In 1996, the American Academy of Pediatrics and the American Academy of Otolaryngology—Head and Neck Surgery (AAOHNS) released guidelines indicating that children younger than 3 be admitted overnight for postoperative observation. Studies had shown that young patients were at greater risk for postoperative complications that required readmission and inpatient care.
Newer surgical techniques for tonsillectomy have helped to decrease the incidence of primary hemorrhage and shorten recovery time. More recent studies looking at complications with tonsillectomy in the very young—in addition to institutional and personal experiences in the operative setting—have caused some clinicians to question the need for overnight admission in these patients. In our experience, many patients who were electively admitted overnight met all of the criteria to be discharged home within 6 hours of their surgery.
A New Retrospective Review of Tonsillectomy
More data are needed to establish an evidence-based justification for challenging the longstanding guidelines from AAOHNS. In the March 19, 2012 Archives of Otolaryngology—Head & Neck Surgery, my colleagues and I had a study published in which we retrospectively examined the outcomes of tonsillectomy performed in children under the age of 3. We recorded the complications they experienced.
Among the 86 patients whose medical records were reviewed, 80 (93.0%) did not experience any intraoperative or postoperative complications. Complications after tonsillectomies were generally mild and typically linked to dehydration. Our study’s overall complication rate was beneath the 10% ceiling that has been deemed acceptable for ambulatory procedures by some in the field. Results from another study have reinforced our findings.
Key Contributors for Success in Young Children
Several factors likely contributed to the low rate of complications we observed. First, all procedures were performed at a teaching hospital that was capable of providing anesthesiologists and nurses with extensive experience in caring for young children. Second, our hospital nursing staff performed follow-up telephone calls to the parents of patients on the first postoperative day to address any concerns. Third, all patients lived within 90 minutes of the hospital and were cared for at home. Patients lived in family settings where responsible adults were readily available to care for the child during the postoperative period and could take them to the hospital if needed.
My current practices have changed because of our findings. I admit all children aged 2 and younger, but reevaluate them 6 hours after admission for possible discharge. Children older than 2 are scheduled for an ambulatory admission, but they’re only admitted if postoperative complications arise. The keys for any surgeon considering this approach are:
Careful patient selection preoperatively.
A dedicated pediatric team of nurses and anesthesiologists.
Communication with families during the postoperative period.
If these principles are in place, healthcare resources can be used more efficiently, and young children can recover comfortably at home after tonsillectomy.
Readings & Resources (click to view)
Spencer DJ. Jones JE. Complications of adenotonsillectomy in patients younger than 3 years. Arch Otolaryngol Head Neck Surg. 2012 Mar 19 [Epub ahead of print]. Available at: http://archotol.ama-assn.org/cgi/content/full/archoto.2012.1.
Ross AT, Kazahaya K, Tom LWC. Revisiting outpatient tonsillectomy in young children. Otolaryngol Head Neck Surg. 2003;128:326-331.
Schmidt R, Herzog A, Cook S, et al. Complications of tonsillectomy: a comparison of techniques. Arch Otolaryngol Head Neck Surg. 2007;133:925-928.
Wiatrak BJ, Myer CM III, Andrews TM. Complications of adenotonsillectomy in children under 3 years of age. Am J Otolaryngol. 1991;12:170-172.
Werle AH, Nicklaus PJ, Kirse DJ, Bruegger DE. A retrospective study of tonsillectomy in the under 2-year-old child: indications, perioperative management, and complications. Int J Pediatr Otorhinolaryngol. 2003;67:453-460.
Tabaee A, Lin JW, Dupiton V, Jones JE. The role of oral fluid intake following adenotonsillectomy. Int J Pediatr Otorhinolaryngol. 2006;70:1159-1164.
Brigger MT, Brietzke SE. Outpatient tonsillectomy in children: a systematic review. Otolaryngol Head Neck Surg. 2006;135:1-7.