Association of Patient Characteristics With Postoperative Mortality in Children Undergoing Tonsillectomy in 5 US States.

Importance: The rate of postoperative death in children undergoing tonsillectomy is uncertain. Mortality rates are not separately available for children at increased risk of complications, including young children (aged <3 y) and those with sleep-disordered breathing or complex chronic conditions. Objective: To estimate postoperative mortality following tonsillectomy in US children, both overall and in relation to recognized risk factors for complications. Design, Setting, and Participants: Retrospective cohort study based on longitudinal analysis of linked records in state ambulatory surgery, inpatient, and emergency department discharge data sets distributed by the Healthcare Cost and Utilization Project for 5 states covering 2005 to 2017. Participants included 504 262 persons younger than 21 years for whom discharge records were available to link outpatient or inpatient tonsillectomy with at least 90 days of follow-up. Exposures: Tonsillectomy with or without adenoidectomy. Main Outcome and Measures: Postoperative death within 30 days or during a surgical stay lasting more than 30 days. Modified Poisson regression with sample weighting was used to estimate postoperative mortality per 100 000 operations, both overall and in relation to age group, sleep-disordered breathing, and complex chronic conditions. Results: The 504 262 children in the cohort underwent a total of 505 182 tonsillectomies (median [IQR] patient age, 7 [4-12] years; 50.6% females), of which 10.1% were performed in young children, 28.9% in those with sleep-disordered breathing, and 2.8% in those with complex chronic conditions. There were 36 linked postoperative deaths, which occurred a median (IQR) of 4.5 (2-20.5) days after surgical admission, and most of which (19/36 [53%]) occurred after surgical discharge. The unadjusted mortality rate was 7.04 (95% CI, 4.97-9.98) deaths per 100 000 operations. In multivariable models, neither age younger than 3 years nor sleep-disordered breathing was significantly associated with mortality, but children with complex chronic conditions had significantly higher mortality (16 deaths/14 299 operations) than children without these conditions (20 deaths/490 883 operations) (117.22 vs 3.87 deaths per 100 000 operations; adjusted rate difference, 113.55 [95% CI, 51.45-175.64] deaths per 100 000 operations; adjusted rate ratio, 29.39 [95% CI, 13.37-64.62]). Children with complex chronic conditions accounted for 2.8% of tonsillectomies but 44% of postoperative deaths. Most deaths associated with complex chronic conditions occurred in children with neurologic/neuromuscular or congenital/genetic disorders. Conclusions and Relevance: Among children undergoing tonsillectomy, the rate of postoperative death was 7 per 100 000 operations overall and 117 per 100 000 operations among children with complex chronic conditions. These findings may inform decision-making for pediatric tonsillectomy.

Mortality after tonsil surgery, a population study, covering eight years and 82,527 operations in Sweden.

The objective of this retrospective cohort study was to evaluate mortality rate and cause of death after tonsil surgery in Sweden. Two national registries were used, both run by The Swedish National Board of Health and Welfare, an agency of the Ministry of Health and Social Affairs. In the National Patient register all tonsil surgeries performed in Sweden from 2004 through 2011 were identified. The result from this search was matched with the National Cause of Death Register to identify all deaths that occurred within 30 days of tonsil surgery. Personal identity numbers were used to do the matching of registers. Details on the cause of death were obtained from the Swedish National Board of Health and Welfare. Two deaths were identified in 82,527 operations. Both patients were male, otherwise healthy, children under the age of five, operated due to tonsil-related upper airway obstruction/snoring with coblation technique. Cause of death was bleeding-related airway obstruction in both cases and hemodynamic failure caused by blood loss. Both deaths occurred after discharge from the hospital within the first postoperative week. No abnormal levels of analgesics were found in the postmortal investigations. Two deaths related to tonsil surgery (performed on benign indications) were identified in 82,527 operations (2004-2011) in a well-defined national population. Both deaths were due to postoperative bleeding. Based on our findings, the frequency of post-tonsil-surgery mortality in Sweden was 1/41,263, 2004-2011. Level of evidence 2b retrospective cohort study.

What lessons can be learned from the Austrian events?

