Complications of adenotonsillectomy

Effect of systemic steroids on post-tonsillectomy bleeding and reinterventions: systematic review and meta-analysis of randomised controlled trials

OBJECTIVE

To evaluate the risk of postoperative bleeding and reintervention with the use of systemic steroids in patients undergoing tonsillectomy.

DESIGN

Systematic review and meta-analysis of randomised controlled trials.

DATA SOURCES

Medline, Embase, Cochrane Library, Scopus, Web of Science, Intute, Biosis, OpenSIGLE, National Technical Information Service, and Google Scholar were searched. References from reviews identified in the search and from included studies were scanned.

REVIEW METHODS

Randomised controlled trials comparing the administration of systemic steroids during tonsillectomy with any other comparator were eligible. Primary outcome was postoperative bleeding. Secondary outcomes were the rate of admission for a bleeding episode, reintervention for a bleeding episode, blood transfusion, and mortality.

RESULTS

Of 1387 citations identified, 29 randomised controlled trials (n=2674) met all eligibility criteria. Seven studies presented a low risk of bias, but none was specifically designed to systematically identify postoperative bleeding. Administration of systemic steroids did not significantly increase the incidence of post-tonsillectomy bleeding (29 studies, n=2674 patients, odds ratio 0.96 (95% confidence interval 0.66 to 1.40), I²=0%). We observed a significant increase in the incidence of operative reinterventions for bleeding episodes in patients who received systemic steroids (12, n=1178, 2.27 (1.03 to 4.99), I²=0%). No deaths were reported. Sensitivity analyses were consistent with the findings.

CONCLUSIONS

Although systemic steroids do not appear to increase bleeding events after tonsillectomy, their use is associated with a raised incidence of operative reinterventions for bleeding episodes, which may be related to increased severity of bleeding events. Systemic steroids should be used with caution, and the risks and benefits weighed, for the prevention of postoperative nausea and vomiting after tonsillectomy before further research is performed to clarify their condition of use.

Treatment options for obstructive sleep apnea

Sleep apnea is a major public health problem that afflicts 9% of women and 24% of men 30 to 60 years of age. It is highly treatable, but when untreated, it has been associated with (but not necessarily linked to) increased probability of cerebral and coronary vascular disease, congestive heart failure, metabolic dysfunction, cognitive dysfunction, excessive daytime sleepiness, motor vehicle accidents, reduced productivity, and decreased quality of life. The gold standard for treatment in adults is positive airway pressure (PAP) therapy: continuous PAP (CPAP), bilevel PAP, autotitrating CPAP, or autotitrating bilevel PAP. Measures to increase compliance with PAP therapy include medical or surgical treatment of any underlying nasal obstruction, setting appropriate pressure level and airflow, mask selection and fitting, heated humidification, desensitization for claustrophobia, patient and partner education, regular follow-up with monitoring of compliance software, and attendance of support groups (eg, AWAKE). Adjunctive treatment modalities include lifestyle or behavioral measures and pharmacologic therapy. Patients with significant upper airway obstruction who are unwilling or unable to tolerate PAP therapy may benefit from surgery. Multilevel surgery of the upper airway addresses obstruction of the nose, oropharynx, and hypopharynx. A systematic approach may combine surgery of the nose, pharynx, and hypopharynx in phase 1, whereas skeletal midface advancement or tracheotomy constitutes phase 2. Clinical outcomes are reassessed through attended diagnostic polysomnogram performed 3 to 6 months after surgery. Oral appliances can be used for patients with symptomatic mild or moderate sleep apnea who prefer them to PAP therapy or for whom PAP therapy has failed or cannot be tolerated. Oral appliances also may be used for patients with severe obstructive sleep apnea who are unable or unwilling to undertake PAP therapy or surgery. For children, the main treatment modality is tonsillectomy and adenoidectomy, with or without turbinate surgery. Children with craniofacial abnormalities resulting in maxillary or mandibular insufficiency may benefit from palatal expansion or maxillary/mandibular surgery. PAP therapy may be used for children who are not surgical candidates or if surgery fails.

