Portuguese Version

Year:  2004  Vol. 70   Ed. 4 - (4º)

Artigo Original

Pages: 464 to 468

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Postoperative complications in adenotonsillectomy

Author(s): Vivian Wiikmann1,
Flávio Augusto Passarelli Prado1,
Marcello Caniello1,
Renata C. Di Francesco2,
Ivan D. Miziara3

Keywords: Key words: adenotonsillectomy, surgical complications, bleeding.

Abstract:
Introduction: Adenoidectomy and tonsillectomy are the most frequent surgeries been practice by otorhinolaryngologists. Usually adenotonsillectomy is a safe procedure, which does not request long hospitalization. In our service, patients are discharged from hospital about 6 hours after the end of the procedure. We regularly apply different surgical techniques for tonsillectomy. Objectives: To evaluate the safeness of a day hospital system, and post-operatory complications, correlating them with the surgical techniques applied. Patients and Methods: We evaluated prospectively 147 patients submitted to tonsillectomies in our service. We applied three different techniques. The surgeon applied a protocol on the same day, a week and a month after procedure, inquiring about the occurrence of bleeding, fever, nausea, vomits, pain and inability to eat or drink. Results: The post-operatory incidence of bleeding was 7,48% in the first day after procedure. Small amount of bleeding occurred in 3,4% cases during the first week. No statistic difference was found correlating the surgical techniques applied and rated complications. Conclusions: Discharging patients from hospital 6 hours after surgery is a safe procedure. Considering that we found no statistic difference between the related complications and the surgical technique applied, we believe the surgeon must utilize his well-known technique.

INTRODUCTION

Adenoidectomy and tonsillectomy are the most frequent surgeries performed by the Department of Otorhinolaryngology, Hospital das Clínicas, Medical School, University of Sao Paulo, and in daily ENT practice 1,2,3. In general they are safe procedures that do not require prolonged hospitalization. In our center, if there are no complications, patients submitted to these surgeries are discharged from hospital the same day and followed up as outpatients one week and one month after surgery. However, this is not the routine in other centers, in which patients are hospitalized for at least five days 3.

The main surgical techniques used in our center are: Sluder-Ballenger technique, introduced by Sluder in 1911, which includes grasping of tonsils with a specific guillotine and digital dissection of the subcapsular plan, under general anesthesia; dissection with Hartmann clamp, in which subcapsular plan is dissected with the clamp, and bipolar dissection with aspirator-detacher, an instrument with a serrated falx on one end, which can dissect the subcapsular plan and aspirate excessive bleeding at the same time 4.

Despite the fact that it is a safe procedure, postoperative complications, if present, may provide risk to the patients' life, such as in the case of postoperative hemorrhage. The latter has an incidence of 10% 3 and it is considered a severe complication. We can classify it as primary (< 24 hours) or secondary (> 24 hours) 3. Most studies state that primary hemorrhage is more frequent than secondary hemorrhage 5, 6, and this type of event occurs between 6 and 8 hours after the surgery in most of the cases (76-89% of the cases)2.

Other common postoperative complications are nausea, vomiting, fever, inability to take solids or liquids, otalgia and pain 2,7. Lee & Sharp7 observed the need to have analgesia in 92.4% and nausea in 20.3% of the patients in the first postoperative visit. In the same period, Rivas Lacarte8 reported fever in 5.52% of the cases. The incidence of vomiting ranges from 1.57% to 33%7,9.

Some of these complications may reach major magnitude, such as for example, as they determine dehydration and the need for volemic replacement.

OBJECTIVES

Considering that in our center patients are routinely discharged from hospital about six hours after the surgery, period in which there are most of the cases of postoperative bleeding 2, the present study aimed at assessing the consequences and safety of this kind of management, as well as the main postoperative complications reported in the literature. We assessed the occurrence of postoperative bleeding, nausea, vomiting, fever, pain and dysphagia, its frequency and severity, and the period of highest incidence.

The other objective was to compare incidence of postoperative complications according to surgical technique used (Sluder-Ballenger technique, dissection with Hartmann clamp or bipolar dissection).

MATERIAL AND METHOD

We prospectively assessed 147 patients submitted to tonsillectomy in the period between March and December 2002 in the Department of Otorhinolaryngology, Hospital das Clínicas, Medical School, University of Sao Paulo. The criteria for surgical indication were based on the Consensus of the Brazilian Society of Otorhinolaryngology.10

Patient were selected for surgery based on clinical history, physical examination and complementary exams, such as paranasal sinuses x-rays, fibroscopy and audiometry, if indicated. We conducted preoperative laboratory analysis of all patients including complete blood count, thrombin time, prothrombin time and thromboplastin time. If needed, patients were assessed by a hematologist before the surgery, and we excluded the patients that had hematological diseases.

