Should Children Stay Overnight in a Hospital After a Tonsillectomy?

Denver, CO - September 9, 2001

Should children stay overnight in a hospital after a tonsillectomy? The otolaryngology group at the Children's Hospital of Philadelphia recommends that upper airway obstruction and sleep apnea may be sufficient reasons for any patient younger than three years to stay at least 24 hours after this common surgical procedure, but that decision cannot be made prior to surgery.

The authors of the study, "Revisiting Outpatient Tonsillectomy in Young Children," are Adam T. Ross, MD, Ken Kazahaya, MD, and Lawrence W.C. Tom, MD from the University of Pennsylvania School of Medine and The Children's Hospital of Philadelphia in Philadelphia, Pennsylvania. Their findings were presented September 9, 2001, at the Academy of Otolaryngology Head and Neck Surgery Annual Meeting/OTO EXPO, being held September 9-12, 2001, at the Colorado Convention Center, Denver, CO.

Methodology

A search by procedure codes identified children younger than three years who underwent tonsillectomy or adeno-tonsillectomy at the Children's Hospital of Philadelphia from July 1, 1997 through June 30, 1999. In each of these patients, general anesthesia was induced, and patients were given intravenous antibiotics, dexamethasone, and ondansetron at weight-appropriate doses.

Tonsillar tissue was removed using monopolar electrocautery and bleeding was controlled with suction cautery and/or suture ligature. Adenoid tissue was removed by curettage while bleeding was controlled with pressure and suction cautery and after initial bleeding was stopped, topical oxymetazoline was often used liberally to obtain vasoconstriction.

Postoperatively, most patients proceeded to the post-anesthesia care unit (PACU) and then to a standard hospital bed where intravenous fluids, analgesics and antibiotics were administered on a routine basis. Children in an intensive care unit (ICU) preoperatively returned to the ICU after surgery. Patients in some cases were transferred to the 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

Data from each patients' postoperative course was extracted from the medical chart and included the following: admitting diagnosis, secondary diagnoses, 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

In a two-year period described, 421 children less than 36 months of age underwent either adeno-tonsillectomy (414) or tonsillectomy alone (seven). The average age of the patients was 27.2 months with five children less than 12 months, 106 between 12 and 24 months, and 310 more than 24 months. Apnea was documented by history, sleep sonography, or polysomnography. Ninety-one percent of patients presented with upper airway obstruction and 56 percent had apnea. Only four percent of children had surgery for recurrent infection alone and another four percent had infection as well as obstruction as their indications. Other findings include:

• Two hundred fifty-one patients underwent adeno-tonsillectomy without another procedure. In this group, surgical and anesthesia times were longer on average for the patients admitted to an ICU.
• Eighty-four percent were admitted to a standard room, while 16 percent were admitted to an ICU for monitoring or respiratory intervention. Thirty one percent of children 12 to 24 months were managed in an ICU compared to 9.4 percent in the age group 24-36 months. This difference was statistically significant.
• 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 patients required one or more forms of additional management to avoid respiratory compromise. In spite of 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 airway intervention with or without oxygen. Twenty-nine patients received an NP airway, 11 were placed on CPAP mask ventilation, 8 patients remained intubated and 2 patients were reintubated postoperatively.
• Of the 33 patients in the 12-24 month age group sent to ICU, 15 required AI. In the 24-36 month age group, 16 out of 29 required AI (table 4). Of the patients needing additional management, 56 percent had no associated co-morbidity. Children less that 24 months were more likely (18 percent) than children 24 through 36 months (5.5 percent) to require AI, supplemental steroids, and hospital admission greater than 3 days.
• Ninety four percent of the patients were admitted for at least one night. The remaining 24 children were discharged after several hours of observation, and only after it was determined that they could be managed safely at home. Only three of these children were less than 24 months. Seventy one percent of admitted patients were discharged the next day. Ninety-eight children (23 percent) were hospitalized for more than one day. The most common reason for an extended admission was the inability for patients to maintain oral intake (59 percent) followed by AI (18 percent). Twenty-four patients were discharged from the hospital with home intravenous supplementation as a result of poor intake in the hospital.
• The most common complication requiring readmission was dehydration (3.1 percent). Postoperative hemorrhage occurred in 12 patients (2.9 percent) at a mean delay of 8.4 days after surgery. All of these children returned to the operating room for control of hemorrhage. This is consistent with prior studies with respect to post-tonsillectomy hemorrhage; there were no mortalities.

Conclusion

The researchers believe that tonsillectomy is a safe procedure for children under 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.