- Email: [email protected]
Revisiting outpatient tonsillectomy in young children
Revisiting outpatient tonsillectomy in young children ADAM T. ROSS,
MD,
KEN KAZAHAYA,
MD,
and LAWRENCE W. C. TOM,
OBJECTIVE: Postoperative same-day discharge is safe for most children undergoing tonsillectomy. However, young children with upper airway obstruction have a higher risk of postoperative complications. We review our tonsillectomy experience in children under 36 months to evaluate the safety of outpatient tonsillectomy in this population. STUDY DESIGN AND SETTING: We conducted a retrospective study of all children under 36 months who underwent tonsillectomy during a recent 2-year period at The Children’s Hospital of Philadelphia. RESULTS: The indication for tonsillectomy in 96% of 421 children was upper airway obstruction. Eighteen percent required postoperative treatment to prevent respiratory compromise; 56% of these patients had no associated medical comorbidity. Patients younger than 24 months and those with medical comorbidities were more likely to require intervention. CONCLUSION AND SIGNIFICANCE: It is not possible to preoperatively anticipate which children will have postsurgical complications. We recommend planning an overnight admission for children younger than 36 months undergoing tonsillectomy. (Otolaryngol Head Neck Surg 2003;128:326-31.)
T onsillectomy is one of the most common surgical procedures performed on children. Most children are now discharged on the same day as surgery, but care must be taken not to generalize this practice to all patients without adequately identifying high-risk groups in whom this practice is inappropriate. Upper airway obstruction (UAO) has taken the From the Department of Otorhinolaryngology–Head and Neck Surgery, The University of Pennsylvania School of Medicine and The Children’s Hospital of Philadelphia. Presented at the Annual Meeting of the American Academy of Otolaryngology–Head and Neck Surgery, Denver, CO, September 9-12, 2001. Reprint requests: Lawrence W. C. Tom, MD, The Children’s Hospital of Philadelphia, 1 Wood Center, Philadelphia, PA 19104; e-mail, [email protected] Copyright © 2003 by the American Academy of Otolaryngology–Head and Neck Surgery Foundation, Inc. 0194-5998/2003/$30.00 ⫹ 0 doi:10.1067/mhn.2003.60 326
MD,
Philadelphia, Pennsylvania
place of recurrent tonsillitis as the most common indication for tonsillectomy in the pediatric population. There has been an increased awareness of the potential harm of UAO, and more children are undergoing tonsillectomy at a younger age. Sleep apnea, mouth breathing, snoring, and sleep disturbances are some of the common effects of UAO, with pulmonary hypertension and cor pulmonale the rare end-stage results in untreated patients.1,2 UAO has been shown to be a cause of developmental delay, failure to thrive, and other behavioral disturbances.3 There has been a reluctance to perform tonsillectomy on children younger than 36 months because of their small airways and low blood volume reserves,4 and it is generally accepted that a planned admission should be arranged for these patients. Advances in anesthetic and surgical techniques have been reported to reduce postoperative morbidity in these children, and third-party payers often recommend that tonsillectomy on these patients be performed on an outpatient basis. With these advances, there may be a group of children in whom same-day surgery is safe. A retrospective study of 421 children younger than 36 months undergoing tonsillectomy was performed to evaluate the safety of outpatient surgery in this age group and to identify higher-risk patients. METHODS AND MATERIALS A search by procedure codes identified all children younger than 36 months who underwent tonsillectomy or adenotonsillectomy at The Children’s Hospital of Philadelphia from July 1, 1997, through June 30, 1999. Surgery was performed by 1 of 6 attending surgeons or by a resident with attending supervision. The institutional review board granted approval for this study. General anesthesia was induced, and most patients were given intravenous paralytics, narcotics, dexamethasone, and ondansetron at doses appropriate for their weight. Most patients received 250 mg amoxicillin intravenously (cefazolin if allergic to penicillin), with the dose adjusted to 500 mg if their weight exceeded 15 kg.
