Complications Following Inpatient Extracapsular Tonsillectomy in Children 36 Months and Younger

Importance  Tonsillectomy is among the most common surgical procedures performed by general and pediatric otolaryngologists. Inpatient surgery is generally recommended for children 36 months and younger owing to concern for a higher incidence of postoperative complications.

Objective  To ascertain the need for a planned inpatient stay for extracapsular tonsillectomy in children 36 months and younger.

Design, Setting, and Participants  Retrospective medical record review of patients 36 months and younger who underwent inpatient extracapsular tonsillectomy or adenotonsillectomy at a tertiary care academic institution from January 2009 to September 2014. Of 279 medical records reviewed, 188 met the inclusion criteria for the study.

Interventions  Extracapsular tonsillectomy.

Main Outcomes and Measures  Inpatient notes, discharge summaries, and postoperative clinic visit notes in the electronic medical record were reviewed for information about complications occurring during postoperative inpatient hospitalization. Specifically, the incidence of postoperative hemorrhage, postoperative pulmonary edema, oxygen desaturation to less than 90% requiring supplemental oxygen overnight, overall poor oral intake, poor oral intake leading to prolonged hospitalization exceeding 1 day, return to the operating room, and mortality were determined.

Results  The 188 patients in the study ranged in age from 18.3 to 35.9 months (mean, 29.5 months). Among the patients, 183 (97.3%) underwent surgery for sleep-disordered breathing, 2 (1.1%) were reintubated for postobstructive pulmonary edema, 1 (0.5%) experienced a self-limited postoperative hemorrhage, 5 (2.7%) required supplemental oxygen postoperatively, and 30 (15.9%) had poor oral intake postoperatively on the day of surgery. The hospital stay for 9 patients (4.8%) exceeded 1 day because of poor oral intake. No patients had to return to the operating room during their hospitalization and there were no deaths of patients in the population studied.

Conclusions and Relevance  Very few children experienced postoperative complications during their hospitalization, suggesting that outpatient tonsillectomy and adenotonsillectomy may be safe in children in this age group. Overnight hospitalization of children in this age group may not always be necessary after an appropriate period of postoperative observation.

Tonsillectomy with or without adenoidectomy is among the most common surgical procedures performed by general and pediatric otolaryngologists. The American Academy of Otolaryngology–Head and Neck Surgery Foundation¹ and the American Academy of Pediatrics² have developed guidelines for the circumstances and times at which to perform tonsillectomy on an inpatient basis, with inpatient surgery generally recommended for children 36 months and younger. Inpatient observation is considered to help prevent mortality by allowing for earlier detection of life-threatening respiratory complications or postoperative hemorrhage. However, a study suggested that this may be necessary only for a subset of children at higher risk for postoperative complications,³ such as those with pulmonary conditions. Although serious complications, such as airway compromise and hemorrhage, can follow tonsillectomy, the timing of these complications is critical to delineating the need for an inpatient overnight stay. A postoperative period of observation is warranted, but a shorter period in the postoperative acute care unit, such as 4 to 6 hours, may be just as adequate and more cost-effective than overnight inpatient observation for otherwise healthy children. To examine the need for inpatient tonsillectomy in toddlers, we looked at the incidence of postoperative complications occurring during hospitalization in children 36 months and younger who underwent inpatient tonsillectomy or adenotonsillectomy at a tertiary care academic institution, with special attention to the timing of presentation of complications.

A retrospective medical record review was done of patients 36 months and younger who underwent inpatient extracapsular tonsillectomy or adenotonsillectomy at a tertiary care academic institution from January 2009 to September 2014. Inpatient notes, discharge summaries, and postoperative clinic visit notes in the electronic medical record were reviewed for information about complications occurring during the postoperative inpatient hospitalization. Specifically, we examined the incidence of postoperative hemorrhage, postoperative pulmonary edema, oxygen desaturation to less than 90% requiring supplemental oxygen overnight, overall poor oral intake (which we defined as <150 mL within the first 24 hours after surgery), poor oral intake leading to prolonged hospitalization exceeding 1 day, return to the operating room, and mortality.