All patients were submitted to surgery under general anesthesia and orotracheal intubation. Tonsillectomy was conducted using Sluder-Ballenger techniques (6 patients), dissection with Hartmann clamp (43 patients) or use of bipolar tonsil dissection (80 patients). Adenoidectomy was conducted using curetage, with Lermoyez curette.

Patients that had no complications six hours after surgery were discharged from hospital to be followed up as outpatients. Follow-up was conducted one week later and one month after the surgery. New visits were scheduled if there were complications that required more frequent follow-up.

We assessed the main complications described in the literature concerning postoperative care of tonsillectomy immediately after surgery, one week and one month later.

The protocol was applied by the physician that performed the surgery immediately after it, and in the outpatient postoperative visit one week and one month later, including demographical data as well as presence of bleeding episodes, fever (temperature higher than 38o C), nausea, vomiting, pain, dysphagia with liquids and solids. We also recorded type of surgical technique employed in each case. We included in the study hemorrhage regardless of severity to be able to quantify the clinical repercussions to the patients.

All patients or their guardians/parents signed the informed consent term including risks and possible complications of the surgical act, in a protocol which had been approved by the Ethics Committee, Hospital das Clínicas, Medical School, University of Sao Paulo.

Patients were initially divided into three groups: those submitted to tonsillectomy (A1), those submitted to adenotonsillectomy (A2), and those submitted to adenoidectomy (Ad).

Patients submitted to tonsillectomy were divided according to the intraoperative technique used: dissection with Hartmann clamp, use of bipolar dissection, and Sluder technique.

Statistical analysis concerning complications was conducted with chi-square test 11 or Fisher exact test11.

The comparison of groups based on variable age was performed with variance analysis of one factor 11, with multiple comparisons made with Bonferroni test11. Level of significance used for the tests was 5%.

RESULTS

We studied 147 patients aged 2 to 47 years, mean age of 8.9 years, 42% female and 57.8% male subjects.

We analyzed the results concerning symptomatology in the three assessed periods, as well as the statistical analysis among them, as listed in Tables 1 and 2.

Chi-square test showed that the results obtained from the first postoperative visit one and week and one month later were statistically different.

The first postoperative visit showed statistically significant difference between groups with dysphagia with liquids, which was significant for patients submitted to tonsillectomy (A1). One week after surgery, there was statistically significant difference between groups concerning pain and dysphagia with solids, which was more frequent in A1 group, and one month later there was statistically significant difference between the groups concerning pain, which was more frequent in A1 group.

As to hemorrhage, we observed higher incidence of bleeding in the early postoperative visit compared to week 1 and month 1. There was no statistically significant difference between the groups comprising nausea, vomiting, fever and otalgia in the first postoperative period, one week and one month later. In two cases, there was the need for reoperation owing to bleeding in groups A1 and A2.

Finally, the group of patients submitted to tonsillectomy was divided according to intraoperative technique used: cold dissection with Hartmann clamp (43 patients), use of bipolar dissection (80 patients) and use of Sluder guillotine (6 patients) (Table 2).

We observed that there was no statistically significant difference concerning the technique used for tonsillectomy and the studied complications.

DISCUSSION

The high cost of medical and hospital procedures is an extremely important topic in modern medicine. In some centers, it is still a common practice to maintain patients submitted to tonsillectomy hospitalized for many days after surgery. As to postoperative hemorrhage, we observed that 11 patients presented hemorrhage in the early postoperative period (7.48%), two of them with severe bleeding, submitted to surgical revision (1.36%) within 6 hours after the initial surgery. The results were compatible with data reported from centers in other countries 3,4,5

During the first week after the surgery, 5 patients (3.4%) presented episodes of bleeding that were mild and improved with wait and see management. There were no cases of bleeding after the first week.

We also observed that patients submitted to tonsillectomy had higher incidence of dysphagia with liquids in the early postoperative visit, pain and dysphagia with solids during the first week, and pain within the first month, compared to the group submitted to adenotonsillectomy and adenoidectomy. This difference may be due to the fact that patients submitted only to tonsillectomy presented higher mean age (22.7 years) when compared to the other groups (A2 = 6.3 years, Ad = 9.25 years), who tend to have slower healing process and take longer to recover 2.

In the first postoperative visit, pain was the most common complaint (62.5%), nausea was present in 22.4% of the patients and vomiting was detected in 19.04%, frequencies similar to those found in other studies 7,8,9. Fever (temperature above 38oC) was observed in 6.8% of the cases in this period, result similar to that found by Rivas Lacarte9. We did not find any significant postoperative difference concerning fever, nausea and vomiting between groups A1, A2 and Ad. Otalgia was significantly more frequent in patients submitted to A2 in early postoperative care, with no difference for week 1 and month 1.

In general, studies compare electrocautery techniques and cold dissection techniques; cautery techniques reduce surgical time and intraoperative bleeding 14, but in general patients present significantly more postoperative pain 15, 16, reason why they are not procedures recommended as routine 15, 16. Homer et al.17 observed that Sluder technique causes less postoperative pain, a result not confirmed by our study. There was no statistically significant difference concerning surgical technique, which also applied to dysphagia, fever, nausea, vomiting and postoperative bleeding.