Otolaryngology– Head and Neck Surgery Volume 128 Number 3
Tonsillar tissue was removed using monopolar electrocautery, and hemostasis was obtained with suction cautery and/or suture ligature. Adenoid tissue was removed by curettage while bleeding was controlled with pressure and suction cautery. After initial hemostasis, topical oxymetazoline was often used liberally to obtain vasoconstriction. The large volume of adenotonsillectomies performed at our institution has resulted in a standardized surgical technique that is followed closely by each attending and resident. Postoperatively, most patients proceeded to the recovery unit and then to a standard hospital bed where intravenous fluids, analgesics, and antibiotics were administered. Children in an intensive care unit (ICU) preoperatively returned to an ICU after surgery. Rarely, patients were transferred to an ICU after initial efforts to manage them in the recovery unit. Criteria for ICU admission included the presence of an artificial airway, significant obstructive episodes or desaturations (regardless of oxygen supplementation), or a strong suspicion of the need for airway intervention (AI) given certain preoperative medical conditions. AI refers to continuous positive airway pressure (CPAP) ventilation, nasopharyngeal (NP) airway placement, or intubation. Data from each patient’s postoperative course were extracted from the medical chart and included the following: admitting diagnosis, secondary diagnoses and medical comorbidities, procedures performed, surgical and anesthetic time, size of removed specimens, intraoperative and postoperative medications, location of postoperative stay, length of stay, supplemental medicinal and supportive therapy, and postoperative complications. RESULTS During the 2-year period described, 421 children younger than 36 months underwent either adenotonsillectomy (n ⫽ 414) or tonsillectomy alone (n ⫽ 7). The average age was 27.2 months, with only 5 children younger than 12 months. Table 1 summarizes age and sex distribution. Surgical indications are listed in Table 2. Apnea was documented by history, sleep sonography, or polysomnography. Ninety-one percent of patients presented with UAO, and 56% had apnea. Only
ROSS et al
327
Table 1. Patient characteristics Total No. of patients Male Female Average age (mean mo) Age ⬍12 mo Age 12-24 mo Age 24-36 mo
421 218 (51.8%) 203 (48.2%) 27.2 5 106 310
Table 2. Indications for surgery Indication
No. of patients (%)
UAO with apnea UAO without apnea Infection ⫹ UAO Infection Indication not documented Total
233 (56) 148 (35) 18 (4) 18 (4) 4 (1) 421
UAO, Upper airway obstruction.
4% of children had surgery for recurrent infection alone, and an additional 4% had infection as well as obstruction as their indications. Two hundred fifty-one patients underwent adenotonsillectomy without another procedure. Thirty-nine of these patients were admitted to an ICU, and for this group, surgical and anesthetic times were longer by an average of 2.7 and 5.4 minutes, respectively. In all except 58 cases, a paralytic was administered, mostly in the form of vecuronium (84%). Antibiotics were given to 358 of the 421 children (322 amoxicillin, 22 cefazolin, 3 clindamycin, 1 erythromycin). The majority of patients received both ondansetron (88%), dexamethasone (94%), and either morphine (93%) or fentanyl citrate (3%). There was no statistically significant relationship between the incidence of postoperative AI or another complication and the combination of anesthetic that was administered. Eighty-four percent of patients were admitted to a standard room after initial recovery in the postanesthesia care unit (PACU); 16% were admitted to an ICU for monitoring or respiratory intervention. Thirty one percent of children aged 12 to 24 months were managed in an ICU compared with 9.4% in the age group 24 to 36 months. This difference was statistically significant (2 test, P ⬍ 0.001). To facilitate comparison between
Otolaryngology– Head and Neck Surgery March 2003
328 ROSS et al
Table 3. Distribution of patients by age and intensive care unit status Current study Age (mo)
0-12 12-24 24-36 Total
Tom et al5
Non-ICU
ICU
Non-ICU
ICU
1 73 281 355 (84.3%)
4 33 29 66 (15.7%)
6 72 128 206 (92.4%)
3 6 8 17 (7.6%)
these data and those from Tom et al,5 both sets of data are listed in Table 3. Most patients were admitted to the ICU due to the need for AI of some type. A minority of patients was admitted to the ICU without a clear clinical indication. Of the 66 patients managed in the ICU, 27 did not require any apparent intervention and went home the next day. The average age of ICU patients was significantly younger (23 months) than those who were monitored on the floor (28 months). The average length of stay in the ICU was 3.6 days. Eighteen percent of all patients required one or more forms of additional management to avoid respiratory compromise. Despite intervention, 41 of these patients still went home the day after surgery. Twenty-eight patients received intravenous steroids to reduce airway edema, 44 children received supplemental oxygen alone, and 32 patients required AI with or without oxygen. Twenty-nine patients received an NP airway. Eleven children were placed on CPAP ventilation. Eight patients remained intubated, and 2 patients were reintubated postoperatively. Of the 33 patients in the 12- to 24-month age group sent to the ICU, 15 required AI. In the 24to 36-month age group, 16 of 29 required AI. Of the patients needing additional management, 56% had no associated comorbidity. Children younger than 24 months were more likely (18%) than children aged 24 through 36 months (5.5%) to require AI, supplemental steroids, and hospital admission of longer than 3 days. Although few in number, those younger than 12 months had a 40% chance of requiring AI versus 14% and 5% for those between 12 and 24 months and those between 24 and 36 months of age, respectively (Table 4). Associated medical conditions were present in 89 patients, the most common of which are listed