Clinical practice guideline: tonsillectomy in children

OBJECTIVE

Tonsillectomy is one of the most common surgical procedures in the United States, with more than 530,000 procedures performed annually in children younger than 15 years. Tonsillectomy is defined as a surgical procedure performed with or without adenoidectomy that completely removes the tonsil including its capsule by dissecting the peritonsillar space between the tonsil capsule and the muscular wall. Depending on the context in which it is used, it may indicate tonsillectomy with adenoidectomy, especially in relation to sleep-disordered breathing. This guideline provides evidence-based recommendations on the preoperative, intraoperative, and postoperative care and management of children 1 to 18 years old under consideration for tonsillectomy. In addition, this guideline is intended for all clinicians in any setting who interact with children 1 to 18 years of age who may be candidates for tonsillectomy.

PURPOSE

The primary purpose of this guideline is to provide clinicians with evidence-based guidance in identifying children who are the best candidates for tonsillectomy. Secondary objectives are to optimize the perioperative management of children undergoing tonsillectomy, emphasize the need for evaluation and intervention in special populations, improve counseling and education of families of children who are considering tonsillectomy for their child, highlight the management options for patients with modifying factors, and reduce inappropriate or unnecessary variations in care.

RESULTS

The panel made a strong recommendation that clinicians should administer a single, intraoperative dose of intravenous dexamethasone to children undergoing tonsillectomy. The panel made a strong recommendation against clinicians routinely administering or prescribing perioperative antibiotics to children undergoing tonsillectomy. The panel made recommendations for (1) watchful waiting for recurrent throat infection if there have been fewer than 7 episodes in the past year or fewer than 5 episodes per year in the past 2 years or fewer than 3 episodes per year in the past 3 years; (2) assessing the child with recurrent throat infection who does not meet criteria in statement 2 for modifying factors that may nonetheless favor tonsillectomy, which may include but are not limited to multiple antibiotic allergy/intolerance, periodic fever, aphthous stomatitis, pharyngitis and adenitis, or history of peritonsillar abscess; (3) asking 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; (4) counseling caregivers about tonsillectomy as a means to improve health in children with abnormal polysomnography who also have tonsil hypertrophy and sleep-disordered breathing; (5) counseling caregivers that sleep-disordered breathing may persist or recur after tonsillectomy and may require further management; (6) advocating for pain management after tonsillectomy and educating caregivers about the importance of managing and reassessing pain; and (7) clinicians who perform tonsillectomy should determine their rate of primary and secondary posttonsillectomy hemorrhage at least annually. The panel offered options to recommend tonsillectomy for recurrent throat infection with a frequency of at least 7 episodes in the past year or at least 5 episodes per year for 2 years or at least 3 episodes per year for 3 years with documentation in the medical record for each episode of sore throat and 1 or more of the following: temperature >38.3°C, cervical adenopathy, tonsillar exudate, or positive test for group A β-hemolytic streptococcus.

[Current techniques in tonsil surgery]

In recent years, consolidation of tonsillar hypertrophy as the principal surgical procedure has led to the emergence of new techniques. Most aim to reduce volume (tonsillectomy or tonsil reduction). These techniques have considerably decreased intra- and postoperative hemorrhages and pain intensity. The present article describes the mechanisms and the advantages and disadvantages of the various techniques, including electro-dissection using electrical scalpels, reduction using a microdebrider, ultrasonic scalpel, radiofrequency (with its different variations) and CO(2) laser. When techniques that reduce tonsil volume are used, the possibility of recurrence of the tonsillar hypertrophy is high if less than 85% of the tonsil is removed. There is also a considerable possibility of infection of the remaining tonsils, whichever technique is used, and therefore these techniques are not valid in the case of repetitive tonsillitis. Recently, alternatives to classical adenoidectomy using adenoid curette have also appeared. Bleeding can be minimized by using a microdebrider, radiofrequency or a blood coagulator. We also discuss the concept of partial adenoidectomy, which is preferred in patients at risk of velopharyngeal insufficiency.

Post-tonsillectomy pulmonary complication in a patient with tonsillar myeloid sarcoma

Myeloid sarcoma in a patient with myelodysplastic syndrome (MDS) manifesting as a non-healing tonsillar ulcer is an extremely rare occurrence. We report the case of a 57-year-old male smoker with a non-healing tonsillar ulcer who underwent tonsillectomy to rule out tonsillar carcinoma after failed antibiotic therapy. On postoperative day 2, he presented with a temperature of 40°C and white blood cell count of 34700/μL. Antibiotic therapy was begun; however, he died 1 day later due to pulmonary infection and septic shock. Though extremely rare, tonsillar involvement of MDS should be considered in the differential diagnosis of a non-healing tonsillar lesion. When definitive diagnosis requires a tissue sample, punch biopsy may be preferable to tonsillectomy in a patient who may be immunocompromised, and appropriate prophylactic antibiotics should be administered.

