Complications of adenotonsillectomy

Current Opinion in Otolaryngology & Head & Neck Surgery:

December 2010 - Volume 18 - Issue 6 - p 539–543

doi: 10.1097/MOO.0b013e3283404dcc

Pediatric otolaryngology: Edited by Lisa Buckmiller

Statham, Melissa M

Abstract

Purpose of review: Tonsillectomy and adenoidectomy are two of the most commonly performed pediatric surgical procedures. As with all surgical intervention, tonsillectomy and adenoidectomy are associated with a host of potential complications. Fortunately, for most children undergoing adenotonsillectomy (T&A), complications are rare. This review is intended to summarize recent reports, which may lead to prevention and treatment of T&A complications.

Recent findings: The presented reports of complications and risk factors for complications in children undergoing T&A highlight perioperative medical management as a means to decrease perioperative complications. Certain tonsillectomy techniques, such as microdebrider intracapsular tonsillectomy, may lead to decreased posttonsillectomy hemorrhage and dehydration. Despite published recommendations, preoperative assessments for bleeding diatheses vary among practitioners. Conversely, guidelines for evaluation of posttonsillectomy hemorrhage are lacking. Some pediatric populations, such as children with coagulopathy, neurologic disease, and obesity, have increased risk of perioperative complications, and recent reports regarding their care are presented.

Summary: We present recent data pertinent to the contemporary management of medical and surgical complications of T&A, with particular focus on specific at-risk pediatric populations. In the patient groups illustrated in this review, anticipation of complications may decrease complications or lead to improved management of complications when they occur.

Postoperative bleeding in paediatric ENT surgery. First results of the German ESPED trial

Hämostaseologie 30 (41), S108-11 (Nov 2010)

Bidlingmaier C, Olivieri M, Stelter K, Eberl W, von Kries R, Kurnik K; 

Bleeding after ear-nose-and throat surgery in children is a serious complication. With the help of the German Surveillance Unit for Rare Paediatric Disorders (Erhebungseinheit für seltene pädiatrische Erkrankungen in Deutschland; ESPED) a two year survey was performed to record the incidence, severity, reasons and treatment of haemorrhages. During the study period, 1069 bleeds were reported from 720 paediatric hospitals and departments of otorhinolaryngology after adenoidectomy and tonsillectomy. 713 reports could be analyzed. Two deaths occurred after adenoidectomy.

Although laboratory screening was performed in more than 70% of all cases, bleeding complications were neither foreseeable nor preventable. Inherited coagulopathies were rare and in most cases not detected, neither by laboratory screening nor by taking a history.

Since preoperative measures cannot help much to improve the situation, all efforts have to be taken to improve the postoperative period, especially since more than 20% of the hemorrhages occurred during weekends. Guidelines on postoperative care and behaviour should therefore be implemented and parents and patients must be informed on bleeding risks and on what to do in case of emergency. If bleeding occurs, extensive coagulation testing is mandatory.

Avoiding airway obstruction after pediatric adenotonsillectomy

International Journal of Pediatric Otorhinolaryngology
Volume 73, Issue 6, June 2009, Pages 803-806
Glenn Isaacsona,  aDepartment of Otolaryngology – Head & Neck Surgery, Temple University School of Medicine, USA  bDepartment of Pediatrics, Temple University School of Medicine, USA

Abstract
Objective

To evaluate the efficacy of a protocol designed to prevent post-adenotonsillectomy airway obstruction in small children with obstructive sleep apnea.
Design

Computerized retrospective review of single surgeon case series.
Setting

Tertiary children's medical center.
Methods

Children with sleep study proven obstructive sleep apnea or children under the age of 3 years with clinically suspected obstructive sleep apnea were treated according to a protocol that included: (1) rapid bloodless tonsillectomy; (2) repeated release of the tonsillar retractor; (3) avoidance of uvular edema; (4) routine intra-operative intranasal oxymetazoline, and placement of nasal airway; (5) extended recovery room observation. Primary outcome measures were (1) avoidance of unexpected intensive care unit admission; (2) post-extubation pulmonary edema; (3) aspiration pneumonia.
Results

During the period March 2004–August 2007, 864 children underwent adenotonsillectomy by a single surgeon—604 for the indication of obstructive sleep apnea or adenotonsillar hypertrophy with obstruction. Two hundred and ten were under the age of 3 years or had sleep study proven obstructive sleep apnea. There were two unexpected admissions to the pediatric intensive care unit for persistent upper airway obstruction—none required intubation. No child developed post-obstructive pulmonary edema. Three children were treated for infiltrates consistent with aspiration pneumonitis.
Conclusion

Most cases of post-extubation pulmonary edema and pneumonia can be avoided in young children and those with mild-to-moderate obstructive sleep apnea following a protocol that anticipates and avoids precipitating causes of upper airway obstruction.