in Table 5. Patients with trisomy 21 and bronchopulmonary dysplasia were more frequently admitted to the ICU and were more likely to receive postoperative steroids, require supplemental oxygen, require AI, and be hospitalized for longer than 3 days. Ninety-four percent of children were admitted for at least one night. The remaining 24 patients were discharged after several hours of evaluation on the floor. These patients were sent home solely based on the clinical avaluation of the attending surgeon. Those sent home on the same day of surgery were on average 3 months older (30.1 months) than the average age in the study (27.2 months), and only 3 of these children were younger than 24 months. Seventy-one percent of admitted patients were discharged the next day. Ninety-eight children (23%) were hospitalized for longer than 1 day. The most common reason for an extended admission was the inability for children to maintain oral intake (59%), followed by AI (18%). Twenty-four patients were discharged from the hospital with home intravenous supplementation as a result of poor intake. The most common complication requiring readmission was dehydration (3.1%). Postoperative hemorrhage occurred in 12 patients (2.9%) at a mean delay of 8.4 days after surgery. All of these children returned to the operating room for control of hemorrhage. One patient bled within 24 hours of surgery, another bled twice, and 1 patient had an adenoid bleed on postoperative day 20. There were no deaths. DISCUSSION UAO has become the most common indication for tonsillectomy in the pediatric population.4,5 The detrimental effects and clinical manifestations
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ROSS et al
329
Table 4. Use of airway intervention Age (mo)
Total No. of patients
Intervention,* n (%)
None or oxygen only, n
5 106 310 421
2 (40) 15 (14) 16 (5) 33 (8)
3 91 294 388
0-12 12-24 24-36 Total *
Interventions included nasopharyngeal airway, continuous positive airway pressure (CPAP) ventilation, or intubation.
Table 5. Presence of selected medical comorbidities Comorbidity
No. of patients
ICU admission, n
Airway intervention, n
Non-ICU admission, n
Asthma Trisomy 21 Bronchopulmonary dysplasia Cardiac disease Blood dyscrasia Craniofacial abnormalities
27 9 9 4 4 2
4 5 7 2 1 0
3 5 6 1 0 0
23 4 2 2 3 2
of UAO have been well documented. Manifestations of prolonged UAO often become apparent at an early age and, if significant, require treatment.4,6 Ninety-six percent of children in our study underwent tonsillectomy to relieve UAO. Tonsillectomy with same-day discharge has been shown to be a safe and cost-effective procedure for many patients. However, physicians must guard against inappropriately discharging patients without identifying those at a higher risk for postoperative complications and their need for hospitalization. Although the safety of outpatient tonsillectomy has been reported in the literature, many of these studies have focused on the low incidence of hemorrhage and dehydration.7-11 Most of these studies exclude from analysis those children with obstructive sleep apnea or chronic medical illness.9-12 Mitchell et al13 studied children younger than 36 months and deemed outpatient tonsillectomy safe but excluded from their study all patients with chronic illness or obstructive sleep apnea. Lalakea et al14 studied patients younger than 12 years and concluded that outpatient tonsillectomy was safe after a 3-hour period of postoperative observation. Again, all patients with significant medical comorbidities and severe apnea were excluded from the study. Despite the fact that the study excluded the least healthy patients, they still reported that 24%
of patients younger than 3 years required conversion to inpatient status based on clinical assessment. It is therefore difficult to justify outpatient tonsillectomy in young children based on the existing literature. In an effort to clarify the risk in young children, Tom et al5 analyzed children younger than 36 months who underwent adenotonsillectomy or tonsillectomy from 1987 through 1988 and concluded that patients younger than 36 months were inappropriate candidates for outpatient surgery. Preoperative apnea, age younger than 12 months, and the presence of associated medical conditions increased the risk of postoperative airway complications. Advances in anesthetic and surgical techniques during the past decade have improved patient care. The use of dexamethasone15 and ondansetron appears to have reduced the incidence of postoperative emesis. Dexamethasone has been shown to reduce postoperative discomfort, improve dietary tolerance, and almost eliminate postoperative emesis, presumably by reducing the inflammatory response in the oropharynx.15 Table 3 summarizes the age distribution and postoperative triage pattern among the different age groups in both this and our earlier study. Despite the fact that the present population was on average 3 months older than that of the previous
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330 ROSS et al
