Embargoed until May 11, 2001
Contact: Kenneth S. Satterfield760-776-8502 (5/11-5/16) 703- 519-1563[email protected]
Overnight Stays Recommended for Tonsillectomy Patientswith Obstructive Sleep Apnea
Enlarged tonsils are a major cause of debilitating sleep disorders in children.
Removing tonsils in these young patients requires at least a 24-hour stay at the hospital.
Palm Desert, CA -- An ongoing debate regarding postoperative management of patients undergoing tonsillectomy continues between physicians and health care insurance companies. Concerns for potentially life threatening complications such as airway obstruction, hemorrhage, emesis, and dehydration have led many physicians to consider overnight hospitalization. Yet, with increased emphasis on cost containment in the health care setting, insurance companies require that the decision to authorize an overnight hospitalization be corroborated by confirmed medical guidelines. Consequently, many physicians adhere to the pressures of control rising health care costs and perform same day surgery.
Two Minnesota ear, nose, and throat specialists have completed new research that specifies medical conditions calling for keeping a tonsillectomy patient overnight for observation. This is an important step in ensuring that physicians and insurance companies use reliable information to ensure that children undergoing this common surgical procedure are not sent home prematurely.
The authors of the study, Postoperative Management of Tonsillectomy Patients, are Susan Pearson, MD, and Robert Maisel, MD, both from the Department of Otolaryngology--Head and Neck Surgery, Hennepin County Medical Center and Department of Otolaryngology--Head and Neck Surgery, University of Minnesota, Minneapolis, MN. Their findings were presented before the Combined Otolaryngologic Spring Meetings, being held May 11-16, 2001, in Palm Desert, CA.
Methodology: The charts of all 122 patients who underwent a tonsillectomy from January 1, 1998 to December 31, 1999 at Hennepin County Medical Center, a tertiary care center, were retrospectively reviewed. Preoperative information obtained and reviewed included age at time of surgery, gender, indications for surgery, preoperative chronic illnesses, and presence of a positive sleep study. Postoperative information included reason for admission, length of admission, and postoperative complications. All patients were observed in the postoperative acute care unit following surgery.
Children under three years old and patients with a diagnosis of sleep apnea were automatically admitted. If other complications were observed in the postoperative period, the patients were then admitted to the inpatient ward. Otherwise, patients whose vital signs were stable, pain well controlled, and they were able to tolerate oral fluids, were discharged home.
Results: The review found that 52 percent of patients had a primary diagnosis of obstructive sleep apnea with tonsillar hypertrophy (enlarged tonsils) that necessitated the tonsillectomy. Other diagnoses included chronic tonsillitis (27 percent), enlarged tonsils (12 percent), recurrent peritonsillar abscess (6 percent), asymmetric tonsils (three percent), and cryptic (hidden) tonsils (one percent).
Of the 122 patients, 47 were discharged the same day, and 75 patients were admitted. Reasons for admission included vomiting or poor oral intake, patients already admitted for a peritonsillar abscess, age of the child, other procedures required, and the overwhelming reason, obstructive sleep apnea. A complication that occurred later and required four patients to be readmitted was post-operative tonsil bleed. Of the patients that were admitted postoperatively for sleep apnea, 65 percent (41/63) had a positive sleep study, and 35percent (22/63) were clinically diagnosed. Six patients that had a diagnosis of sleep apnea developed post-operative respiratory distress that was life threatening and necessitated a transfer to the intensive care unit.
The length of hospitalization was, for one day, 70 percent or 44/63; for two days, 16 percent or 16/63; for three days, five percent or 3/63; four days, 1.5 percent or 1/63; five days, 1.5 percent or 1/63; six days, 1.5 percent or 1/63; seven days, 1.5 percent or 1/63; nine days, 1.5 percent or 1/63; and eleven days 1.5 percent or 1/63. The patients who developed post-operative respiratory distress were admitted for 3-11 days, with a mean 6.33-day and median 6-day length of admission.
There were 58 males and 64 females in the study. Males and females were admitted on an equal basis. The admitted group had a male to female ratio of 1 to 1. A slightly higher number of females were in the same day discharged group.The age range in months for the study was 13-808. The mean age in months was 159.5, and the median age was 92. The admitted group had an age range of 13-808 months, with a mean age of 129.9 months and a median age of 72 months. The same day discharge group had an age range of 37-620 months, with a mean age of 206.7 months and a median age of 169. The obstructive sleep apnea (OSA) group had an age range of 13-717 months, with a mean age of 115.5 months and a median age of 65 months.
Conclusion: Tonsillectomy done on an outpatient basis appears to be a relatively safe procedure if there is careful patient selection. To try to identify and treat life-threatening respiratory distress, patients who have the clinical diagnosis of OSA in which a sleep study has not been performed should be admitted for overnight observance with an oxygen saturation monitor, especially if they meet any of the below criteria.
The criteria includes less than three years of age, craniofacial anomalies affecting the airway, failure to thrive, hypotonia, cor pulmonale, and/or morbid obesity. Patients with major concomitant medical conditions, such as heart disease, bleeding diathesis, and mental retardation should also be admitted for observation post-operatively. If a sleep study was performed and the patient has a respiratory distress index of >40 and/or a SaO2 nadir of less than 70, he/she should also be admitted postoperatively. For others, it is recommended that the patient be observed for a minimum of four hours and that before discharge, the patient be able to tolerate adequate fluid intake, have no evidence of bleeding or respiratory distress, and have pain which is well controlled.
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