Complications common for adults after tonsillectomy
Adults have a high rate of complications after getting their tonsils removed, so plan for adequate recuperation after the surgery, researchers say.
“Most of these are not life threatening problems, but people may not be back to work in a hurry,” said Dr. David Rosen, a specialist in Otolaryngology and Head and Neck Surgery at Thomas Jefferson University Hospital in Philadelphia.
“Just go into it realistically,” said Rosen, who was not involved in the new study. “Most people will feel pretty good in a week, but it may really be more uncomfortable than you think.”
Researchers analyzing a database of insurance claims found that one in five adults who had tonsillectomy surgeries also had serious complications within two weeks of the operation. One in 10 went to an emergency room as a result.
Tonsils are clusters of tissue in the throat that are part of the lymphatic system. They can become swollen with infections and can interfere with breathing.
Children commonly have surgery to remove swollen tonsils that cause sleep problems, and they tend to have easier recoveries than adults, which is something most ear, nose and throat doctors already know.
Surgically removing the tonsils can help adults who have repeated cases of strep throat each year or bad sleep apnea. But for adults, recovery isn’t always as easy as patients expect.
The researchers examined 36,000 cases of adult outpatient tonsillectomy in a nationwide insurance database and identified patents who had a record of a health problem one, two or four weeks later that may have been related to the surgery.
They were led by Dr. Meena Seshamani, a head and neck surgeon with The Permanente Medical Group in San Francisco.
The team tallied complications including bleeding, pain, dehydration, blood transfusion, dislocation of cervical vertebra and fever, among other conditions.
After one week, 15 percent of patients had at least one possible complication, which rose to 20 percent by the two- and four-week points, according to the results published in Otolaryngology-Head and Neck Surgery.
Pain was the most common complication, affecting 11 percent of patients, compared to the 6 percent who experienced bleeding and 2 percent who had dehydration.
“Keeping yourself well hydrated is usually going to lead to less complications,” Rosen said. Having a raw spot in your mouth can make it painful to swallow, especially since some of the liquid medicines people use sting the wound, but if you get dehydrated the scab will fall off and that’s how bleeding starts, he said.
“One of the lessons here for surgeons is that we need to give better instructions and a better pain management plan for patients,” said Dr. Craig Derkay, professor and vice-chairman of the Department of Otolaryngology Head Neck Surgery at Eastern Virginia Medical School in Norfolk. Derkay was not part of the new study.
It’s important for adult patients to understand that recovery might not be a picnic, he said.
“Children regulate their activity after a tonsillectomy much better than adults do,” which is one reason kids have an easier recovery, he said.
“Kids lie around, watch cartoons, play videogames for a few days until their parents send them back to school, but adults immediately try to go back to work.”
Another reason adults have a tougher time is that the older you are, the harder it is for a surgeon to get your tonsils out, he said. Every time you have a sore throat some scar tissue builds up on the tonsils, and the more sore throats you have had, the more scar tissue will get in the way during the surgery.
For adults who have problems with their tonsils, there is no real alternative to surgery, although some can elect to have an in-office procedure instead, said Dr. Neil Bhattacharyya, professor of Otology & Laryngology at Harvard Medical School in Boston.
He offers that service, he told Reuters Health by phone, but it’s not widely available and may not be an option for most patients.
Though the experts agreed that tonsillectomy does have an unusually high complication rate compared to other common outpatient surgeries, not all were convinced it is quite as high as the one in five rate seen in the study.
“Twenty percent will have a complication - that is a big number. I’m not sure many people would sign up for a surgery where they have such a high complication rate,” Bhattacharyya said.
Seshamani and colleagues included some conditions, like dislocation of cervical vertebrae and outer ear infection, that are either very rare or likely not related to tonsillectomy, Bhattacharyya told Reuters Health.
“In my time in practice, I’ve never seen an outer ear infection related to tonsillectomy,” he said.
That ten percent of patients were admitted to the emergency room to treat a complication also seemed unrealistic to some.
“I don’t think my patients are getting readmitted with this rate,” Rosen said.
Bleeding is common, however, and there’s not much the surgeon can do during the procedure to reduce that risk, Bhattacharyya said.
“We have no way of proving that this is causal,” said David Scanlon, the study’s senior author, at The Pennsylvania State University in State College. “We freely acknowledge that there’s some uncertainty.”
Working from an insurance database means there’s less certainty about exactly what happened to each patient, and it’s possible they included some “complications” that weren’t actually related, Scanlon said.
There could also have been complications that were not coded, or coded incorrectly, in the database, which would also skew the results, he said.
But the overall results should help get doctors and patients talking about recovery after tonsillectomy surgery, and making a plan in advance for some possible complications, he said.
“When you know there’s a possibility for these complications, you can set up processes to monitor your patients,” Scanlon told Reuters Health.
SOURCE: Otolaryngology Head and Neck Surgery, April 2014
Prevalence of Complications from Adult Tonsillectomy and Impact on Health Care Expenditures
Results This analysis suggests that of adult patients who undergo a tonsillectomy, 20% will have a complication, 10% will visit an ED, and approximately 1.5% will be admitted to a hospital within 14 days of the tonsillectomy. Six percent were treated for postoperative hemorrhage, 2% for dehydration, and 11% for ENT pain within 14 days of surgery. Patients with comorbidities, prior peritonsillar abscess, or an increased number of antibiotic prescriptions in the past year were significantly more likely to develop complications. Three out of 4 patients with postoperative hemorrhage went to the ED (4.63% of all patients), and 50% had a procedural intervention (3.09% overall). The average cost associated with a tonsillectomy was $3832 if no complication. If there was a complication within 14 days, hemorrhage was the most expensive ($6388 vs $5753 for dehydration and $4708 for ENT pain).
Conclusions Complications of adult outpatient tonsillectomies are common and may be associated with significant morbidity, health care utilization, and expenditures.
Meena Seshamani, MD, PhD
Emily Vogtmann, PhD, MPH
Justin Gatwood, MPH
Teresa B. Gibson, PhD
Dennis Scanlon, PhD
Department of Head and Neck Surgery, The Permanente Medical Group, San Francisco, California, USA
Truven Health Analytics, Ann Arbor, Michigan, USA
The Pennsylvania State University, State College, Pennsylvania, USA