this include Down's Syndrome, where airway obstruction is primarily a function of a constricted oral-nasopharynx, with a relative macroglossia.  Oral pharyngeal obstruction in children with the Pierre-Robin Anomaly (retrognathia and cleft palate) is caused by a posteriorly displace tongue and neuromuscular incoordination.  Anatomically, these structural problems cannot be addressed by removing the tonsils and adenoids, and removing the adenoid will greatly increase the chances of persistent hypernasality post-palatoplasty.

The treatment of serous otitis media by adenoidectomy has been extensively studied in the literature but a firm consensus has yet to be established.17  Many authors have found adenoidectomy not to be effective in the treatment of chronic ear disease. 18, 19, 20  However, other studies have found a positive effect even when children with severe nasal obstruction were eliminated.21  Most studies evaluating children with nasal obstruction have found adenoidectomy to be beneficial16, 22 but other studies have not.23  It is obvious that there are many conflicting reports and a large randomized prospective study which controls for nasal obstruction is needed.

Gates et. al. reported that adenoidectomy was more efficacious than tubes in preventing otitis media.24

Our present clinical policy is similar to that of with Snow,17 and we do not perform adenoidectomy on most children who have CSOM without nasal symptoms.  The primary treatment for acute otitis medial and serous otitis media is ventilation tubes.25

Adenoidectomy can be used to obtain a representative sample of nasopharyngeal tissue.  This is of the utmost importance in patients where the question of a nasopharyngeal malignancy (nasopharygeal squamous cell carcinoma, rhabdomyosarcoma) is being entertained.  Biopsy of should always be done with caution in a controlled environment (operating room) and only after obtaining and I.V. enhanced C.T. scan.  Vascular tumors (juvenile angiofibroma) are commonly found in this area and their inadvertent curettage during surgery could lead to vigorous hemorrhage with disastrous complications.

Complications of Adenotonsillectomy:
Bleeding, anesthetic reactions and infection are potential complications of most surgical procedures.  Of these, the first two are responsible for the majority of serious complications associated with adenotonsillectomy.  In the United States approximately 1/35,000 cases has a fatal outcome. Prati (1979) 1/7000-8000 in 1995.  This figure may be higher due to reporting difficulties.  In a one-year period Belenky26 reported four postoperative deaths in the State of Michigan.

The risk of anesthetic complications does not seem to be greater for adenotonsillectomy than for other surgical procedures.  Malignant hyperthermia, a rare but potentially fatal anesthetic reaction, should be mentioned.  It is an autosomally inherited disease where skeletal and cardiac muscle react to certain inhalational anesthetic agents (e.g. halothane), or skeletal muscle relaxants (e.g. succinylcholine).  Patients exhibit elevated temperatures, tachycardia, muscle rigidity, hypotension and arrhythmias.27  An astute operating room team that recognizes these signs early and responds promptly is essential if one is to avoid the associated fatal consequences.  This devastating complication that can be avoided in many instances by obtaining a good family history.  An at risk patient can be evaluated pre-operatively with serum and histopathologic studies in an attempt to confirm a positive family history.  Unfortunately, these measures are not 100% accurate and the history remains the best indicator for determining the patients risk for this complication.

A small amount of bleeding after tonsillectomy is not uncommon.  Approximately 2 to 5% Belenky (1986), 28,29,30,31 of tonsillectomies performed demonstrate post-operative bleeding which requires medical treatment.  The bleeding usually occurs with in the first 24 hours after the procedure or is delayed occurring from 4 to 8 days post operatively.27  Hemorrhage as late as 21 days after surgery has been reported.  A substantial percentage of these bleeds can be controlled with pharyngeal pressure and cauterization out of the operating room.  One must remember to evaluate the hematocrit, hemoglobin and urine specific gravity in all post-operative tonsil bleeders.  Bleeding can be asymptomatic with the patient swallowing the majority of the blood and not realizing it.  This slow oozing compounds the blood loss and can turn a seemingly minor bleeding episode into a major emergency.  Also, the dehydrated post-operative patient with a marginal hematocrit will have a reduced capacity to respond to a hemorrhagic insult.