Inclusion criteria were an age of 36 months or younger and extracapsular tonsillectomy at our institution during the study period, either as a planned admission or planned after a 23-hour observation. Patients older than 36 months at the time of surgery and those who underwent intracapsular tonsillectomy, tonsillectomy while an inpatient for another medical issue, did not have a planned admission or 23-hour period of observation, had concurrent airway procedures, were syndromic, had a history of a bleeding disorder or seizure disorder, or for whom sufficient data in our electronic medical record were lacking were excluded.

Body mass index, severity of obstructive sleep apnea, presence of a medical condition. and history of prematurity were recorded when possible but not used to exclude patients.

Descriptive and complication incidence statistics were calculated using Microsoft Excel, version 14.1.0 (Microsoft). The West Virginia University Institutional Review Board approved this study.

In a review of 279 medical records, 188 patients were found to meet the study inclusion criteria, of whom 119 (63.2%) were male and 69 (36.7%) were female. The patients’ ages ranged from 18.3 to 35.9 months (mean, 29.5 months), and their body mass indices (calculated as weight in kilograms divided by height in meters squared) ranged from 13.4 to 44.6 (median, 16.4). Sixteen patients (8.5%) were admitted for longer than 1 night, and 7 (3.7%) underwent tonsillectomy alone, with the remainder of the patients undergoing adenotonsillectomy. Tonsillectomy was done in 167 children (88.8%) to relieve sleep-disordered breathing or upper airway obstruction, in 15 others (8%) to relieve recurrent tonsillitis combined with sleep-disordered breathing, in 5 (2.7%) to relieve recurrent tonsillitis, and in 1 (0.5%) to relieve periodic fever, aphthous stomatitis, pharyngitis, and adenitis syndrome, combined with sleep-disordered breathing. A preoperative sleep study was done on 44 children (23.4%).

Overall, 34 children (18.1%) experienced at least 1 postoperative complication (Table 1). No child experienced postoperative hemorrhage in the recovery area, but 1 (0.5%) coughed up a small amount of blood after leaving the recovery area. After an overnight period of observation, no further bleeding occurred. Five children (2.7%) experienced postoperative oxygen desaturation to less than 90% requiring supplemental oxygen overnight.

Thirty children (15.9%) experienced poor postoperative oral intake on the day of surgery. Poor oral intake was defined as less than 150 mL of fluid recorded in the electronic medical record, and it resulted in a prolonged hospitalization of more than 1 day in 9 children (4.8%). No child had to return to the operating room. Two children (1.1%) developed pulmonary edema after surgery, both of whom had a normal body mass index and had undergone tonsillectomy for sleep-disordered breathing (Table 2). There were no deaths of patients in the population studied.

All tonsillectomies were done with monopolar cautery. With the exception of the 2 patients who developed postoperative pulmonary edema, all patients were held for postoperative observation in the postoperative acute care unit for at least 4 hours before being transferred to the pediatric inpatient unit with continuous pulse oximetric monitoring or to the pediatric step-down unit.

Traditionally, inpatient stay has been recommended after tonsillectomy for children younger than 36 months, but whether a 24-hour period of observation is necessary for all patients in this age group is controversial. The 2011 guidelines of the American Academy of Otolaryngology–Head and Neck Surgery Foundation and American Academy of Pediatrics describe hospitalization as generally recommended for this age group,¹ and this is based on several historical studies.^4-6

In 1991, Wiatrak et al⁵ reviewed the medical records of 200 patients younger than 36 months who had undergone adenotonsillectomy. They found that 25 patients (12.5%) had complications, of whom 3 (12%) had postoperative hemorrhage, 8 (32%) experienced dehydration, and 14 (56%) had respiratory problems. They recommended inpatient tonsillectomy for all patients. They noted that their results conflicted with prior studies at smaller academic centers.

In 2003, Ross et al⁷ retrospectively studied 421 patients younger than 36 months who had undergone tonsillectomy and found that 76 patients (18%) had required intervention with corticosteroids, supplemental oxygen, or other interventions to prevent airway compromise, but they did not comment on the time between the end of surgery and the observed need for intervention. They also did not exclude patients who had chronic illness. Their conclusion was that some young children can, after a period of observation, be discharged on the day of surgery but that identifying these patients is a challenge.