study, there is a statistically significant increase in the percentage of patients admitted to an ICU. More than fifty percent of patients who were sent to an ICU required AI. Age of less than 24 months and the presence of a significant medical comorbidity, especially bronchopulmonary dysplasia and trisomy 21, increased the risk of requiring intervention (2 test, P ⬍ 0.001 and ⬍ 0.005). The ICU population was on average 5 months younger than those who were sent to a standard hospital bed. Intraoperative times were longer for the ICU population, most likely due to more complicated anesthesia in a less healthy population. There are several possible explanations for the increase in ICU admission in this study. We hypothesize that our experience with a large volume of patients in this young age group has reduced our threshold for admission to an ICU, especially in children with severe apnea, airway narrowing, or other medical comorbidities. This is supported by the fact that although a higher proportion of patients were admitted to the ICU (15.7% versus 7.6%) in the current study, 41% did not require any special intervention and were discharged home on the first postoperative day directly from the ICU. It is also possible that our large clinical experience has resulted in referrals of a more unhealthy population of patients. However, the fact that a lower proportion of patients in the current study had comorbid conditions (15.6% versus 18%) would speak against such a hypothesis. Studies in the literature emphasize the risk of postoperative hemorrhage as the most dangerous life-threatening complication of adenotonsillectomy. The rate of postoperative hemorrhage in the current study (2.9%) is consistent with prior studies regarding this complication. Our data have shown that a significantly larger proportion of patients younger than 36 months have life-threatening airway events than they do postoperative hemorrhage, which occurs long after discharge from the hospital. Therefore, it is the reasonable concern for respiratory compromise that warrants observation. Patients whose primary indication for tonsillectomy was recurrent infection had an low incidence of immediate postoperative complications. Only 1 of the 18 patients in this group was admitted to the
ICU. Two other patients required postoperative supplemental oxygen on the floor, and all 3 were discharged on the first postoperative day. Conversely, 32 of 50 patients who had apnea documented by sleep studies were admitted to the ICU, and 24 required AI of some type. Eighteen percent of patients required intervention with intravenous steroids, supplemental oxygen, or AI to prevent respiratory compromise. Fifty-four percent of children did not have an associated medical comorbidity to account for their respiratory compromise. This makes it difficult to predict which children will do well in the immediate postoperative period. Patients with conditions that reduce the size of the pharyngeal airway are prone to obstruction; this group includes those with craniofacial abnormalities, most commonly trisomy 21. Children with associated medical comorbidities, especially bronchopulmonary dysplasia, and those of younger age (⬍24 months) had a significantly higher risk of postoperative complications. CONCLUSION Tonsillectomy is a safe procedure for children younger than 36 months, but there is a significant risk for postoperative problems. Anticipation of airway complications and dehydration must be included in the proper management of these patients. There are young children who, after a period of observation, can be discharged on the same day of surgery, but there is no way to identify these patients preoperatively. A planned postoperative hospitalization for these children is recommended. Parents should be made aware of the risk of complications and the possibility of ICU admission. REFERENCES
1. Noonan JA. Reversible cor pulmonale due to hypertrophied tonsils and adenoids: studies of two cases. Circulation 1965;32:164. 2. Menashe VD, Ferrehi C, Muller M. Hypoventilation and cor pulmonale due to chronic airway obstruction. J Pediatr 1965;67:198-203. 3. Schiffmann R, Faber J, Eidelman AI. Obstructive hypertrophic adenoids and tonsils as a cause of infantile failure to thrive: reversed by tonsillectomy and adenoidectomy. Int J Pediatr Otorhinolaryngol 1985;9:183-7. 4. Berkowitz RG, Zalzal GH. Tonsillectomy in children
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5. 6. 7. 8. 9. 10.
ROSS et al
under 3 years of age. Arch Otolaryngol Head Neck Surg 1990;116:685-6. Tom LWC, DeDio RM, Cohen DE, et al. Is outpatient tonsillectomy appropriate for young children? Laryngoscope 1992;102:277-80. Rosenfeld RM, Green RP. Tonsillectomy and adenoidectomy: changing trends. Ann Otol Rhinol Laryngol 1990;99:187-91. Haberman RS, Shattuck TG, Dion NM. Is outpatient suction cautery tonsillectomy safe in a community hospital setting? Laryngoscope 1990;100:511-5. Reiner SA, Sawyer WP, Clark KF, et al. Safety of outpatient tonsillectomy and adenoidectomy. Otolaryngol Head Neck Surg 1990;102:161-8. Maniglia AJ, Kushner H, Cozzi L. Adenotonsillectomy: a safe outpatient procedure. Arch Otolaryngol Head Neck Surg 1989;115:92-4. Guida RA, Mattucci KF. Tonsillectomy and adenoidec-
11. 12. 13.
14. 15.
tomy: an inpatient or outpatient procedure? Laryngoscope 1990;100:491-3. Nicklaus PJ, Herzon FS, Steinle EW. Short-stay outpatient tonsillectomy. Arch Otolaryngol Head Neck Surg 1995;121:521-4. Gabalski EC, Mattucci KF, Setzen M, et al. Ambulatory tonsillectomy and adenoidectomy. Laryngoscope 1996; 106:77-9. Mitchell RB, Pereira KD, Friedman NR, et al. Outpatient adenotonsillectomy: is it safe in children younger than 3 years? Arch Otolaryngol Head Neck Surg 1997;123: 681-3. Lalakea ML, Marquez-Biggs I, Messner A. Safety of pediatric short-stay tonsillectomy. Arch Otolaryngol Head Neck Surg 1999;125:749-52. Tom LWC, Templeton JJ, Thompson ME, et al. Dexamethasone in adenotonsillectomy. Int J Pediatr Otorhinolaryngol 1996;37:115-20.
