Applied Evidence

Don’t overlook the complications of tonsillectomy

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These pre- and postop steps can help you make an already safe procedure even safer.


 

References

PRACTICE RECOMMENDATION

Monitor patients for pain, nausea and vomiting, and bleeding, as they are the most common complications of tonsillectomy. A

Effectively manage postoperative pain to prevent dehydration, which can occur when patients fail to take in enough fluids because swallowing is painful. B

Strength of recommendation (SOR)

A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series

Although the number of patients undergoing tonsillectomy has gradually declined since the 1970s, it remains one of the most common surgical procedures performed worldwide.1 The procedure, of course, is fairly routine—but not without risk.

Mortality rates for the operation range from 1 in 10,000 to 1 in 35,000, with morbidity rates ranging from 1.5% to 14%; mortality and morbidity after tonsillectomy are usually the result of postoperative bleeding.2,3 In addition to bleeding, other common complications include pain, nausea, and vomiting.

The patient’s surgeon plays a central role in minimizing risk. But as a primary care physician, you, too, play an important role in ensuring that your patient’s tonsillectomy is uneventful. This review will help toward that end.

Refine your preop approach

Address informed consent issues. While the surgeon is responsible for obtaining informed consent, a patient may discuss the procedure with you, the family physician. (See TABLE 1 for the indications for tonsillectomy.) Although the procedure is safe and effective, the patient and his or her family need to know that bleeding will most likely occur immediately after the procedure, although it can occur at any time during the first 2 weeks postop. Advise the patient and family that postop pain is similar to that of a throat infection, but is often felt in the ears (“referred otalgia”). Because postop swallowing is painful, the patient may not drink enough fluids. If this problem because severe, he or she may need to be admitted for IV fluid replacement.

Discuss the patient’s length of stay. An increasing number of tonsillectomies are performed on an outpatient basis. However, high-risk patients—those with sleep apnea, coagulation disorders, or other underlying diseases, and anyone younger than 4 years of age or living a long distance from the hospital—should be admitted for overnight observation.4

Ask about previous surgeries. Tonsillectomies are performed under general anesthesia in most facilities. Ask about previous surgeries and conditions that may adversely affect the surgery: Does the patient have any upper airway obstruction, difficulty extending his cervical spine, or enzymatic deficiencies? A pseudocholinesterase deficiency, for instance, may cause prolonged paralysis of the respiratory muscles, requiring an extended period of time during which the patient must be mechanically ventilated.

Anesthesiologists use the Mallampati score to predict the ease of intubation.5 It’s derived by visualizing the base of the uvula, the tonsillar pillars, and the soft palate. Scoring may be done with or without phonation. A patient is considered to be in 1 of 4 classes, depending upon what can be visualized:

  • Class 1: the tonsils, uvula, and soft palate
  • Class 2: the hard and soft palate and upper portion of the tonsils and uvula
  • Class 3: the soft and hard palate and base of the uvula
  • Class 4: the hard palate.

As a general rule, patients scheduled for tonsillectomy are prone to higher scores because of underlying disease.

Order lab tests, stop certain medications. Instruct patients to discontinue aspirin 7 days before surgery, and naproxen and other nonsteroidal anti-inflammatory drugs (NSAIDs) 4 days before surgery.6 Antiplatelet aggregation drugs such as clopidogrel should also be stopped 7 days before surgery.6

While you should routinely order a complete blood count, experts disagree on the value and cost-effectiveness of routinely running prothrombin time and partial thromboplastin time.7

Assess whether the patient is anxious about the surgery. Tonsillectomy and the subsequent hospitalization can make patients anxious, bringing on sleep disturbances, behavioral problems, nightmares, enuresis, and emotional regression. Fortunately, these problems usually disappear without any intervention, but offering patients preop reassurance, demonstrations, and educational materials may help prevent them (TABLE 2).

TABLE 1
Indications for tonsillectomy

Tonsils are infected ≥3 times a year despite adequate medical therapy
Peritonsillar abscess is unresponsive to medical management and drainage documented by surgeon, unless surgery is performed during acute stage
Chronic or recurrent tonsillitis associated with the streptococcal carrier state and not responding to beta-lactam antibiotics given with a beta-lactamase inhibitor
Hypertrophy causing dental malocclusion or adversely affecting orofacial growth that has been documented by orthodontist
Hypertrophy causing upper airway obstruction, severe dysphagia, sleep disorders, or cardiopulmonary complications
Persistent foul breath or bad taste in mouth due to chronic tonsillitis that has not been responsive to medical therapy
Unilateral tonsil hypertrophy that is presumed to be neoplastic
Source: Erickson BK, Larson DR, St Sauver JL, et al. Changes in incidence and indications of tonsillectomy and adenotonsillectomy, 1970-2005. Otolaryngol Head Neck Surg. 2009;140:894-901.

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