Children can have Tonsillectomy and Adenoidectomy Surgery with Little Risk
Embargo expired: 9-Sep-2001 12:00 AM EDT
Source Newsroom: American Academy of Otolaryngology Head and Neck Surgery (AAOHNS)
Release: September 9, 2001
Contact: Kenneth Satterfield
CHILDREN AGE THREE AND OLDER CAN HAVE OUTPATIENT TONSILLECTOMY AND ADENOIDECTOMY SURGERY WITH LITTLE RISK
A new study assesses incidence of postoperative obstructive breathing
and bleeding in more than 1,400 patients
Denver, CO -- An outpatient approach to tonsillectomy and/or adenoidectomy (T &/or A) is not unique. However, there remain institutions where children are hospitalized for a week after tonsillectomy. A group of ear, nose, and throat specialists with access to an inpatient pediatric unit, have maintained an outpatient approach for all their patients having T &/or A, whether they have obstructive sleep apnea or not. In order to evaluate an outpatient approach, they began in 1996 to study all children undergoing T&/or A at their single outpatient facility.
The authors of the study, "The Case for an Outpatient 'Approach' for All Pediatric Tonsillectomies and/or Adenoidectomies: A Four-Year Review of 1,419 Cases at a Community Hospital," are Duncan S. Postma, MD, FACS, Assistant Clinical Professor, University of North Carolina, School of Medicine, Chapel Hill, NC, and Fain Folsom, RN, BSN, from the Florida State University, Tallahassee, FL. Their findings were presented on September 9 at the American Academy of Otolaryngology--Head and Neck Surgery Annual Meeting/OTO EXPO, being held September 9-12, at the Colorado Convention Center, Denver, CO.
Methodology: The study was limited to children under 18 years of age who underwent tonsillectomy and/or adenoidectomy (T&/or A) from 1996 through 1999 at a single outpatient facility. Excluded were patients with significant medical or surgical problems (two patients) unrelated to their need for T&/or A. The study group included 1,419 patients, with procedures performed by six physicians in one private practice group in a community setting. Charts were reviewed for patient age, gender, surgeon, indication for surgery, use of medications, perioperative treatments, and complications.
During the 31-day postoperative period, emergency room visits or hospital admissions were reviewed; significant postoperative bleeding was defined as severe enough to require operative intervention or observation. A major complication was defined as one that was potentially life threatening, required reintubation, or other invasive therapy. Other complications in this study included upper airway obstruction (UAO), stridor, nausea, vomiting, oxygen desaturations, or decreased oral intake or inability to take oral medications.
Adenoidectomy was performed with use of mirrors and curettes, generally with suction
cautery used for hemostasis. Tonsillectomy was performed with minimal use of cautery and emphasis on blunt dissection. The statistical analyses separated the children into two surgical groups: (1) patients undergoing adenoidectomy only; and (2) patients undergoing tonsillectomy with or without adenoidectomy. As there was no statistical difference in patient outcomes in the tonsillectomy alone and tonsillectomy with adenoidectomy, the two groups were combined. Data were collected retrospectively from patient medical records. The main events evaluated were unplanned admissions following surgery and the occurrence of complications after the surgery.
Results: Obstructive sleep apnea was defined as a clinical syndrome of observed apnea with severe snoring and documented enlarged adenoids and/or tonsils. UAO would be a similar clinical diagnosis but less severe. Patients with a clinical diagnosis of UAO would inevitably include patients with sleep apnea. Accordingly, these two diagnoses may have more appropriately been called obstructive breathing during sleep (OBS).
A statistical comparison did not show any difference between the OSA and UAO groups in terms of age, gender, or outcomes. Therefore, the data sets for these two groups were defined.
Tonsillectomy patients: 621 (75 percent) of the 826 patients undergoing tonsillectomy had OBS, and their average age was 5.9 years old. 205 (25 percent) had chronic tonsillitis as their indication for tonsillectomy, and this group's average age was 9.1 years. 440 (53 percent) of 826 children were female, and 386 (47 percent) were male. Data analysis showed the clinical diagnosis of OBS (OSA or OSA) to be associated with lower age.
Three patients had a later postoperative bleeding that required operative intervention. No patients required blood transfusions. Three other patients were seen in the emergency department for dehydration, and one of these was admitted. Overall, four (0.5 percent) tonsillectomy patients required readmission, including two of the patients that bled and two for dehydration.
Adenoidectomy patients: Of the 593 patients undergoing adenoidectomy, 251 had a preoperative diagnosis of OBS, and their average age was 3.8 years. 342 had chronic rhinosinusitis, recurrent otitis media, or adenoiditis as their preoperative diagnosis, and their average age was 2.9 years. 246 (41 percent) of this 593 children were female, and 347 (59 percent) were male. A significant bleeding complication did not occur after any of the 593 children had an adenoidectomy.
Twenty-six (four percent) of the 593 patients undergoing adenoidectomy were observed overnight, with only one child admitted for a second hospital day. The reasons for overnight observation closely paralleled those of the patients having tonsillectomy. Of the children less than three years of age only two percent (four of 190) without OBS compared to 15 percent (16 of 108) with OBS were observed overnight. This was statistically significant.
There was no significant postoperative bleeding after 593 adenoidectomy procedures and in four (0.5 percent) of 826 tonsillectomy procedures. No patients required readmission after adenoidectomy while only four (0.5 percent) of 826 patients whose procedure included tonsillectomy needed readmission. There were no readmissions for airway problems. Four percent (26 of 593) of the patients undergoing adenoidectomy and 21 percent (171 of 826) of those undergoing tonsillectomy were observed overnight with most of these children discharged the morning after surgery.
Conclusions: All children undergoing T&/or A benefit from an outpatient "approach" to their surgical procedure. A decision about the need for overnight observation can be deferred until after surgery. Children younger than age 3 who have had a tonsillectomy are significantly more likely to have complications. A few of these younger children, and almost all children older than 3 years of age, regardless of the diagnosis of OBS, can be safely discharged when there is proper surgical and anesthetic technique, appropriate use of perioperative medications, and careful outpatient nursing care. Upper airway complications after these procedures will always be evident within the first 2-4 hours after surgery, so that proper disposition can be reliably made. With overnight observation, readmission rates can be kept less than one percent, a rate that is appropriate for "outpatient surgery".
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