Immediate and delayed complications of adenotonsillectomy

INTRODUCTION

Tonsils and adenoid act as host defense and sentinels at the portal of aerodigestive tract.¹ Aggregated mucosa associated lymphoid tissue (MALT) in the subepithelial pharyngeal layer at the entrance of the aerodigestive tract are collectively called as the Waldeyer’s ring.² The T-lymphocytes in the parafollicular region of these lymphoid aggregates provide cell mediated immunity. B-lymphocytes in the germinal centers of these lymphoid tissue produce IgA antibodies. The most common problems affecting the tonsils and adenoid tissue are recurrent infections (throat or ear), significant enlargement and obstruction that causes swallowing and breathing problems. Abscesses around the tonsils and chronic infections can also affect the tonsils and adenoids, making them sore and swollen.

Group A beta-hemolytic Streptococci is the most commonly recognized pathogen.³ Many other organisms are also involved, few of particular importance are beta-lactamase producing organisms like Staphylococcus aureus, Moraxella catarrhalis, and Hemophilus influenza.⁴ In polymicrobial infections beta-lactamase producing organisms can protect group A Streptococci from eradication with Penicillins.⁵ Any virus infection can initiate an attack of acute tonsillitis which also predisposes to secondary bacterial infection. The viruses implicated in acute tonsillitis include adenovirus, Epstein barr virus and herpes simplex virus. Anaerobes have also been found to be present in moderate amounts in 30% of superficial swabs.⁶

Recurrent and resistant infections of adenoid and tonsils warrant the situation to go for surgical management. Studies show that quality of life significantly improves following adenotonsillectomy in sleep–disordered breathing (SBD) children.⁷ Absolute indications for adenotonsillectomy include adenotonsillar hyperplasia with obstructive sleep apnea, failure to thrive, or abnormal dentofacial growth, suspicion of malignant disease, and hemorrhagic tonsillitis (for tonsillectomy). Relative indications for both procedures are adenotonsillar hyperplasia with upper airway obstruction, dysphagia, or speech impairment, and halitosis.⁸

Roman surgeon Aulus Cornelius Celsus and Paul of Aeigina in 30 AD were the first to describe early tonsillectomies by blunt removal using fingernail or hook and to remove them with a knife.⁹ Morel Mackenzie (1837-1892) is considered as true founder of modern tonsillectomy.¹⁰ In 2002, microdebrider and coblation tonsillectomy evolved with minimal intra operative bleeding. Nowadays coblation has become a more commonly practiced technique for tonsillectomy. Newer tools such as the coblator and plasma knife have gained popularity with some surgeons, which makes the practicing patterns even more diverse. Varying techniques for tonsillectomy have been described under cold and hot tonsillectomy.¹¹

This study was conducted with the following objectives:

(1) to evaluate the incidence of immediate and delayed complications following adenotonsillectomy and (2) to compare the intra and postoperative complications in conventional and coablation tonsillectomy.

METHODS

Study population

This observational study was conducted among 150 patients who had undergone adenotonsillectomy in Government Stanley Medical College between June 2012 and September 2013. 100 patients who had undergone conventional tonsillectomy and 50 patients who had undergone coblation tonsillectomy within the study period were included in the study with the following inclusion and exclusion criteria.

Inclusion and exclusion criteria

The children between the age 5 and 15 years and of both the genders were included in the study. The patients who had been diagnosed with one the following like acute recurrent tonsillitis, peritonsillitis, streptococcal carriers, OSA, conductive hearing loss due to secretory otitis media or diphtheria carriers were included in the study. Patients with one of the following like acute tonsillitis, blood dyscariasis, palatal abnormalities like submucus cleft palate or down’s syndrome were excluded from the study.

Assessment

Clinical assessment was done by taking accurate history. History of throat pain, odynophagia, difficulty in swallowing, mouth breathing, snoring, ear block and recurrent upper respiratory tract obstruction were taken. Clinical examination for adenoid facies-elongated face, short open upper lip, crowded teeth, high arched plate and hyponasal speech were done. Clinical examination of oral cavity including lips, teeths, gums, tongue, palate - both hard and soft, floor of the mouth, cheeks and the clinical examination of oropharynx including uvula, soft palate, anterior and posterior tonsillar pillars, tonsils and posterior pharyngeal wall were done.