Moderate to severe hemorrhage should be addressed in the operating room.  Post-operative tonsillar bleeding can be immediately life-threatening with the involvement of major vessels (internal carotid, facial and lingual arteries).  The patient often will require resuscitation with intravenous fluids and blood if it is available, prior to or during surgery.  There is no method of hemostasis during tonsillectomy (Cockley knots, suture ligature or suction cautery) that does not have a postoperative incidence of hemorrhage.  suture ligatures should be performed with caution since the needle can perforate near-by major vessels.

Subluxation of the atlantoaxial joint is a potential complication in patients with joint laxity (10% of patients with the Down Syndrome).32, 33, 34  Patients at risk for this complication should not undergo mouth gag suspension, and preferably should be screened preoperatively by a competent orthopedic surgeon or neurosurgeon.  This complication can also occur from damage to the anterior transverse ligament of the atlas during adenoid surgery,35 but has never been reported after a T&A.

Adenoidectomy has several unique complications.  They are postoperative hypernasality, nasopharyngo-stenosis, damage to the alantoaxial joint and toris tubaris damage (eustachian tube).  Postoperative hypernasality occurs in 1/2000 to 1/3000 cases36,37 and rarely occurs if only a tonsillectomy is performed.  This can result in a submucous cleft of the palate, mental retardation, cerebral palsy or other neuromuscular disorder 35, 38, 39  Some at risk patients can be identified by examination of the palate for a submucous cleft (loss of the posterior nasal spine, palate muscle diastases and a bifed uvula).  Location of the palatal dimple (seen when the patient gags) should be at a distance of 75% or greater along the soft palate's length.40  Also the location of a uvular hump as seen with the nasopharyngoscope may also be helpful.41  Surgical treatment of this complication is considered after a nine-month trial of speech therapy and usually involves a pharyngeal flap.  Such a flap trades a degree of airway obstruction for improvement in the quality of speech.

Nasopharyngeal stenosis is a rare complication.  It usually occurs after adenotonsillectomy and consists of a circumverential scar contracture at the junction of the oral pharynx with nasopharynx.  This condition can be very difficult to treat and may require surgical intervention.42  Unfortunately, surgical correction often cannot fully rehabilitate the patient with nasopharyngeal stenosis.

Damage to the toris tubaris (eustachian tube) is a surprisingly rare complication.  The incidence may be higher than acknowledged because the nasopharynx is not routinely examined postoperative and only symptomatic patients are reported.  Damage to the interior of the toris can cause stenosis of the eustachian tube with resultant chronic serous otitis.  Extensive fibrosis in the Fossa of Rosenmuller can cause a patulous eustachian tube with disturbing auditory perception of the patients breathing.

Out-patient Tonsil Surgery:
Much debate is taking place regarding outpatient tonsillectomy and adenoidectomy.  Admitting the patients the day of surgery is common place and same day discharges are being encouraged by many third party payers.  The decision regarding these matters should be individualized for each patient and made by the physician and family.  Factors to consider include age of child, competence of the caretakers, traveling distance, and certainly the condition of the patient.  Patients should not be discharged until the immediate post-operative bleeding period has passed (In the case of tonsillectomy this may be 6 to 8 hours) and they demonstrate an adequate oral intake.  If observed over night and not discharged the same day.  Acute relief of nasopharyngeal airway obstruction has been associated with caridac arrhythmias and death in adults.  Severely obstructed children should be observed in an intensive care situation for at least 24 hours postoperatively.

Postoperative Care:
Aspirin products are generally forbidden since they can cause an increase in post operative bleeding.  Perioperative antibiotics have been shown to decrease fever, pain, and odor and facilitate patient recovery.43  A five day course of penicillin is standard.  Diet should be advanced as tolerated.  With tonsillectomy, cool liquids are best and hard or salty foods should be avoided.  Citrus juices can also cause considerable discomfort and are discourage.

Parents are also instructed about postoperative bleeding and where to obtain emergency care.  Minor episodes of adenoid bleeding may be controlled with vasoconstrictive nose drops and minor tonsillar bleeding can be controlled with gargling with ice water.  Any persistence in bleeding, no matter how small the blood loss appears, requires a medical evaluation.

Conclusions:
As with any procedure the patient and/or family should be aware of the risks and benefits of the surgery.  Major risks always include bleeding, reactions to anesthetic regarding the possibility of hypernasality and the palate should be reinspected, with the patient asleep, in the operating room before the adenoidectomy is performed.  The surgeon's discussions with the patient/family along with the pertinent findings regarding surgical indications and absence (or presence) of risk factors for hypernasality should be documented in the medical record.