A review of malpractice cases after tonsillectomy and adenoidectomy

OBJECTIVE

To examine sources of litigation following tonsillectomy and/or adenoidectomy.

STUDY DESIGN

Analysis of malpractice claims filed after tonsillectomy or adenoidectomy provided by 16 medical liability insurance companies.

SETTING

Not applicable.

SUBJECTS AND METHODS

Data was obtained from 16 members of the Physician Insurers Association of America. All claims were either filed or closed between 1985 and 2006. Claims were evaluated and categorized according to the type of complication.

RESULTS

One hundred and fifty-four claims were identified between 1985 and 2006. Six categories were created based on frequency of claims (bleeding complication n=27 [17.5%], airway fire n=2 [1.5%], burns n=28 [18.2%], consent related n=9 [5.8%], medication related n=9 [5.8%] and residual tissue/recurrence n=9 [5.8%]). Other less frequent claims were grouped as miscellaneous n=70 [45.5%].

CONCLUSIONS

A significant portion of malpractice claims following tonsillectomy or adenoidectomy are related to complications not commonly discussed in the literature.

Topical clindamycin in post-adenotonsillectomy analgesia in children: a double-blind, randomized clinical trial

OBJECTIVES

Tonsillectomy, with or without adenoidectomy, is one of the most common surgical procedures in pediatric otolaryngology. Pain is the main cause of morbidity in the postoperative period, where it is serious in some cases, leading to odynophagia and resultant complications such as dehydration. We evaluated the effect of topical clindamycin in the reduction of oropharyngeal pain in children who underwent adenotonsillectomy. Secondary outcomes were otalgia, analgesic use, oral bacterial count, type of diet, secondary bleeding, vomiting, fever, and weight loss.

STUDY DESIGN

Double-blind, randomized clinical trial.

SETTING

Tertiary hospital.

SUBJECTS AND METHODS

Eighty-two children of both sexes between four and 12 years of age who underwent adenotonsillectomy were allocated to receive topical clindamycin or placebo in the immediate preoperative, intraoperative, and eight-to-12-hours postoperative periods. Pain was measured using a faces pain scale for five days.

RESULTS

Reduction of oropharyngeal pain was significant with the use of clindamycin only on the first postoperative day (95% confidence interval, 2.22 to 4.41 [clindamycin] vs 4.53 to 6.3 [placebo]; P = .002). No difference was observed in the aerobic and anaerobic counts by tongue swab between premedication and third-postoperative-day samplings. There were no differences with respect to reduction in otalgia, paracetamol use, return to normal diet, variation in weight, secondary hemorrhage, vomiting, and fever.

CONCLUSION

The use of topical clindamycin was beneficial in reducing pain on the first postoperative day, without effect on subsequent days. Future investigations could examine the use of topical clindamycin not only in the first 12 hours but also during five days of follow-up.

Incidence of bleeding complications in pediatric patients with type 1 von Willebrand disease undergoing adenotonsillar procedures

OBJECTIVE

To review the incidence of postoperative bleeding in children with type 1 von Willebrand disease (VWD) who were treated with a single institution protocol.

STUDY DESIGN

We performed a retrospective study to determine the postoperative hemorrhage rate in pediatric patients with type 1 VWD who were treated via the Children's Hospital of Philadelphia institutional protocol. This protocol utilizes intravenous desmopressin (DDAVP), oral aminocaproic acid, and overnight observation.

RESULTS

Between the years of 2000 to 2006, 41 children with type 1 VWD underwent an adenotonsillar procedure and were treated with this protocol. Seven patients (17%) experienced delayed (>24 hours after surgery) postoperative hemorrhage requiring intervention. Five of the 7 patients required cautery to control the bleeding, and the remaining 2 patients responded to DDAVP and aminocaproic acid alone. Older age and lower VW antigen levels were associated with postoperative hemorrhage (P = .05).

CONCLUSIONS

Despite therapeutic intervention to decrease the risk of postoperative hemorrhage, the incidence of hemorrhage was higher in pretreated patients with type 1 VWD than in children without bleeding disorders. Further prospective studies are necessary to determine the optimal treatment to reduce bleeding complications in these patients.

Rare post-tonsillectomy complication in human immunodeficiency virus positive patient: ulcero-necrotic lesion of tonsillar fossa

OBJECTIVE

Post-tonsillectomy complications are common. The majority are easily recognised because of their frequent occurrence and can be managed as required. Infrequent complications may be misdiagnosed or managed inappropriately. We present a previously unreported complication of tonsillectomy.