INTRODUCTION: The death of 5 children in Austria below the age of 6 years due to posttonsillectomy haemorrhage in 2006 and 2007 led to an intensive discussion on the potential life-threatening risks of tonsil surgery. On this occasion, a consensus paper with clear recommendations for tonsil surgery was released by the Austrian Societies of Otorhinolaryngology, Head and Neck Surgery and Paediatrics followed by a nationwide multicentre study. METHODS: All consecutive tonsillectomies, tonsillotomies and adenoidectomies performed in public hospitals in Austria within 9 months were assessed. Data on all participating patients were collected via an online questionnaire requesting patient characteristics, surgery details and postoperative haemorrhage. A strict definition for postoperative bleeding episodes with 7 severity grades was applied. Every bleeding episode after extubation was counted as postoperative bleeding event. RESULTS: The study population - all younger than 18 years of age - consisted of 6,765 patients (tonsillectomy 2,080, 31%; tonsillotomy 1,292, 19%; adenoidectomy 3,393, 50%). Postoperative haemorrhage episodes were reported in 15% after tonsillectomy and in 2.3% after tonsillotomy, with the risk increasing parallel to age. Multiple bleeding episodes were recorded in one fourth of all tonsillectomy bleedings, but were rare after tonsillotomy. Surgical revision under general anaesthesia was necessary in 4.2% after tonsillectomy and in 0.9% after tonsillotomy. DISCUSSION: As the incidence of tonsillectomy in children younger than 6 years has declined following the recommendations of the consensus paper issued in 2007, tonsillotomy has become more frequent in this age group. Overnight hospital admission and observation is suggested for all patients experiencing postoperative haemorrhage, as the occurrence of one minor bleeding doubled the risk of a second severe bleeding.

[The Austrian tonsil study 2010--part 1: statistical overview]. / "Die Österreichische Tonsillenstudie 2010"--Teil 1: Statistischer Überblick.

BACKGROUND: Tonsillectomy (TE), tonsillotomy (TO) and adenoidectomy (AE) are surgeries performed routinely by otorhinolaryngologists. There were 5 cases of fatal postoperative bleeding in Austria during the years 2006 and 2007, all in children under 6 years of age. The intensive discussion following these sad events resulted in a Consensus Paper of the Austrian Society of ORL, H&NS with the Austrian Society of Pediatrics with modified recommendations towards indications and surgical techniques in different age groups; in addition, the prospective study presented here was initiated. In Austria for the first time a full census could be performed assessing all TE, TO and AE with standardized definitions. MATERIAL AND METHODS: Within the study period of 9 months' from October 1, 2009, to June 30, 2010, data on patients' characteristics, indication for surgery, surgical technique and postoperative haemorrhage were prospectively collected. Postoperative haemorrhage was defined as any bleeding after extubation regardless of whether or not a surgical intervention was required. Postoperative bleeding events were categorised into 7 grades depending on severity. RESULTS: More than one million data of 9,405 patients from 32 ENT-departments in Austria were collected and analysed. One third were children younger than 6 years (n=3,474; 37%) and one third were adults (n=3,507, 37%). A TE ±AE was performed in 48.8% (n=4,594), an AE in 37.1% (n=3,492) and a TO in 14.0% (n=1, 319). For the indication "recurrent tonsillitis and tonsilar hypertrophy" 70% of children had a TO but 95% of adults had a TE (p<0.001). Adults with OSAS had a TE whereas in children aged younger than 6 with the same indication a TO was preferably performed in 90% (p<0.001). For TO the Colorado-needle and the Coblation technique were most commonly used. The Adenotome by La Force and the Adenoid curette by Beckmann, with or without endoscopic control, were most frequently used for AE. CONCLUSIONS: For the first time a prospective full survey could be performed in one country assessing all tonsil and adenoid surgeries along standardized criteria. The study gives an overview about the types of surgery, the indications, the operation techniques and the frequency of postoperative haemorrhage. The latter, because of its clinical importance, is dealt with and described in detail in the second part of this publication.

Outcome, risk, and error and the child with obstructive sleep apnea.

Adenotonsillectomy is the mainstay of treatment for pediatric obstructive sleep apnea syndrome (OSAS). However, there is evidence that the child with severe OSAS is at increased risk of respiratory compromise. The most difficult risk factor to assess is the severity of OSAS, and these difficulties are reviewed.

Postoperative bleeding in paediatric ENT surgery. First results of the German ESPED trial.

Bleeding after ear-nose-and throat surgery in children is a serious complication. With the help of the German Surveillance Unit for Rare Paediatric Disorders (Erhebungseinheit für seltene pädiatrische Erkrankungen in Deutschland; ESPED) a two year survey was performed to record the incidence, severity, reasons and treatment of haemorrhages. During the study period, 1069 bleeds were reported from 720 paediatric hospitals and departments of otorhinolaryngology after adenoidectomy and tonsillectomy. 713 reports could be analyzed. Two deaths occurred after adenoidectomy. Although laboratory screening was performed in more than 70% of all cases, bleeding complications were neither foreseeable nor preventable. Inherited coagulopathies were rare and in most cases not detected, neither by laboratory screening nor by taking a history. Since preoperative measures cannot help much to improve the situation, all efforts have to be taken to improve the postoperative period, especially since more than 20% of the hemorrhages occurred during weekends. Guidelines on postoperative care and behaviour should therefore be implemented and parents and patients must be informed on bleeding risks and on what to do in case of emergency. If bleeding occurs, extensive coagulation testing is mandatory.

