TABLE 2
Patient education resources
Address postop complications
Ensure that your patient has proper pain relief. Sore throat and referred otalgia are common, but usually subside within 2 weeks. The pain typically manifests as dysphagia, which results from trauma to the pharyngeal muscles. Keep in mind that pain is not always a minor complication; if prolonged, it may be accompanied by dehydration, fever, and even bleeding. Be sure to rule out otitis media in any patient complaining of otalgia who has had both tonsillectomy and adenoidectomy.
Nearly 50% of children who have had a tonsillectomy experience severe pain, defined as a visual analog score of 8 or more.8 According to 1 large-scale study, all children will experience moderate or severe pain while at rest and when swallowing during the first 48 hours after surgery—despite an appropriate around-the-clock dose of acetaminophen with codeine.9
Although high-dose acetaminophen, with or without codeine, is the most common analgesic prescribed for children after ambulatory surgery, its analgesic effect varies widely, so it may need to be administered in conjunction with other agents.10
One meta-analysis of several prospective, randomized, double-blind trials concluded that the risk of posttonsillectomy bleeding was nearly 4 times greater when patients received nonselective NSAIDs. This prompted the recommendation that these agents be avoided.11 However, a more recent analysis that included selective cyclooxygenase-1 (COX-1) and COX-2 inhibitors found that these NSAIDs did not significantly alter perioperative bleeding.12 With that in mind, selective COX-2 inhibitors such as celecoxib may safely relieve posttonsillectomy pain.13
Because so many patients develop postop nausea and vomiting, many surgeons avoid postop opioids such as codeine or tramadol, which can aggravate nausea without significant analgesic benefit. These agents are usually prescribed only after the gastrointestinal adverse effects have subsided, or when combined with antiemetics.
Ensure that nausea and vomiting have been properly addressed. Up to 89% of children undergoing tonsillectomy have postop vomiting and nausea.14 During the surgery, intravenous dexamethasone is usually administered because of its antiemetic effect—which can last up to 48 hours—and because of its role in preventing postop oropharyngeal edema.14
Watch for postop bleeding. Bleeding, followed by hypovolemic shock, is the most common cause of morbidity and mortality among patients undergoing tonsillectomy, affecting an estimated 0.5% to 10%. Approximately 1 in 200 patients returns to the operating room (OR) so that the bleeding can be controlled. Mortality from bleeding is 2 in 10,000 tonsillectomies. Most cases of fatal postop bleeding occur within the first 24 hours after surgery.15-17
Although clinicians should attempt to estimate blood loss during active bleeding, the estimate may be too low in children because they tend to swallow blood. Despite this caveat, consider blood transfusion when the estimated blood loss is 10% or more of the blood volume in infants, 25% in children, and 20% in adults.18
If transfusion is warranted, 2 large intravenous lines will need to be inserted, blood samples will need to be sent for typing and cross-matching, and a complete blood count and coagulation studies will need to be ordered. The patient’s airway will need to be protected and hemodynamic monitoring maintained.
If the bleeding is not excessive, applying local pressure with gauze on the tonsillar bed may be effective, assuming the patient is cooperative. However, if this doesn’t work, the patient will need to be rushed to an OR to control the bleeding. Anesthetizing a patient with massive oral bleeding is among the most challenging emergencies. Always anticipate aspiration once the bleeding has been controlled.
Be ready for these complications, too
The following complications are occasionally encountered after tonsillectomy, but no large controlled studies have estimated their frequency.
Airway obstruction
Mucosal damage during intubation may cause air to enter parapharyngeal tissues, which in turn can result in laryngeal spasm and cervical emphysema after extubation. It can progress to pneumomediastinum and tension pneumothorax.19,20 Excessive pressure on the surgical blades and manipulation within the oral cavity during surgery can cause lingual and oropharyngeal edema.21 With these potential complications in mind, the primary care physician will need to monitor the patient postoperatively for dyspnea.
Acute airway obstruction can occur if blood or clots accumulate in the hypo pharynx as the patient is awakening, immediately after extubation, or later. The most important way to prevent this complication is to ensure that there are no active bleeding sites. The airway can also be compromised from residual bleeding and an evolving airway edema.
On rare occasions, a patient’s airway can become obstructed if dislodged tonsillar tissue is not fully removed during surgery, or if loose teeth and parts of surgical instrumentation find their way into the airway. Being cognizant of these possibilities will help you, the primary care physician, to make an accurate differential diagnosis postoperatively.