Postnasal examination was done by using St.Clair Thompson’s post nasal mirror. This examination was augmented using a 2.7 mm internal diameter 0° nasal endoscope. Radiological assessment were done with x ray neck soft tissues: lateral view which will usually reveal the degree of adenoid hypertrophy.

Following investigations were done while the patients were assessed prior to surgery: haemoglobin, total count, differential count, erythrocyte sedimentation rate, bleeding time, clotting time, blood grouping and rh typing, prothrombin time, absolute partial thromboplastin time, urine-albumin, sugar and deposits, X-ray chest pa view, diagnostic nasal endoscopy and pure tone audiometry.

Outcome measures

Intra operative and postoperative events were observed among the patients. intraoperative anesthetic complications like dislodging of loose tooth, Accidental extubation and compression of ET tube were noted. Intraoperative surgical complications like primary hemorrhage, edema of uvula and pillar injury were observed. Postoperative complications observed were the following like nausea, vomiting, loss of taste, primary hemorrhage, oropharyngeal pain, referred otalgia, secondary hemorrhage, dehydration and pneumonia atelectasis.

The study protocol was approved by the Institutional Ethical Committee. Informed written consent for adenotonsillectomy and consent for inclusion into the study was obtained from the parents of the patients.

Statistical analysis

The data collected were entered on excel spreadsheet and analysed with SPSS version 18.0. Analysis was based on the comparison of results obtained intra operatively and post operatively. Incidence of complications observed in both groups were compared using chi square test.

RESULTS

General description of the study population

There were totally 150 patients included in the study. 100 patients were in conventional tonsillectomy group and 50 patients were in coblation tonsillectomy group. In the conventional tonsillectomy group, 43 (43.0%) were males and 57 (57.0%) were females. In the same manner, in the coblation tonsillectomy group, 21 (42.0%) were males and 29 (58.0%) were females and both groups are comparable as evident by p>0.05 (Table 1). The minimum age of the study population is from 5 years to maximum of 15 years. The mean age was 9.42 years with standard deviation of 2.67 years. The mean age (±SD) in conventional tonsillectomy group is 9.67 (±2.69) years while the mean age (±SD) in coblation tonsillectomy group is 8.92 (±2.58) years. This difference is not significant as the p-value is >0.05. So both the groups are comparable by age too (Table 2).

Preoperative symptoms

Figure 1 shows the preoperative symptoms of the study population. Odynophagia was the most common symptom as seen in 144 (96.0%) patients followed by throat pain in 143 (95.3%) and difficulty in swallowing in 134 (89.3%) patients. Then mouth breathing was seen in 85 (56.7%) of the patients and Snoring was seen only 35 (23.3%) patients (Figure 1).

Table 3 shows the comparison of preoperative symptoms between both conventional tonsillectomy and coblation tonsillectomy group of patients. Throat pain was seen in 96 (96.0%) of the conventional tonsillectomy patients and 47 (94.0%) of the coblation tonsillectomy patients. This difference is not statistically significance as seen in p-value >0.05. In the same way, odynophagia was seen in 94 (94.0%) of the conventional tonsillectomy patients and all the 50 (100%) of the coblation tonsillectomy patients. But this difference is not statistically significance as seen in p-value is 0.077.

Regarding difficulty in swallowing, it was seen in 89 (89.0%) of the conventional tonsillectomy patients and 45 (90.0%) of the coblation tonsillectomy patients and this difference is not statistically significance (p-value – 0.852). Mouth breathing was seen in 53 (53.0%) of the conventional tonsillectomy patients and in 32 (64.0%) of the coblation tonsillectomy patients. But this difference is not statistically significance as p-value is 0.200. Snoring was observed in 24 (24.0%) of the conventional tonsillectomy patients and in 11 (22.0%) of the coblation tonsillectomy patients and there is no statistically significant difference between the groups as p-value is only 0.785. Thus both the groups were comparable (Table 3).

Complications of adenotonsillectomy

Complications of adenotonsillectomy have been given in to two categories as immediate (intraopetative) and delayed (postoperative).

