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Tonsillectomy and/or adenoidectomy in children: Preoperative and intraoperative care

Anna H Messner, MD
Section Editor
Glenn C Isaacson, MD, FAAP
Deputy Editor
Elizabeth TePas, MD, MS
UPDATE COM         All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Nov 2013. | This topic last updated: Nov 6, 2013.

INTRODUCTION — Tonsillectomy and/or adenoidectomy (T&A) is one of the most common surgical procedures performed in children [1-3]. Preparing children and their families appropriately can improve the safety and recovery following surgery.

PREOPERATIVE MEDICAL EVALUATION — The preoperative medical evaluation includes a standard history and physical examination. In addition, the evaluation should include assessment for potential velopharyngeal, hematologic, or infectious contraindications and/or conditions associated with increased risk of complications. Indications for postponing surgery (eg, acute pharyngitis, fever, cough/wheezing) and management of preoperative anxiety and postoperative pain should also be discussed with the patient/caregivers during this evaluation.

Anatomic assessment — Preoperative assessment should include examination of the oropharynx (uvula and palate) for submucous cleft and tonsil size. Children in whom submucous cleft of the palate is detected and those in whom velopharyngeal insufficiency is suspected (even if the examination is normal) should be referred to an individual or a team skilled in cleft palate evaluation and management.

Assessment of atlantoaxial stability should be performed in children who are at increased risk for atlantoaxial instability (eg, children with Down syndrome, achondroplasia, or mucopolysaccharidoses)

Hematologic evaluation — Patients/caregivers should be asked about a family or past history of unusual bleeding or bruising, particularly since certain hemostatic disorders may not be detectable with readily available tests. Consensus statements and guidelines, such as those published by the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) in 1999 (and updated in 2012) and the French Society of ENT and Head and Neck Surgery (SFORL) in 2012, recommend the performance of laboratory studies in children only if the individual and/or family history is concerning for a hematologic abnormality or family history is unavailable.

One of the most feared complications following tonsillectomy is hemorrhage. Regardless of the surgical technique, hemorrhage rates following surgery range from 1 to 5 percent and can occur up to three weeks postoperatively. Bleeding after adenoidectomy can also occur, but is much less common (approximately 0.5 percent) and most often occurs within the first 24 hours following surgery.

Preoperative blood coagulation studies (eg, prothrombin time [PT], activated partial thromboplastin time [aPTT], international normalized ratio [INR], platelet count, and occasionally a bleeding time) have been recommended by some practitioners in an effort to identify children at risk for postoperative hemorrhage. However, these studies have low sensitivities and positive predictive values and many studies have demonstrated that preoperative coagulation evaluation is not effective in identifying those children who will have postoperative tonsillectomy or adenoidectomy hemorrhage. In addition, the practice of ordering routine coagulation studies is not cost effective.

Cardiac evaluation — Otherwise healthy children do not require a preoperative cardiac evaluation for tonsillectomyand/or adenoidectomy (T&A).

Polysomnogram and airway assessment — Preoperative assessment includes evaluation for risk factors associated with upper airway obstruction and/or central apnea in the postoperative period. Such factors include obstructive sleep apnea (OSA) (particularly evidence of severe apnea on polysomnography), age <3 years, obesity or increased body mass index (BMI), and craniofacial anomalies affecting the pharyngeal airway.

Children do not routinely need a polysomnogram (PSG) before tonsillectomy with or without adenoidectomy. A 2011 guideline recommends PSG in children who are obese, have Down syndrome, craniofacial abnormalities, neuromuscular disorders, sickle cell disease, or mucopolysaccharidoses. The purpose of the PSG in these children is to improve diagnostic accuracy in high-risk populations and define the severity of OSA to optimize perioperative planning. A preoperative PSG can help determine the postoperative level of care and the need for postoperative oximetry. As an example, an apnea-hypopnea index (AHI) >24 significantly predicted postoperative airway complications in a retrospective study of 83 children with severe OSA. In addition, results from a preoperative PSG can lead to postponing or avoiding surgery if a high-risk patient is found to have mild disease by PSG. PSG is also useful when the parental history and physical examination are discordant.

PREOPERATIVE CARE IN SPECIFIC PATIENT POPULATIONS — Certain patients, such as those with a bleeding disorder, sickle cell disease, or Down syndrome, may require additional preoperative screening and management.

Children with a bleeding disorder — Children with known coagulation defects are at increased risk of perioperative and postoperative bleeding. Von Willebrand disease and platelet function defects are the most common hematologic disorders leading to perioperative bleeding.

Children with a known bleeding disorder should have a preoperative hematologic assessment (eg, prothrombin time [PT], activated partial thromboplastin time [aPTT], international normalized ratio [INR], and complete blood count [CBC]), with subsequent production of a management plan by a hematologist.

Postoperative hemorrhage rates in children with mild hematologic disorders, such as mild Von Willebrand disease, who receive prophylactic medical intervention can approach those of unaffected children, but those children with more significant bleeding dyscrasias, such as hemophilia A, have increased rates of postoperative bleeding problems.

Children with sickle cell disease — Children with sickle cell disease are at risk for pain crises, acute chest syndrome (ACS), priapism, or stroke if they become hypoxic, acidotic, hypothermic, or hypovolemic in the perioperative period. A pediatric hematologist should be involved in the perioperative care of patients with sickle cell disease. Preoperative transfusions are often recommended in addition to preoperative hydration. A preoperative polysomnogram (PSG) is recommended for sickle cell patients. Postoperative observation as an inpatient is planned in order to observe for hypoxia and to administer oxygen therapy as needed.

Children with Down syndrome — Children with Down syndrome are at increased risk of anesthesia-related complications, primarily due to soft tissue and skeletal alterations.