American Academy of Otolaryngology–Head and Neck Surgery Annual Meetings 2003 2004 2005
Orlando, Florida New York, New York Los Angeles, California
331
September 21-24 September 19-22 September 25-28
MD,
KEN KAZAHAYA,
MD,
and LAWRENCE W. C. TOM,
OBJECTIVE: Postoperative same-day discharge is safe for most children undergoing tonsillectomy. However, young children with upper airway obstruction have a higher risk of postoperative complications. We review our tonsillectomy experience in children under 36 months to evaluate the safety of outpatient tonsillectomy in this population. STUDY DESIGN AND SETTING: We conducted a retrospective study of all children under 36 months who underwent tonsillectomy during a recent 2-year period at The Children’s Hospital of Philadelphia. RESULTS: The indication for tonsillectomy in 96% of 421 children was upper airway obstruction. Eighteen percent required postoperative treatment to prevent respiratory compromise; 56% of these patients had no associated medical comorbidity. Patients younger than 24 months and those with medical comorbidities were more likely to require intervention. CONCLUSION AND SIGNIFICANCE: It is not possible to preoperatively anticipate which children will have postsurgical complications. We recommend planning an overnight admission for children younger than 36 months undergoing tonsillectomy. (Otolaryngol Head Neck Surg 2003;128:326-31.)
T onsillectomy is one of the most common surgical procedures performed on children. Most children are now discharged on the same day as surgery, but care must be taken not to generalize this practice to all patients without adequately identifying high-risk groups in whom this practice is inappropriate. Upper airway obstruction (UAO) has taken the From the Department of Otorhinolaryngology–Head and Neck Surgery, The University of Pennsylvania School of Medicine and The Children’s Hospital of Philadelphia. Presented at the Annual Meeting of the American Academy of Otolaryngology–Head and Neck Surgery, Denver, CO, September 9-12, 2001. Reprint requests: Lawrence W. C. Tom, MD, The Children’s Hospital of Philadelphia, 1 Wood Center, Philadelphia, PA 19104; e-mail, [email protected] Copyright © 2003 by the American Academy of Otolaryngology–Head and Neck Surgery Foundation, Inc. 0194-5998/2003/$30.00 ⫹ 0 doi:10.1067/mhn.2003.60 326
MD,
Philadelphia, Pennsylvania
place of recurrent tonsillitis as the most common indication for tonsillectomy in the pediatric population. There has been an increased awareness of the potential harm of UAO, and more children are undergoing tonsillectomy at a younger age. Sleep apnea, mouth breathing, snoring, and sleep disturbances are some of the common effects of UAO, with pulmonary hypertension and cor pulmonale the rare end-stage results in untreated patients.1,2 UAO has been shown to be a cause of developmental delay, failure to thrive, and other behavioral disturbances.3 There has been a reluctance to perform tonsillectomy on children younger than 36 months because of their small airways and low blood volume reserves,4 and it is generally accepted that a planned admission should be arranged for these patients. Advances in anesthetic and surgical techniques have been reported to reduce postoperative morbidity in these children, and third-party payers often recommend that tonsillectomy on these patients be performed on an outpatient basis. With these advances, there may be a group of children in whom same-day surgery is safe. A retrospective study of 421 children younger than 36 months undergoing tonsillectomy was performed to evaluate the safety of outpatient surgery in this age group and to identify higher-risk patients. METHODS AND MATERIALS A search by procedure codes identified all children younger than 36 months who underwent tonsillectomy or adenotonsillectomy at The Children’s Hospital of Philadelphia from July 1, 1997, through June 30, 1999. Surgery was performed by 1 of 6 attending surgeons or by a resident with attending supervision. The institutional review board granted approval for this study. General anesthesia was induced, and most patients were given intravenous paralytics, narcotics, dexamethasone, and ondansetron at doses appropriate for their weight. Most patients received 250 mg amoxicillin intravenously (cefazolin if allergic to penicillin), with the dose adjusted to 500 mg if their weight exceeded 15 kg.