CONCLUSION

We consider it safe to discharge tonsillectomy patients from hospital after a period of clinical observation of at least 6 hours, a practice that has been used in our center and has considerably reduced the cost of the surgical procedure, given that if present, hemorrhage is much more frequent in the early postoperative period 5.

Surgical technique of Sluder, cold dissection with Hartmann clamp and bipolar dissection did not present statistically significant differences concerning postoperative bleeding and other complications (nausea, vomiting, fever, otalgia, pain and dysphagia), suggesting that the surgeon should prefer to use the technique that he/she is the most familiar with.

REFERENCES

1. Gabalski EC, Mattucci KF et al. Ambulatory Tonsillectomy and Adenoidectomy. Laryngoscope 1996; 106: 77-80.

2. Randall DA, Hoffer ME. Complications of tonsillectomy and adenoidectomy. Otolaryngol Head Neck Surg 1998; 118(1): 61-8.

3. Windfuhr JP, Ulbrich, T. Post-tonsillectomy hemorrhage: Results of a 3-month follow-up. Ear, Nose & Throat J 2001; 80(11): 790-802.

4. Feldmann H. 200 year history of tonsillectomy. Images from the history of otorhinolaryngology, highlighted by instruments from the collection of the German Medical History Museum in Ingolstadt]. Laryngorhinootologie 1997; 76(12): 751-60.

5. Windfuhr JP, Chen YS. Post-tonsillectomy and -adenoidectomy hemorrhage in nonselected patients. Ann Otol Rhinol Laryngol 2003 Jan; 112(1): 63-70.

6. Johnson LB, Elluru RG, Myer CM. Complications of adenotonsillectomy. Laryngoscope 2002 Aug; 112(8 Pt 2): 35-6.

7. Castellano P, Gámiz MJ, Bracero F, Santiago F, Soldado L, Solanellas J, Ruiz-Mondéjar A, Esteban F. "Usual" morbidity of pediatric tonsillectomy: a study of 126 cases. Acta Otorrinolaringol Esp 2001 Jun-Jul; 52(5): 390-5.

8. Lee WC, Sharp JF. Complications of pediatric tonsillectomy post-discharge. J Laryngol Otol 1996 Feb; 110(2): 136-40.

9. Rivas LM. Tonsillectomy as a major outpatient procedure. Prospective 8-year study: indications and complications. Comparison with inpatients. Acta Otorrinolaringol Esp 2000 Apr; 51(3): 221-7.

10. Almeida ER, Campos VAR. Indicações e contra-indicações de adenotonsilectomias. In: Campos CAH, Costa HOO. Tratado de Otorrinolaringologia. Editora Roca; 2002. Cap. 28, 3: 248-52.

11. Rosner B. Fundamentals of Biostatistics. Boston: PWS Publishers. Second edition, 1986.

12. Rakover Y, Almog R, Rosen G. The risk of postoperative haemorrhage in tonsillectomy as an outpatient procedure in children. Int J Pediatr Otorhinolaryngol 1997 Jul 18; 41(1): 29-36.

13. Windfuhr JP, Chen YS. Hemorrhage following pediatric tonsillectomy before puberty. Int J Pediatr Otorhinolaryngol 2001 May; 58(3): 197-204.

14. Raut V, Bhat N, Kinsella J, Toner JG, Sinnathuary AR, Stevenson M. Bipolar scissors versus cold dissection tonsillectomy: a prospective, randomized, multi-unit study. Laryngoscope 2001 Dec; 111(12): 2178-82.

15. Carr MM, Muecke CJ, Sohmer B, Naner JG, Finley GA. Comparison of postoperative pain: tonsillectomy by blunt dissection or electrocautery dissection. J. Otolaryngol 2001 Fev; 30 (1): 10-4.

16. Lassaletta L, Martin G, Villafruela MA, Bolãnos C, Alvarez-Vicent JJ. Pediatric tonsillectomy: post-operative morbidity comparing microsurgical bipolar dissection versus cold sharp dissection. Int. J. Pediatr. Otorhinolaryngol 1997 Sep; 41 (3): 307-17.

17. Homer JJ, Williams BT, Semple P, Swanepoel A, Knight LC. Tonsillectomy by guillotine is less painful than by dissection. Int. J. Pediatr. Otorhinolaryngol 2000 Jan; 52 (1): 25-9.

Table 1. Comparison between symptoms and groups (in absolute numbers).

N = number of total cases. p= level of significance
* A1 = tonsillectomy, A2 = adenotonsillectomy, Ad = adenoidectomy

Table 2. Comparison between symptoms and techniques used (in percentage).

" Asp = technique using bipolar dissection (aspirator-detacher)
Hart = technique using Hartmann clamp
Slud = technique using Sluder guillotine

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