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Archive December 2000 I, No. 12

Outpatient Adenotonsillectomy: How Young Is Too Young?

You can accept very young patients on an outpatient basis. Heres why.

Dianne Taylor, Contributing Editor

BIO

If your facility has a large pediatric population and refuses adenotonsillectomy patients based solely on age, your patient selection criteria may be unnecessarily rigid. For years, many facilities have adhered to the age standard now endorsed by the current American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) guidelines-which recommend an overnight stay for all adenotonsillectomy patients aged three or younger-when screening children for ambulatory surgery. More recently, however, many outpatient surgery facilities have relaxed this age standard or disregarded it altogether, opting instead to rely primarily on medical criteria to determine if patients really need to stay overnight.

Safety Concerns
The three-year age cutoff is based on studies that show increased rates of certain post-op complications in these very young patients. Younger children can be more prone to dehydration-which can result from postoperative nausea and vomiting (PONV) from anesthesia or swallowed blood and decreased oral intake due to pain-simply because they are usually less cooperative than older children and have less volume reserve. Respiratory compromise is also a primary concern in this population, due in large part to pre-existing upper airway obstruction and sleep apnea that often does not resolve immediately after surgery.1

Many now believe, however, that when the healthcare team carefully screens patients based on appropriate medical criteria, the rigid age cutoff becomes arbitrary. Rande H. Lazar, MD, FICS, a pediatric ENT surgeon with the Memphis-based LeBonheur Children's Medical Center who has performed the outpatient procedure on patients as young as 14 months, says his facility considers all adenotonsillectomy patients to be outpatients unless there is a clear medical reason for admission. Lazar co-authored a review of the records of 102 otherwise healthy outpatient adenotonsillectomy patients from 16 months to less than three years old2 and found that just 10 children (10 percent) required overnight admission, all for poor oral intake. Note that all children with obstructive sleep apnea were screened out of this population.

Medical Reasons for Inpatient Stay
Experts agree that the following medical criteria necessitate a 24-hour admission:1, 3, 4

  • Co-existing medical conditions that can compromise recovery (i.e. congenital heart disease, neuromotor diseases such as seizure disorders or cerebral palsy, chromosomal abnormalities such as Down's syndrome, morbid obesity, severe asthma, and bleeding disorders);

  • Prematurity;

  • Severe upper airway obstruction with or without sleep apnea. The obstruction and apnea often take several days to resolve after surgery, and a large minority may not experience any resolution of the obstructive symptoms at all. Children who undergo surgery because of severe obstructive symptoms also have more sequelae (poor oral intake, fever, PONV) than those who undergo surgery because of chronic or severe infection, although children with only mild obstructions may do well on an outpatient basis;

  • Unresolved postoperative sequelae such as continued respiratory compromise, poor oral intake, or primary bleeding.

Assistant Professor with the Pediatric Otolaryngology Department of the UCLA School of Medicine Nina Shapiro, MD, also considers acute peritonsillar abscess as a medical indication for overnight admission due to an increased (5 to 10 percent) risk of postoperative bleeding.

Safety Assurance
To ensure the safety of these youngest of patients, pediatric ENT physicians recommend the following measures:

  • Ensure adequate hydration. To minimize the need for an overnight stay, the surgical team must ensure adequate IV hydration without overhydrating. "This is somewhat of a fine line," explains Evelyn A. Kluka, MD, a pediatric ENT surgeon with the Louisiana State University Health Sciences Center. "If you overhydrate, the child has no stimulus to drink."

  • Administer an intraoperative steroid. A single intraoperative dose of a steroid seems to decrease inflammation and swelling, according to several experts, and studies have linked preoperative IV dexamethasone 0.5 to 1 mg/kg to decreased PONV and improved oral intake.5, 6

  • Consider an anesthetic injection. Several physicians we interviewed inject the tonsillar fossae with Xylocaine intraoperatively. The resultant pain relief does not last long but helps get the patient drinking during the early recovery period.

  • Consider an antiemetic to decrease PONV.

  • Educate. Any successful pediatric outpatient procedure begins and ends with education, agree the experts. The healthcare team members need to teach parents about the importance of hydration both before and after surgery, and they need to reinforce this message constantly. "We view this as a partnership between the family and us, and our nurses and nurse practitioners work very closely with the families to remind them about the importance of drinking," notes Dr. Lazar. Other important educational topics include a discussion of the types of foods and liquids parents need to have available after surgery. "We also review the medications to avoid before surgery, such as aspirin and NSAIDs, which can increase the risk of postoperative bleeding," says Dr. Shapiro.

  • Follow up closely. To catch any complications, early postop phone calls beginning on the first postoperative day to check on the patient's urine output, energy state, and ability to sleep are essential, say the experts. Dr. Lazar says his outpatient clinic calls all parents at 24 hours, 48 hours, and five days postoperatively. The postop assessment should also be geared to identifying any secondary bleeding, which can develop from seven to 10 days postoperatively, according to Jeffrey A. Koempel, MD, ENT surgeon with the Childrens' Hospital of Los Angeles and assistant professor with the USC School of Medicine. Finally, a follow-up visit is also necessary to ensure patent nasal airways and an otherwise normal healing process, notes Dr. Shapiro.