Immediate (intraopetative) complications

Immediate complications were divided in to two categories as intraoperative anesthetic complications and intraoperative surgical complications. Among the intraoperative anesthetic complications in the study populations, compression of ET tube was the commonest complication as seen in 19 (12.7%) patients followed by accidental extubation seen in 10 (6.7%) patients and dislodging of loose tooth seen in 9 (6.0%) patients. None of the patients had any dislocation of temparo mandibular joint. Regarding intraoperative surgical complications, Primary hemorrhage was seen in maximum as many as 43 (28.7%) patients followed by edema uvula seen in 39 (26.0%) and pillar injury seen in 33 (22.0%) patients (Table 4).

Delayed (postoperative) complications

Oropharyngeal pain was the commonest postoperative complication in the study population as seen in 28 (18.7%) followed by primary hemorrhage seen in 21 (14.0%) patients and nausea, vomiting was seen in 20 (13.3%) patients. Referred otolgia and secondary hemorrhage were observed in 12 (8.0%) patients respectively each and loss of taste was seen in 6 (4.0%) of the patients. Regarding postoperative other rare complications, dehydration was observed in 9 (6.0%) and pneumonia atelectasis was seen in 3 (2.0%) of the patients. Velopharyngeal insufficiency and nasopharyngeal stenosis were not seen in any of the patients (Table 5).

Comparison of immediate and delayed complications

Immediate complications

Table 4 shows the comparison of intra operative anesthetic complications and the intra operative surgical complications between the two groups. Dislodging of loose tooth was seen in 7 (7.0%) of the conventional tonsillectomy patients but it was observed in only 2 (4.0%) of the coblation tonsillectomy patients but this difference is not statistically significant (p-value –0.466).

Accidental extubation was seen in 6 (6.0%) of the conventional tonsillectomy patients and it was seen only 4 (8.0%) of the coblation tonsillectomy patients and this difference is not statistically significant (p-value –0.642). Compression of ET tube was seen in 15 (15.0%) of the conventional tonsillectomy patients but it was seen in only 4 (8.0%) of the coblational tonsillectomy patients but this difference is not statistically significant (p-value –0.224).

Primary hemorrhage which is the commonest intra operative surgical complications was observed in 40 (40.0%) of the conventional tonsillectomy patients while it was seen in only 3 (6.0%) of the coblation tonsillectomy patients. This is the highly statistically significant difference as seen in p-value 0.0001. In the same way, edema uvula was observed in 32 (32.0%) of the conventional tonsillectomy patients while it was seen in only 7 (14.0%) of the coblation tonsillectomy patients. This difference is also statistically significant as seen in p-value 0.018. Pillar injury was observed in 19 (19.0%) of the conventional tonsillectomy patients and 14 (28.0%) of the coblation tonsillectomy patients but this difference is not statistically significance (p-value –0.210).

Delayed complications

Table 5 compares the postoperative complications between the groups. Nausea, vomiting was observed in 12 (12.0%) of the conventional tonsillectomy patients and it was seen in 8 (16.0%) of the coblation tonsillectomy patients. But this is difference is not statistically significant as seen in p-value is only 0.497. In the same way, loss of taste was observed in 2 (2.0%) of the conventional tonsillectomy patients while it was seen in 4 (8.0%) of the coblation tonsillectomy patients. But this difference is also not statistically significant as seen by p value 0.077.

Primary hemorrhage was observed in 12 (12.0%) of the conventional tonsillectomy patients and 9 (18.0%) of the coblation tonsillectomy patients but this difference is not statistically significance (p=0.318). Oropharyngeal pain which was commonest among the postoperative complications was observed in 19 (19.0%) of the conventional tonsillectomy patients and it was seen in 9 (18.0%) of the coblation tonsillectomy patients and the difference is not statistically significant as seen in p-value is only 0.882.

Referred pain was observed only in 4 (4.0%) of the conventional tonsillectomy patients but it was seen in 8 (16.0%) of the coblation tonsillectomy patients. This difference is statistically significant as seen in p-value 0.011. Secondary hemorrhage was not observed in any of the conventional tonsillectomy patients but it was observed in 12 (24.0%) of the coblation tonsillectomy patients. This difference is highly statistically significant as seen in p=0.0001.