Morbidity and mortality from adenotonsillectomy in children with trisomy 21.

OBJECTIVE: Adenotonsillectomy (AT) is common in children with trisomy 21 but outcomes are variable. Therefore, practitioners must have accurate information regarding the risks of the procedure specific to trisomy 21 to help patients weigh the risks and benefits of surgery. The objective of this study was to better characterize morbidity and mortality risk factors from AT in children with trisomy 21. METHODS: A single-center retrospective chart review of children with trisomy 21 who underwent AT was conducted from 1992 to 2019. The primary outcome was 30-day post-operative complication rate. Secondary outcomes included intraoperative complications, admission duration, emergency department visits, readmissions, reoperation rate and treatment failures. RESULTS: Two-hundred and fifty one children met study criteria (median age 4.5 years). Seventy-eight patients (31.5%) had a post-operative complication requiring medical intervention, with respiratory issues (42, 53.8%), poor oral intake (29, 37.2%), and bleeding (14, 17.9%) being most common. Postoperatively, 72 patients (28.7%) had a prolonged hospital stay. Sleep disordered breathing (p = 0.003), ASA score >2 (p < 0.001), severe OSA (p = 0.003), preoperative ICU admission (p < 0.001), and aerodigestive comorbidities (p = 0.004) were associated with increased post-operative respiratory complications. No mortalities were identified. CONCLUSION: This large single institution study evaluating morbidity and mortality following AT in children with trisomy 21 identified a morbidity rate of 31.5%. These findings may improve our ability to anticipate and manage postoperative morbidity in this vulnerable population and facilitate informed discussions with patients and caregivers considering AT.

A devastating outcome after adenoidectomy and tonsillectomy: ideas for improved prevention and management.

OBJECTIVE: To develop strategies that may assist the surgeon to prevent and manage severe bleeding complications after adenoidectomy and tonsillectomy. STUDY DESIGN: Retrospective. SUBJECTS AND METHODS: Expert reports for malpractice lawsuits or professional boards were reviewed. The review was restricted to "deaths" and "permanent generalized neurological deficiencies." RESULTS: Forty-three cases matched our search criteria, including 32 deaths. Adenoidectomy cases (2) were associated with immediate bleeding because of direct vascular injury resulting in one death. Tonsillectomy cases were associated with delayed and repeated episodes of bleeding resulting in 31 deaths, including 19 children. Autopsy verified predominantly aspiration and vascular injuries. An apallic syndrome prevailed in surviving patients. CONCLUSION: Careful inspection of the nasopharynx immediately before adenoidectomy and curettage in a piecemeal fashion under visual control is helpful to prevent direct injury to aberrant arteries. Tonsillectomy cases are associated with delayed and episodic bleeding with spontaneous cessation and young age. Inpatient observation should be strongly considered in cases with repeated bleeding episodes to provide immediate treatment. The follow-up should be focused on disturbed wound healing. Outcome appears to be dependent on adequate airway management. Rigid instruments and tracheotomy in case of intubation failure are highly recommended to facilitate airway protection and ventilation.

Role of adenotonsillectomy in the management of pediatric ear, nose and throat infections.

Tonsil and adenoid diseases in children continue to result in considerable morbidity despite the age of antibiotics. Immunologic studies have thus far shown no adverse effects as a result of adenoidectomy or tonsillectomy. However, because the indications for surgery remain controversial, each child must be considered on a case-by-case basis.

More codeine fatalities after tonsillectomy in North American children.

In 2009 we reported the fatal case of a toddler who had received codeine after adenotonsillectomy for obstructive sleep apnea syndrome. The child was an ultra-rapid metabolizer of cytochrome P4502D6 (CYP2D6). We now report 3 additional fatal or life-threatening cases from North America. In the 2 fatal cases, functional gene duplications encoding for CYP2D6 caused a significantly greater production of potent morphine from its parent drug, codeine. A severe case of respiratory depression in an extensive metabolizer is also noted. These cases demonstrate that analgesia with codeine or other opioids that use the CYP2D6 pathway after adenotonsillectomy may not be safe in young children with obstructive sleep apnea syndrome.

Tonsillectomy and adenoidectomy: incidence and mortality, 1968--1972.

To determine the number of tonsillectomies and adenoidectomies (T-As) from 1968 to 1972 and their associated morbidity and mortality rates, a questionnaire was sent to all the hospitals listed in the Directory of the American Hospital Association (6,759). The data were analyzed and statistical projections were made. An analysis was also made of the summary report of the "Study on Surgical Services for the United States," with regard to the incidence of T-A was also made. The results are presented in the following report.