CASE REPORT

A 45-year-old Afro-Caribbean man underwent routine tonsillectomy. Eight weeks post-operatively, he developed an ulcero-necrotic lesion of the tonsillar fossa. Subsequent investigation revealed that he was human immunodeficiency virus positive. It is highly likely that the patient's underlying immuno-compromised state, secondary to human immunodeficiency virus infection, contributed to this ulcero-necrotic lesion.

CONCLUSIONS

This case highlights the importance of clinician awareness of rare complications of tonsillectomy, in order to facilitate identification and appropriate investigation.

Referred otalgia: a structured approach to diagnosis and treatment

Many patients who present with otalgia have a normal otological examination, and a distant source of pain must be considered. The ear receives an extensive sensory innervation arising from six nerve roots. Many other structures in the head, neck and thorax share a common neuronal pathway with the ear, and these tissues represent the possible sites of disease in the cases of referred otalgia. Consequently, the differential diagnosis is extensive and varied. Making an accurate diagnosis relies on an understanding of the complex distribution of nerve fibres and a structured approach to patient assessment. This article aims to classify the aetiology of referred otalgia and to outline current treatments for these conditions. The origins of referred otalgia may be as remote as the cranial cavity and thorax; however, dental disease, tonsillitis, temporomandibular joint disorders and cervical spine pathology represent the most frequent causes. Ear pain may also be the first sign of a head and neck malignancy. Patients complaining of otalgia, with risk factors for an aerodigestive neoplasm, and a normal ENT examination require an urgent otolaryngological opinion.

A forgotten gauze pack in the nasopharynx: an unfortunate complication of adenotonsillectomy

A case of a foreign body lodged in the nasopharynx for a long time as a complication of adenotonsillectomy is presented. The patient was an 11-year-old boy admitted with nasal obstruction and bilateral foul-smelling purulent rhinorrhea. The diagnosis was confirmed with nasal endoscopy. Immediate removal of foreign body in the nasopharynx was performed under general anesthesia. Although foreign bodies lodged into the nasopharynx are rare, they may cause serious and even fatal complications. A high index of suspicion, particularly for persistent symptoms, is essential and necessitates further investigation before diagnosis of a case of rhinosinusitis or empirically prescribing antibiotics.

Efficacy of tonsillectomy in treatment of recurrent group A beta-hemolytic streptococcal pharyngitis

OBJECTIVE

The objective of this study was to determine whether children with tonsillectomies experienced fewer recurrent group A beta-hemolytic streptococcal (GABHS) infections after surgery compared with children who did not receive tonsillectomies.

STUDY DESIGN/METHODS

The authors conducted a retrospective cohort study of 290 children 4 to <16 years who experienced three or more episodes of group A beta-hemolytic streptococcal pharyngitis at least 1 month apart in 12 months.

RESULTS

Children without tonsillectomy were 3.1 times (95% confidence interval, 1.9-4.9; P < .001) more likely to develop a subsequent group A beta-hemolytic streptococcal pharyngitis infection during follow up than children who underwent tonsillectomy after adjusting for the number of group A beta-hemolytic streptococcal pharyngitis infections per patient within the previous year and the presence of preexisting conditions. Among the children who developed a subsequent group A beta-hemolytic streptococcal pharyngitis infection, the children without a tonsillectomy developed a group A beta-hemolytic streptococcal pharyngeal infection sooner (median, 0.6 vs. 1.1 years).

CONCLUSIONS

Tonsillectomy is associated with a decrease in the number of group A beta-hemolytic streptococcal pharyngitis infections in children with a history of recurrent groups A beta-hemolytic streptococcal pharyngitis infection. Tonsillectomy also increased the amount of time before development of further GABHS pharyngitis.

Three extraordinary complications of adenotonsillectomy

In a 6-month period, three patients aged 5-11 years were transferred to our tertiary care children's hospital for management of severe complications following adenotonsillectomy. The first patient presented with headaches and lethargy and was found to have a sagittal sinus thrombosis from severe dehydration. The second patient was admitted immediately following an intra-operative oral cavity fire due to electrocautery malfunction. She suffered partial-thickness burns to the buccal mucosa, palate, and lips. The third patient was admitted with torticollis. Grisel's syndrome was initially suspected, but a thorough work up resulted in the diagnosis of a conversion disorder. These cases comprise an interesting cohort of three little-known complications of adenotonsillectomy.