In 2006, Statham et al⁸ in a retrospective analysis, identified 737 children younger than 3 years who had undergone adenotonsillectomy for obstructive sleep apnea (and of whom 51.4% had medical comorbidities) and noted that 9.8% had experienced respiratory complications. They did not comment on the timing of these complications.

The blanket recommendation to hospitalize all children younger than 36 months who undergo tonsillectomy was influenced by studies like those discussed. However, other studies have suggested that this may not be uniformly necessary, and our data support this.

Mitchell et al⁹ studied 102 children younger than 36 months who underwent outpatient tonsillectomy. The patients had to have no history of chronic illness or obstructive sleep apnea, had to live within 1 hour of transport to the hospital, and had to have been observed for at least 4 hours in the postoperative acute care unit. Nine were admitted overnight because of poor oral intake. None of the patients had postoperative bleeding, respiratory tract problems, or admission to the intensive care unit on the day of or the day after surgery.

Belyea et al¹⁰ studied 127 children under 3 years of age and found that 4 patients (3.1%) had complications during the first 24 hours after tonsillectomy. They concluded that postoperative admission for children younger than 3 years who undergo tonsillectomy might not always be necessary.

Obstructive sleep apnea can lead to increased rates of respiratory compromise after tonsillectomy, but our results suggest that many children younger than 3 years will do well after surgery. Sleep-disordered breathing was the reason for tonsillectomy in 183 (97.3%) of our patients, and 5 (2.7%) required supplemental oxygen postoperatively. A further 2 patients developed pulmonary edema, both within the first 4 hours after surgery. The 2011 guidelines of the American Academy of Otolaryngology–Head and Neck Surgery Foundation and American Academy of Pediatrics state that the level of severity of sleep-disordered breathing that warrants inpatient hospitalization is not clear.¹ What the guidelines list as indications for hospitalization are a complicated medical history, cardiac complications of obstructive sleep apnea, neuromuscular disorders, prematurity, obesity, failure to thrive, craniofacial anomalies, and recent respiratory tract infection.

Although 30 (15.9%) of our patients had poor oral intake after surgery, this is certainly not a problem limited to the age group of patients younger than 3 years, and we do not believe that it necessarily merits an overnight hospital stay. If outpatient tonsillectomy is performed in this age group and the patient lives far from the hospital, it may be prudent to consider asking the family to stay at a nearby hotel on the night of surgery, with instructions to contact the on-call otolaryngologist if there are any concerns.

Our study has several potential weaknesses. First, it was a retrospective observational study, and the quality of our data are only as good as the quality of the documentation in the electronic medical record. The study was also nonblinded and lacked a comparison group, preventing us from using any inferential statistics. In addition, the study did not clearly examine the distinction between patients falling into the American Academy of Anesthesiology’s Physical Classification 1 or 2 as opposed to those in class 3 or 4.

Very few children in our study population experienced postoperative complications during their hospitalization, leading us to conclude that outpatient tonsillectomy and adenotonsillectomy may be safe in this age group. When potentially life-threatening pulmonary edema did arise in our series, it was noticed expeditiously in the immediate postoperative period. Overnight hospitalization after tonsillectomy in patients younger than 3 years may not always be necessary after an appropriate period of postoperative observation.

Submitted for Publication: August 16, 2015; final revision received October 29, 2015; accepted December 2, 2015.

Corresponding Author: Hassan H. Ramadan, MD, MSc, Department of Otolaryngology, West Virginia University, 1 Medical Center Dr, Morgantown, WV 26506 (hramadan@hsc.wvu.edu).

Published Online: February 4, 2016. doi:10.1001/jamaoto.2015.3562.

Author Contributions: Drs Ramadan and Castaño had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Castaño, Ramadan.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Castaño, Freiser.

Critical revision of the manuscript for important intellectual content: Ramadan.

Statistical Analysis: All authors.

Study supervision: Ramadan.

Conflict of Interest Disclosures: None reported.

Previous Presentation: This study was presented as a poster at the 2015 American Society of Pediatric Otolaryngology Annual Meeting during the Combined Otolaryngology Spring Meetings; April 22-26, 2015; Boston, Massachusetts.