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Adenotonsillectomy


Case Synopsis

An obese 3-year-old boy (body mass index 30) with obstructive sleep apnea (apnea hypopnea index 10) presents for tonsillectomy and adenoidectomy. In the postanesthesia care unit, his respiratory rate is 10 breaths per minute with significant respiratory pauses, and his heart rate is 140 beats per minute. A small amount of blood is noted in the oropharynx, and he has bilateral rales on auscultation. Oxygen saturation by pulse oximetry is 86%.

Problem Analysis

Definition

Tonsillectomy, with or without adenoidectomy, is one of the most frequently performed surgical procedures in the United States, with more than 700,000 cases completed per year. Many patients have medical comorbidities that must be optimized preoperatively, and the potential for perioperative complications must be thoroughly understood. The vast majority of children do well after surgery; however, complications can be serious and at times life threatening. The risk of death after tonsillectomy in all patients is 1:10,000. The proper selection of patients and attention to anesthetic risk and technique can reduce this risk and complications related to the following factors:

  • Bleeding

  • Young age

  • Postoperative pulmonary edema

  • Postoperative pain

  • Obstructive sleep apnea

Recognition

Bleeding

Postoperative hemorrhage occurs in 0.1% to 8.1% of patients. In 75% of cases, bleeding occurs within 6 hours of surgery and is usually the result of surgical technique; in the remaining 25%, it can occur as late as the eighth postoperative day and is related to sloughing of the postoperative eschar. Most bleeding is noted by blood-stained sputum or the vomiting of “coffee grounds” material.

Young Age

In the past, all children were admitted to the hospital postoperatively after tonsillectomy for management of vomiting, dehydration, bleeding, pain, and apnea. The advent of cost containment, along with a trend toward ambulatory surgery, has changed this practice. Recent guidelines suggest that only children age 3 years or younger are routinely admitted to the hospital after tonsillectomy, in addition to those who have severe obstructive sleep apnea syndrome (OSAS) (apnea-hypopnea index of 10 or more obstructive events per hour), oxygen saturation nadir less than 80%, or both.

Pulmonary Edema

Pulmonary edema may present as frothy pink fluid in the endotracheal tube, decreased oxygen saturation, wheezing, dyspnea, or increased respiratory rate after tracheal extubation. The differential diagnosis of postobstruction pulmonary edema includes aspiration of gastric contents, respiratory distress syndrome, congestive heart failure, volume overload, and anaphylaxis. A chest radiograph illustrating diffuse, usually bilateral, interstitial pulmonary infiltrates, combined with an appropriate clinical history, confirms the diagnosis.

Postoperative Pain

Pain is minimal after adenoidectomy but often severe after tonsillectomy. The combined effects of irritant blood in the stomach, interference with the gag reflex caused by edema, and stimulation of receptors in the chemoreceptor trigger zone contribute to postoperative vomiting, which can occur in up to 70% of tonsillectomy patients who do not receive prophylactic antiemetic therapy.

Obstructive Sleep Apnea

Hypertrophied tonsils may obstruct the upper airway during sleep, causing OSAS in approximately 3% to 12% of children. The highest incidence is in children younger than 5 years of age. The definitive diagnosis of OSAS is confirmed by polysomnography, which is a graphic record of respiratory activity during natural sleep; however, it is not feasible to test every child suspected of OSAS and sleep-disordered breathing. For this reason many authors have attempted to design a pediatric preoperative questionnaire to facilitate the diagnosis of OSAS in the same way the STOP-BANG questionnaire has been validated in the adult population. A positive sleep study is an indication for tonsillectomy, especially if related systemic abnormalities are present. The clinical presentation of OSAS is quite varied. Some patients have significant limitations, whereas others are minimally affected ( Box 30.1 ).

BOX 30.1
Clinical Presentation of Obstructive Sleep Apnea

  • Young age (<6 years old)

  • Snoring during sleep

  • Failure to thrive

  • Recurrent respiratory tract infections

  • Craniofacial dysmorphism

  • Cardiac arrhythmias

  • Apnea during sleep

  • Somnolence while awake

  • Developmental delay

  • Obesity

  • Behavioral difficulty

  • Cor pulmonale

Risk Analysis

Bleeding

The tonsillar fossa, nasopharynx, or both are the sites for 67%, 27%, or 6% of postoperative bleeding, respectively.

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