Otolaryngology– Head and Neck Surgery Volume 128 Number 3
Tonsillar tissue was removed using monopolar electrocautery, and hemostasis was obtained with suction cautery and/or suture ligature. Adenoid tissue was removed by curettage while bleeding was controlled with pressure and suction cautery. After initial hemostasis, topical oxymetazoline was often used liberally to obtain vasoconstriction. The large volume of adenotonsillectomies performed at our institution has resulted in a standardized surgical technique that is followed closely by each attending and resident. Postoperatively, most patients proceeded to the recovery unit and then to a standard hospital bed where intravenous fluids, analgesics, and antibiotics were administered. Children in an intensive care unit (ICU) preoperatively returned to an ICU after surgery. Rarely, patients were transferred to an ICU after initial efforts to manage them in the recovery unit. Criteria for ICU admission included the presence of an artificial airway, significant obstructive episodes or desaturations (regardless of oxygen supplementation), or a strong suspicion of the need for airway intervention (AI) given certain preoperative medical conditions. AI refers to continuous positive airway pressure (CPAP) ventilation, nasopharyngeal (NP) airway placement, or intubation. Data from each patient’s postoperative course were extracted from the medical chart and included the following: admitting diagnosis, secondary diagnoses and medical comorbidities, procedures performed, surgical and anesthetic time, size of removed specimens, intraoperative and postoperative medications, location of postoperative stay, length of stay, supplemental medicinal and supportive therapy, and postoperative complications. RESULTS During the 2-year period described, 421 children younger than 36 months underwent either adenotonsillectomy (n ⫽ 414) or tonsillectomy alone (n ⫽ 7). The average age was 27.2 months, with only 5 children younger than 12 months. Table 1 summarizes age and sex distribution. Surgical indications are listed in Table 2. Apnea was documented by history, sleep sonography, or polysomnography. Ninety-one percent of patients presented with UAO, and 56% had apnea. Only
ROSS et al
327
Table 1. Patient characteristics Total No. of patients Male Female Average age (mean mo) Age ⬍12 mo Age 12-24 mo Age 24-36 mo
421 218 (51.8%) 203 (48.2%) 27.2 5 106 310
Table 2. Indications for surgery Indication
No. of patients (%)
UAO with apnea UAO without apnea Infection ⫹ UAO Infection Indication not documented Total
233 (56) 148 (35) 18 (4) 18 (4) 4 (1) 421
UAO, Upper airway obstruction.
4% of children had surgery for recurrent infection alone, and an additional 4% had infection as well as obstruction as their indications. Two hundred fifty-one patients underwent adenotonsillectomy without another procedure. Thirty-nine of these patients were admitted to an ICU, and for this group, surgical and anesthetic times were longer by an average of 2.7 and 5.4 minutes, respectively. In all except 58 cases, a paralytic was administered, mostly in the form of vecuronium (84%). Antibiotics were given to 358 of the 421 children (322 amoxicillin, 22 cefazolin, 3 clindamycin, 1 erythromycin). The majority of patients received both ondansetron (88%), dexamethasone (94%), and either morphine (93%) or fentanyl citrate (3%). There was no statistically significant relationship between the incidence of postoperative AI or another complication and the combination of anesthetic that was administered. Eighty-four percent of patients were admitted to a standard room after initial recovery in the postanesthesia care unit (PACU); 16% were admitted to an ICU for monitoring or respiratory intervention. Thirty one percent of children aged 12 to 24 months were managed in an ICU compared with 9.4% in the age group 24 to 36 months. This difference was statistically significant (2 test, P ⬍ 0.001). To facilitate comparison between
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328 ROSS et al
Table 3. Distribution of patients by age and intensive care unit status Current study Age (mo)
0-12 12-24 24-36 Total
Tom et al5
Non-ICU
ICU
Non-ICU
ICU
1 73 281 355 (84.3%)
4 33 29 66 (15.7%)
6 72 128 206 (92.4%)
3 6 8 17 (7.6%)
these data and those from Tom et al,5 both sets of data are listed in Table 3. Most patients were admitted to the ICU due to the need for AI of some type. A minority of patients was admitted to the ICU without a clear clinical indication. Of the 66 patients managed in the ICU, 27 did not require any apparent intervention and went home the next day. The average age of ICU patients was significantly younger (23 months) than those who were monitored on the floor (28 months). The average length of stay in the ICU was 3.6 days. Eighteen percent of all patients required one or more forms of additional management to avoid respiratory compromise. Despite intervention, 41 of these patients still went home the day after surgery. Twenty-eight patients received intravenous steroids to reduce airway edema, 44 children received supplemental oxygen alone, and 32 patients required AI with or without oxygen. Twenty-nine patients received an NP airway. Eleven children were placed on CPAP ventilation. Eight patients remained intubated, and 2 patients were reintubated postoperatively. Of the 33 patients in the 12- to 24-month age group sent to the ICU, 15 required AI. In the 24to 36-month age group, 16 of 29 required AI. Of the patients needing additional management, 56% had no associated comorbidity. Children younger than 24 months were more likely (18%) than children aged 24 through 36 months (5.5%) to require AI, supplemental steroids, and hospital admission of longer than 3 days. Although few in number, those younger than 12 months had a 40% chance of requiring AI versus 14% and 5% for those between 12 and 24 months and those between 24 and 36 months of age, respectively (Table 4). Associated medical conditions were present in 89 patients, the most common of which are listed