Obstructive sleep apnea (OSA) is a common problem in children with Down syndrome, and many of them will require tonsillectomy and/or adenoidectomy (T&A). A PSG is recommended prior to surgical intervention.

Children with Down syndrome are also at increased risk of atlantoaxial instability. This instability can rarely lead to neurologic impairment following general anesthesia. The clinical findings suggestive of symptomatic atlantoaxial instability and management of it in patients with Down syndrome are discussed in greater detail separately.

Children with Down syndrome are more likely to require an inpatient stay postoperatively due to an increased likelihood of respiratory complications and the possibility of delayed oral intake. Patients and their families should be prepared for the possibility of a postoperative hospitalization.

PREOPERATIVE EMOTIONAL AND PAIN PREPARATION — It is common for children to experience preoperative anxiety before undergoing any surgery. In addition, parents are often anxious about the surgery, further increasing the anxiety level of their children. Children's preoperative anxiety can influence their postoperative pain experiences. Effective measures to reduce preoperative anxiety also improve postoperative pain. Thus, whenever possible, children and their families should be educated about the tonsillectomy and/or adenoidectomy (T&A) procedure using a comprehensive approach in an effort to reduce anxiety and improve postoperative recovery.

A prospective study of 241 children, aged 5 to 12 years, undergoing T&A found that the children who were more anxious preoperatively experienced significantly more pain postoperatively. These children consumed more pain medication, had a higher incidence of emergence delirium after anesthesia, and had a higher incidence of postoperative anxiety and sleep problems.

Children perceived a comprehensive family-centered, behaviorally-oriented approach to pain education as helpful. A prospective study of 408 children who were scheduled to undergo elective surgery compared standard preoperative care with standard care plus one of three additional measures: a preoperative program consisting of a 23-minute videotape, three pamphlets, and a mask practice kit, parental presence during induction of anesthesia, or oral midazolampreoperatively prior to parental separation. The parents and children who underwent the preoperative preparation program had significantly lower anxiety in the preoperative holding area and were less anxious during induction of anesthesia than parents and children in the other three groups. These children also had a lower incidence of emergence delirium after surgery, required significantly less analgesia in the recovery room, and were discharged from the recovery room earlier.

Providing children with a preoperative pain education booklet alone made no difference in children's postoperative pain level, quality of pain, anxiety level, sleep, or oral intake in one study. Allowing parental presence during induction of anesthesia was also not effective in reducing parent or child preoperative anxiety in several randomized trials.

INTRAOPERATIVE PROPHYLAXIS — Several intraoperative interventions have been shown to improve postoperative outcomes. An intraoperative dose of dexamethasone is effective in decreasing postoperative nausea, vomiting, pain, and time to first oral intake. Serotonergic antagonists (ondansetron, granisetron, tropisetron, dolasetron, and ramosetron) are also effective in preventing postoperative nausea and vomiting. However, intraoperative prophylactic antibiotics do not improve outcomes in the postoperative period and are not recommended. In addition, data suggest that perioperative local anesthetics have no effect on postoperative pain control.

Prevention of nausea and vomiting for all postoperative patients is discussed in detail separately. Studies specific to children undergoing tonsillectomy or adenotonsillectomy are reviewed here.

Glucocorticoids — Administration of a single, intraoperative dose of intravenous dexamethasone to children undergoing tonsillectomy is strongly recommended in the 2011 American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) guidelines. This recommendation is based upon a series of randomized trials and a 2006 systematic review and meta-analysis that have shown that the administration of a single intraoperative dose of intravenous dexamethasone in children undergoing tonsillectomy results in decreased nausea and vomiting during the first 24 hours following tonsillectomy (summary odds ratio [OR] 0.23; 95% confidence interval [CI] 0.16-0.33), together with decreased time to first oral intake and decreased postoperative pain. Doses of intravenous dexamethasone used in these trials ranged from 0.15 to 1 mg/kg (highest maximum dose 25 mg). The administration of dexamethasone after induction of anesthesia for prevention of postoperative nausea and vomiting was associated in one randomized trial with an increased risk of postoperative bleeding, but four subsequent meta-analyses [50-53], a randomized trial, and several case series did not find an association.

Additional antiemetic therapy — A 2006 systematic review and meta-analysis of randomized trials of antiemetic therapies found that serotonergic antagonists (ondansetron, granisetron, tropisetron, dolasetron) were efficacious in preventing postoperative nausea and vomiting in children undergoing tonsillectomy (summary OR for antiserotonergic agents 0.12; 95% CI 0.07-0.20). A prophylactic dose of a serotonergic antagonist, such as ondansetron, can be given perioperatively in addition to intraoperative dexamethasone, particularly in patients with a history of intense postoperative nausea/vomiting. Use of serotonergic antagonists for postoperative nausea and vomiting is reviewed in greater detail separately.

This same review concluded that the limited available data from three small trials suggested that acupuncture was not effective (summary OR 0.83; 95% CI 0.45-1.4). A subsequent small, unblinded, randomized trial found that acupuncture performed during the surgery while the child was under anesthesia, in conjunction with acupressure wristbands worn for 24 hours after surgery, decreased postoperative nausea and vomiting [58]. Results from ongoing trials should help determine whether or not this is an effective therapy.

Promethazine is associated with a risk of respiratory depression and should not be used as an antiemetic in children undergoing tonsillectomy.

Local anesthetics — Perioperative injection or topical application of local anesthetics were not found to be effective in reducing pain following tonsillectomy in children in 2 systematic reviews of randomized trials.

Antimicrobial therapy — The use of antimicrobial prophylaxis at the time of, or for short periods following, tonsillectomy does not improve postoperative outcomes !! ... This issue is discussed in detail separately.




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Partial Intracapsular Tonsillectomy and Adenoidectomy (PITA)

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