References:

1.      Prati, L.W. and Gallagher, R.A.  Tonsillectomy and adenoidectomy: incidence and mortality.  Otolaryngolo. Head Neck Surg.  87:159-166, 1979.

2.      Freeman, J.L., Jekel, J.F., and Freeman, D.H.  changes in Age and Sex Specific Tonsillectomy Rates:  United States, 1970-1977.  Am. J. Public Health.  72:488-491, 1982.

3.      Rutkow, I.M.  Ear, Nose, and Throat Operations in the United States, 1979 to 1984.  Arch.  Otolaryngol Head Neck Surg.  112:873-876, 1986.

4.      Paradise, J.L., Bluestone, C.D., et. al.  Efficacy of tonsillectomy for recurrent throat infection in severely affected children.  The New England Journal of Medicine.  310:674-683, 1984.

5.      Brook, I.  The presence of Beta-lactamase producing bacteria as a guideline in the management of children with recurrent tonsillitis.  Am. J. Otolaryngol.  5:382-386, 1984.

6.      Brook, I., Yocum, P. and Friedman, E.M.  Aerobic and anaerobic bacteria in tonsils of children with recurrent tonsillitis.  Annals of Oto., Rhino. and Laryngo.  90:261-263, 1981.

7.      Randolph, M.F., Redys, J.J., and Hibbard, E.W.  Streptococcal Pharyngitis:  Part III-Streptococcal recurrence rates following therapy with penicillin or with clindamycin (7-chlorolincomycin).  Del Med. J.  42:87-92, 1970.

8.      Bresse, B.B., Disney, F.A., Talpey, W.B., and Green, J.  Beta hemolytic streptococcal infection: comparison of penicillin and lincomycin in the treatment of recurrent infections of the carrier state.  Am., J., Dis. Child.  117:147-152, 1969.

9.      Maisel, R.H. Peritonsillar abscess:  Tonsil Antibiotic levels in patients treated by acute abscess surgery.  Laryngoscope.  92:80-87, 1982.
 
10.  Sugita, R., Kawamura, S., et. al.  Microorganisms Isolated From Peritonsillar Abscess and Indicated Chemotherapy.  Arch. Otolaryngol.

11.  Herzon, F.S.  Perimucosal Needle Drainage of Peritonsillar Abscesses.  Arch.  Otolaryngol.  110:104-105, 1984.

12.  Holt, G.R., and Tinsley, P.O.  Peritonsillar abscesses in children.  The laryngoscope.  91:1125-1230, 1981.

13.  Richardson, K.U. and Brick, H.  Peritonsillar Abscess in the pediatric population.  Otolaryngol Head Neck Surg.  89:907-909, 1981.

14.  Herbild, O. and Bonding, P.  Peritonsillar abscess.  Arch. Otolaryngol.  107:540-542, 1981.

15.  Potsic, W.P., and Pasquariell, P.S., et. al.  Relief of upper airway obstruction by adenotonsillectomy.  Otolaryngology-Head and Neck Surgery.  94:476-480, 1986.

16.  Bluestone, C.  Tonsillectomy and Adenoidectomy course.  AAO-HNS course.  September 15, 1986.

17.  Snow, J.B.  Role of tonsillectomy and adenoidectomy in the management of children with middle ear effusion.  Ann. Otol. Rhinol Laryngeal.  (suppl 74) 89:43-46, 1980.

18.  Roydhouse, M.  Adenoidectomy for otitis media with mucoid effusion.  Ann. Otol Rhinol.  Laryngology.

19.  Fiellau-Nikolajsen, M., Hojslet, P.E. and Felding, J.U.  Adenoidectomy for eustachian tube dysfunction:  Long-term results from a randomized controlled trial.  Acta Otolaryngol.  Sup 386:129-131, 1982.

20.  Rynnel-Dagoo, B, ahibom, A., and Schiratzki, H.  Effects of adenoidectomy:  A controlled two-year follow-up.  Ann of Otol. Rhinol. Laryngol.  87:272-278, 1978.