in Table 5. Patients with trisomy 21 and bronchopulmonary dysplasia were more frequently admitted to the ICU and were more likely to receive postoperative steroids, require supplemental oxygen, require AI, and be hospitalized for longer than 3 days. Ninety-four percent of children were admitted for at least one night. The remaining 24 patients were discharged after several hours of evaluation on the floor. These patients were sent home solely based on the clinical avaluation of the attending surgeon. Those sent home on the same day of surgery were on average 3 months older (30.1 months) than the average age in the study (27.2 months), and only 3 of these children were younger than 24 months. Seventy-one percent of admitted patients were discharged the next day. Ninety-eight children (23%) were hospitalized for longer than 1 day. The most common reason for an extended admission was the inability for children to maintain oral intake (59%), followed by AI (18%). Twenty-four patients were discharged from the hospital with home intravenous supplementation as a result of poor intake. The most common complication requiring readmission was dehydration (3.1%). Postoperative hemorrhage occurred in 12 patients (2.9%) at a mean delay of 8.4 days after surgery. All of these children returned to the operating room for control of hemorrhage. One patient bled within 24 hours of surgery, another bled twice, and 1 patient had an adenoid bleed on postoperative day 20. There were no deaths. DISCUSSION UAO has become the most common indication for tonsillectomy in the pediatric population.4,5 The detrimental effects and clinical manifestations
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329
Table 4. Use of airway intervention Age (mo)
Total No. of patients
Intervention,* n (%)
None or oxygen only, n
5 106 310 421
2 (40) 15 (14) 16 (5) 33 (8)
3 91 294 388
0-12 12-24 24-36 Total *
Interventions included nasopharyngeal airway, continuous positive airway pressure (CPAP) ventilation, or intubation.
Table 5. Presence of selected medical comorbidities Comorbidity
No. of patients
ICU admission, n
Airway intervention, n
Non-ICU admission, n
Asthma Trisomy 21 Bronchopulmonary dysplasia Cardiac disease Blood dyscrasia Craniofacial abnormalities
27 9 9 4 4 2
4 5 7 2 1 0
3 5 6 1 0 0
23 4 2 2 3 2
of UAO have been well documented. Manifestations of prolonged UAO often become apparent at an early age and, if significant, require treatment.4,6 Ninety-six percent of children in our study underwent tonsillectomy to relieve UAO. Tonsillectomy with same-day discharge has been shown to be a safe and cost-effective procedure for many patients. However, physicians must guard against inappropriately discharging patients without identifying those at a higher risk for postoperative complications and their need for hospitalization. Although the safety of outpatient tonsillectomy has been reported in the literature, many of these studies have focused on the low incidence of hemorrhage and dehydration.7-11 Most of these studies exclude from analysis those children with obstructive sleep apnea or chronic medical illness.9-12 Mitchell et al13 studied children younger than 36 months and deemed outpatient tonsillectomy safe but excluded from their study all patients with chronic illness or obstructive sleep apnea. Lalakea et al14 studied patients younger than 12 years and concluded that outpatient tonsillectomy was safe after a 3-hour period of postoperative observation. Again, all patients with significant medical comorbidities and severe apnea were excluded from the study. Despite the fact that the study excluded the least healthy patients, they still reported that 24%
of patients younger than 3 years required conversion to inpatient status based on clinical assessment. It is therefore difficult to justify outpatient tonsillectomy in young children based on the existing literature. In an effort to clarify the risk in young children, Tom et al5 analyzed children younger than 36 months who underwent adenotonsillectomy or tonsillectomy from 1987 through 1988 and concluded that patients younger than 36 months were inappropriate candidates for outpatient surgery. Preoperative apnea, age younger than 12 months, and the presence of associated medical conditions increased the risk of postoperative airway complications. Advances in anesthetic and surgical techniques during the past decade have improved patient care. The use of dexamethasone15 and ondansetron appears to have reduced the incidence of postoperative emesis. Dexamethasone has been shown to reduce postoperative discomfort, improve dietary tolerance, and almost eliminate postoperative emesis, presumably by reducing the inflammatory response in the oropharynx.15 Table 3 summarizes the age distribution and postoperative triage pattern among the different age groups in both this and our earlier study. Despite the fact that the present population was on average 3 months older than that of the previous