Ensure Your Comfort Level
Each year, as many as 400,000 children undergo tonsillectomy with or without adenoidectomy, making it one of the most commonly performed pediatric surgical procedures. Thanks to current anesthesia and surgical techniques, the majority are performed safely and with minimal recovery time. Provided the patient's oral intake is good and there are no signs of respiratory compromise or other complications, Dr. Lazar sends these patients home from two to 2.5 hours after surgery. Dr. Shapiro, who generally prefers to admit patients younger than 2.5 years old but will send these children home if they are doing well and live nearby, releases her patients as early as one hour postoperatively.

Nevertheless, all the experts agree that facilities should accept these very young patients on an outpatient basis only when there is a high degree of confidence in the physician's skill level and the entire team's ability to care for the patient. Dr. Lazar notes that both preparation and experience are key. "Pre- and post-op teaching is important. You also need the ability to carefully screen out medical problems," he says. Importantly, all of the team members-including the surgeon, anesthesiologist or anesthetist, nursing staff, patients and parents-must approach the care as a partnership because all are intimately involved in the patient's care. "There really isn't any one age standard for this procedure," concludes Dr. Koempel, "but you do need to be comfortable knowing that the decision to release or admit is not the surgeon's alone."

 

Does Technique Predict Complication Rate?

There are two basic types of tonsillectomy techniques: Cold and hot dissection. With cold (sharp) dissection, the surgeon simply uses a scalpel to remove the tissues, and most use spot electrocautery for hemostasis. With hot dissection, or electrodissection, the surgeon uses electrocautery to both cut and stop bleeding.

Some surgeons strongly believe the hot technique increases the risk of postoperative bleeding and pain because the heat can cut muscle and/or cause thermal necrosis of remaining tissue. However, studies show that each method may have its advantages, and it is still unclear if one approach is associated with fewer complications than the other.1-6 This may be due, in part, to the fact that specific surgical techniques differ with the surgeon. For example, Jeffrey A. Koempel, MD, with the Childrens' Hospital of Los Angeles, uses suction cautery, which he says is quick yet minimizes minimizes postop bleeding. "This is a very efficient technique, and our average blood loss is often less than 5 cc," he notes. "Average recovery room time for these patients is 2.5 hours, ranging from 1.5 hours to four hours, usually when there is postoperative nausea and vomiting."

There are several new devices under evaluation that attempt to further minimize complications by combining the best of both worlds:

  • Bipolar scissors. Two recent studies7, 8 show that bipolar scissors-which simultaneously cut and coagulate-may shorten surgery and minimize blood loss.

  • Harmonic scalpel. One study suggests that this laser-like scalpel, which both divides and coagulates tissue at a lower temperature than electrocautery, may reduce pain and allow patients to eat sooner than those who undergo a conventional electrocautery technique. However, several pediatric ENT surgeons who have limited experience with the device say the jury is still out, citing concerns about cost, a potential for longer surgery, and no perceived reductions in recovery room time.

 

References
1. Clemens J, McMurray JS, Willging JP. Electrocautery versus curette adenoidectomy: Comparison of postoperative results. Int J Pediatr Otorhinolaryngol. 1998;43(2):115-122.
2. Wexler DB. Recovery after tonsillectomy: Electrodissection vs sharp dissection techniques. Otolaryngol Head Neck Surg. 1996;114(4):576-581.
3. Nunez DA, Provan J, Crawford M. Postoperative tonsillectomy pain in pediatric patients: Electrocautery (hot) vs cold dissection and snare tonsillectomy--A randomized trial. Arch Otolaryngol Head Neck Surg. 2000;126(7):837-841.
4. Ahmed M, Khan AA, Siddiqi T, et al. A comparison of dissection-method and diathermy tonsillectomies. JPMA J Pak Med Assoc. 2000;50(7):215-216.
5. Pizzuto MP, Brodsky L, Duffy L, et al. A comparison of microbipolar cautery dissection to hot knife and cold knife cautery tonsillectomy. Int J Pediatr Otorhinolaryngol. 2000;52(3):239-246.
6. Lassaletta L, Martin G, Villafruela MA, et al. Pediatric tonsillectomy: Post-operative morbidity comparing microsurgical bipolar dissection versus cold sharp dissection. Int J Pediatr Otorhinolaryngol. 1997;41(3):307-317.
7. Saleh HA, Cain AJ, Mountain RE. Bipolar scissor tonsillectomy. Clin Otolaryngol. 1999;24(1):9-12.
8. Isaacson G, Szeremeta W. Pediatric tonsillectomy with bipolar electrosurgical scissors. Am J Otolaryngol. 1998;19(5):291-295.
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