Obstructive Sleep Apnea

Obstructive sleep apnea (OSA) is a major public health problem in the US that afflicts at least 2% to 4% of middle-aged Americans and incurs an estimated annual cost of 3.4 billion dollars. At Stanford, we utilize a multispecialty team approach combining the expertise of sleep medicine specialists (adult and pediatric), maxillofacial and ear, nose, and throat surgeons, and orthodontists to determine the most appropriate therapy for complicated OSA patients. The major treatment modality for children with OSA is tonsillectomy and adenoidectomy with or without radiofrequency treatment of the nasal inferior turbinate. Children with craniofacial anomalies resulting in maxillary or mandibular insufficiency may benefit from palatal expansion or more invasive maxillary/mandibular surgery. Continuous positive airway pressure (PAP) therapy is used in children with OSA who are not surgical candidates or have failed surgery. As a last resort, tracheotomy may be used in patients with persistent or severe OSA who do not respond to other measures. The cornerstone of treatment in adults utilizes PAP: continuous PAP, bilevel PAP, or auto PAP. Treatment of nasal obstruction, appropriate titration, attention to mask-fit issues, desensitization for claustrophobia, use of heated humidification for nasal dryness and nasal pain with continuous PAP, patient education, regular follow-up, use of compliance software (in selected individuals), and referral to support groups (AWAKE) are measures that can improve patient compliance. Adjunctive treatment modalities include lifestyle/behavioral/pharmacologic measures. Oral appliances can be used in patients with symptomatic mild sleep apnea or upper airway resistance syndrome. Patients who are unwilling or unable to tolerate continuous PAP or who have obvious upper airway obstruction may benefit from surgery. Surgical success depends on appropriate patient selection, the procedure performed, and the experience of the surgeon. Phase I surgeries have a success rate of 50% to 60%, whereas phase II surgeries have a success rate greater than 90%.

[Inpatient treatment of tonsillectomy from the patient's point of view]

BACKGROUND

Hospitalization after tonsillectomy for more than 24 h is still controversial. In order to obtain the patient's point of view, we designed a questionnaire for all patients undergoing tonsillectomy.

METHODS AND RESULTS

From January 2002, we asked all patients admitted for elective tonsillectomy to fill out an anonymous questionnaire on their preferences for the duration of hospitalization after surgery. The majority of patients (79.6%) returning the questionnaire supported a hospital stay of at least 4 days after surgery. Options for a shorter stay of only 24 h or tonsillectomy in day-surgery without overnight stay were declined by all patients.

CONCLUSION

We found that most patients preferred to remain in hospital for about 4 days postoperatively because they felt that they would have better access to effective analgesia. Another reason involved the increased risk for haemorrhage during the first few days after tonsillectomy.

Coblation tonsillectomy versus dissection tonsillectomy: postoperative hemorrhage

OBJECTIVES/HYPOTHESIS

Coblation tonsillectomy is a recently introduced surgical technique. To measure its benefits against traditional tonsillectomy techniques, it is necessary to compare their complication rates. The study aims to identify differences in reactionary and secondary hemorrhage proportions, comparing coblation with dissection tonsillectomy.

STUDY DESIGN

Prospective observational cohort study.

METHODS

Rates of reactionary and delayed postoperative hemorrhage were measured, comparing 844 coblation tonsillectomies with a control group of 743 tonsillectomies performed by blunt dissection with bipolar diathermy hemostasis.

RESULTS

The secondary hemorrhage rate with coblation-assisted tonsillectomy was 2.25% compared with 6.19% in the control group (P <.05). The rate of secondary hemorrhage in children following coblation tonsillectomy was 0.95% compared with 4.77% in the control group (P <.05). The difference was also significant (P <.05) in the adult population (4.40% vs. 8.81%, respectively). No difference was found in the reactionary hemorrhage proportions.

CONCLUSION

In the study, coblation tonsillectomy was associated with a lesser incidence of delayed hemorrhage, more significantly in the pediatric population. The new technique using tissue coblation for tonsil dissection offers significant advantages in the postoperative period compared with dissection tonsillectomy with bipolar diathermy hemostasis. Coblation is associated with less postoperative pain and early return to daily activities. Also, there are fewer secondary infections of the tonsil bed and significantly lower rates of secondary hemorrhage with coblation. These results and the disposable nature of the coblation equipment promote coblation tonsillectomy as the authors' preferred dissection method.