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330 ROSS et al
study, there is a statistically significant increase in the percentage of patients admitted to an ICU. More than fifty percent of patients who were sent to an ICU required AI. Age of less than 24 months and the presence of a significant medical comorbidity, especially bronchopulmonary dysplasia and trisomy 21, increased the risk of requiring intervention (2 test, P ⬍ 0.001 and ⬍ 0.005). The ICU population was on average 5 months younger than those who were sent to a standard hospital bed. Intraoperative times were longer for the ICU population, most likely due to more complicated anesthesia in a less healthy population. There are several possible explanations for the increase in ICU admission in this study. We hypothesize that our experience with a large volume of patients in this young age group has reduced our threshold for admission to an ICU, especially in children with severe apnea, airway narrowing, or other medical comorbidities. This is supported by the fact that although a higher proportion of patients were admitted to the ICU (15.7% versus 7.6%) in the current study, 41% did not require any special intervention and were discharged home on the first postoperative day directly from the ICU. It is also possible that our large clinical experience has resulted in referrals of a more unhealthy population of patients. However, the fact that a lower proportion of patients in the current study had comorbid conditions (15.6% versus 18%) would speak against such a hypothesis. Studies in the literature emphasize the risk of postoperative hemorrhage as the most dangerous life-threatening complication of adenotonsillectomy. The rate of postoperative hemorrhage in the current study (2.9%) is consistent with prior studies regarding this complication. Our data have shown that a significantly larger proportion of patients younger than 36 months have life-threatening airway events than they do postoperative hemorrhage, which occurs long after discharge from the hospital. Therefore, it is the reasonable concern for respiratory compromise that warrants observation. Patients whose primary indication for tonsillectomy was recurrent infection had an low incidence of immediate postoperative complications. Only 1 of the 18 patients in this group was admitted to the
ICU. Two other patients required postoperative supplemental oxygen on the floor, and all 3 were discharged on the first postoperative day. Conversely, 32 of 50 patients who had apnea documented by sleep studies were admitted to the ICU, and 24 required AI of some type. Eighteen percent of patients required intervention with intravenous steroids, supplemental oxygen, or AI to prevent respiratory compromise. Fifty-four percent of children did not have an associated medical comorbidity to account for their respiratory compromise. This makes it difficult to predict which children will do well in the immediate postoperative period. Patients with conditions that reduce the size of the pharyngeal airway are prone to obstruction; this group includes those with craniofacial abnormalities, most commonly trisomy 21. Children with associated medical comorbidities, especially bronchopulmonary dysplasia, and those of younger age (⬍24 months) had a significantly higher risk of postoperative complications. CONCLUSION Tonsillectomy is a safe procedure for children younger than 36 months, but there is a significant risk for postoperative problems. Anticipation of airway complications and dehydration must be included in the proper management of these patients. There are young children who, after a period of observation, can be discharged on the same day of surgery, but there is no way to identify these patients preoperatively. A planned postoperative hospitalization for these children is recommended. Parents should be made aware of the risk of complications and the possibility of ICU admission. REFERENCES
1. Noonan JA. Reversible cor pulmonale due to hypertrophied tonsils and adenoids: studies of two cases. Circulation 1965;32:164. 2. Menashe VD, Ferrehi C, Muller M. Hypoventilation and cor pulmonale due to chronic airway obstruction. J Pediatr 1965;67:198-203. 3. Schiffmann R, Faber J, Eidelman AI. Obstructive hypertrophic adenoids and tonsils as a cause of infantile failure to thrive: reversed by tonsillectomy and adenoidectomy. Int J Pediatr Otorhinolaryngol 1985;9:183-7. 4. Berkowitz RG, Zalzal GH. Tonsillectomy in children
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under 3 years of age. Arch Otolaryngol Head Neck Surg 1990;116:685-6. Tom LWC, DeDio RM, Cohen DE, et al. Is outpatient tonsillectomy appropriate for young children? Laryngoscope 1992;102:277-80. Rosenfeld RM, Green RP. Tonsillectomy and adenoidectomy: changing trends. Ann Otol Rhinol Laryngol 1990;99:187-91. Haberman RS, Shattuck TG, Dion NM. Is outpatient suction cautery tonsillectomy safe in a community hospital setting? Laryngoscope 1990;100:511-5. Reiner SA, Sawyer WP, Clark KF, et al. Safety of outpatient tonsillectomy and adenoidectomy. Otolaryngol Head Neck Surg 1990;102:161-8. Maniglia AJ, Kushner H, Cozzi L. Adenotonsillectomy: a safe outpatient procedure. Arch Otolaryngol Head Neck Surg 1989;115:92-4. Guida RA, Mattucci KF. Tonsillectomy and adenoidec-
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American Academy of Otolaryngology–Head and Neck Surgery Annual Meetings 2003 2004 2005
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September 21-24 September 19-22 September 25-28