DISCUSSION

Adenotonsillitis is one of the commonest health problems encountered in the general population particularly in children. Tonsillectomy with or without adenoidectomy is the most commonly performed pediatric otorhinolaryngological procedure.¹² Variety of techniques and approaches for adenotonsillectomy have been tested and tried over the years. Since adenotonsillecotmy procedure by both conventional and coblation methods are routinely happening in the centre where this study was conducted, a comparison was made between them on the immediate and delayed complications.

Among the intraoperative anesthetic complications in the study population, compression of ET tube was the commonest complication as seen in 19 (12.7%) patients followed by accidental extubation seen in 10 (6.7%) patients and dislodging of loose tooth seen in 9 (6.0%) patients. It has been found that the compression and obstruction of the anesthetic tube is the predominant complication due to selection of faulty size of the blade of Davis mouth gag.¹³ Accidental extubation while changing the head position and also during Doughty’s tongue blade removal is another commonly encountered anaesthetic complications in both conventional and coablation tonsillectomy.

Regarding intraoperative surgical complications, primary hemorrhage was seen in maximum as many as 43 (28.7%) patients followed by edema uvula seen in 39 (26.0%) and pillar injury seen in 33 (22.0%) patients. Primary haemorrhage is the most commonly recorded intra operative surgical complication.¹⁴ The reason for primary haemorrhage may be due to inadequate preoperative patient preparation, faulty surgical technique, in advertent injury to superior constrictor muscles and difficulty in ligating the bleeders in the tonsillar bed especially in superior and inferior pole. Edema of the uvula, is another intra operative complication which is mainly encountered due to in advertent and frequent suctioning over the uvula.

Oropharyngeal pain was the commonest postoperative complication in the study population as seen in 28 (18.7%) patients followed by primary hemorrhage seen in 21 (14.0%) patients. Oropharyngeal pain has been found to be the most commonest postoperative complication in a study by Linden et al.¹⁵

Odynophagia is due to muscle spasm, especially the superior constrictor fibres and dissection of the tonsil substance. Similar irritation of the superior constrictor occurs while curreting the adenoids. In our study referred otolgia and secondary hemorrhage were observed in 12 (8.0%) patients respectively. Referred otolgia is probably due to close removal of the tonsil from the tongue base. In our study it was significantly higher with coblation group. But in a study Schmidt et al, the pain scores were compared it was significantly lower, which is 3.3 in the coblation group and 3.7 in conventional group.¹⁶ Secondary hemorrhage was observed in 12 (8.0%) patients. It is significantly more associated with coablation tonsillectomy because of dislodgement of the infective slough.

Invention of equipments like coblation, mono/bipolar electrocautery and laser have made the outlook better for adenotonsillectomies with respect to intraoperative and postoperative complications. Primary haemorrhage is less in coblation technique because: (a) dissection is done extracapsular, hence no surgical trauma to the para tonsillar vein and the superior constrictor muscle which lies in the tonsillar bed, (b) hemostasis was possible for vessels less than 1 mm in diameter and (c) histopathological thermal injury of only 0.13-mm depth is reported.¹⁷ Hence training and experience of the surgeon, technical preferences and its complications, cost-effectiveness should be considered in choosing the surgical technique. All trainee surgeons should become competent in conventional dissection method and in achieving haemostasis using ligatures before learning other modern techniques.

Irrespective of seniority and experience, every surgeon should undergo appropriate training before using new techniques like coblation. Emphasis must be placed on explaining the risk of postoperative haemorrhage to the patient, teaching the correct technique like checking the power settings prior to surgery and the potential hazards of coblation technique. Every complication should be recorded and analyzed regularly to improve the patient’s safety. Yet it can be argued that the use of coblation tonsillectomy is equivalent to the use of conventional technique in the current scenario with respect to intra and post operative complications.

CONCLUSION

Compression of ET tube was the commonest intraoperative anesthetic complication (12.7%) and primary hemorrhage was observed as the commonest intraoperative surgical complication (28.7%) in the study population. Immediate complications like primary haemorrhage and uvula edema were significantly associated with conventional tonsillectomy group. Delayed complications like secondary haemorrhage and referred otalgia were significantly associated with coblation tonsillectomies.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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