 21.  Maw, R.  Chronic otitis media with effusion and adeno-tonsillectomy--A prospective randomized controlled study.  International J. of Pediatric Otorhinolaryngology, 6:239-246, 1983.

22.  Elverland, H.H., Mair, I.W.S, Haugeto, O.K., and Schroder, K.E.  Influence of adenoid hypertrophy on secretory otitis media.  Ann. of Otol. Rhinol. and Laryngol.  90:7-11, 1981.

23.  Marshak, G. and Neriah, Z.B.  Adenoidectomy versus tympanostomy in chronic secretory otitis media.  Ann. Otol. Rhinol. Laryngology. (Suppl 68) 89:316-318, 1980.

24.  Gates, G.A., Avery, C.A., Prihoda, T.J.  Effect of adenoidectomy upon children with chronic otitis media with effusion.  Laryngoscope 98:58-63, 1988.

25.  Sade, J. and Luntz, M.  Adenoidectomy in otitis media:  A review.  Ann Otol Laryngol.  100:226-231, 1991.
 
26.  Walter Belenky.  Children's Hospital at Detroit Mich.  Cesession on Tonsillectomy and Adenoidectomy at the AAO-HNS.  San Antonio, Texas, September 1986.

27.  Thorn, G.W. et. al.  Harrison's Principles of Internal Medicine, McGraw-Hill Inc.  New York, 1977, p.57.

28.  Nielsen, V.M., and Greisen, O. II. Peritonsillar abscess.  Cases treated with tonsillectomy a' chaud.  J. Laryngol.  Otol. 95:805-807, 1981.

29.  Kristensen, S. and Tveteras, K.  Post-tonsillectomy hemorrhage.  a retrospective study of 1150 operations.  Clin Otolaryngol.  9:347-350, 1984.

30.  Handler, S.D., Miller, L, richmond, K.H. and Varanak, C. Post-Tonsillectomy Hemorrhage:  Incidence, Prevention and Management.  Laryngoscope. 96:1243-1247, 1986.

31.  Bluestone, C.  Children's Hospital at Pittsburgh, Pa.  Session on Tonsillectomy and Adenoidectomy at the AAO-HNS.  San Antonio, Texas.  September 1986.

32.  Semine A.A., Ertel, A.N., Goldberg, M.J., et. al.:  Cervical Spine Instability in Children with Down Syndrome (Trisomy 21). Journal of Bone and Joint Surgery.  60:649-652, 1978.

33.  Pueschel , S.M., Scola F.H., Perry, C.D., and Pezzullo, J.C.:  Atlanto-axial Instability in Children with Down Syndrome.  Pediatr Radiol.  10:129-132, 1981.

34.  Tishler, J.M. and Martel, W.:  Dislocation of the Atlas in Mongolism;  Preliminary Report.  Radiology.  84:904, 1985.

35.  Sipila, P., Palva, A., Sorri, M., and Ojala, K.  Atlantoaxial Subluxation.  An unusual complication after local anesthesia for tonsillectomy.  Arch.  Otolaryngol.  107:181-182, 1981.

36.  Gibb, A.G.  Hypernasality (rhinolalia aperta) following tonsil and adenoid removal.  J. Laryngol Otol.  72:433-451, 1958.

37.  Gelder L.V.:  Open Nasal Speech Following Adenoidectomy and Tonsillectomy. Journal of Communication Disorders 7:263-267, 1974.

38.  Minami, R.T., Kaplan, E.N., Wu, G., Jobe, R.P.:  Velopharyngeal Incompetence without Overt Cleft Palate.  Plastic & Reconstructive Surgery 55:573-587, 1975.

39.  Mason, R.M.:  Preventing Speech Disorders Following Adenoidectomy by Preoperative Examination.  Clinical Pediatrics 12:405-414, 1973.

40.  Morris, H.L., Krueger, L.J., and Bumsted, R.M.  Indications of congenital palatal incompetence before diagnosis.  Ann. Otol 91:115-118, 1982.

41.  Croft, C.B., Shprintzen, R.J., and Ruben, R.J. Hypernasal speech following adenotonsillectomy.  Otolaryngol. Head Neck Surg 89:179-188, 1981.

42.  Cotton, R.T.  Nasopharyngeal Stenosis.  Arch Otolaryngol. 111:146-148, 1985.