Tonsillectomy Circa 1940s [video]

I encountered this interesting video of tonsillectomy being performed in a child with sedation (but NO intubation) performed circa 1940s.



Of course, nowadays, tonsillectomy is performed under general anesthesia with intubation for airway protection. Here's a video of the way it is now done.

That is, unless, you practice in other parts of the world where modern medicine is not up to United States standards. In those nations, tonsillectomy is STILL being performed WITHOUT general anesthesia or any sedation for that matter. In fact, here's a blog I wrote earlier this year showing a graphic video depicting tonsillectomy being recently performed in a young child WITHOUT any sedation.

Twins Die after Tonsillectomy and Adenoidectomy

Twin Ohio boys, 3 years old, both died on April 19, 2006 after both kids underwent tonsillectomy & adenoidectomy (T&A) less than 48 hour earlier. Both children were discharged home on the same day of surgery. Read the story here.

On Aug 6, 2010, A malpractice suit was found against the otolaryngologist who performed the surgery, based on the assertion that if the surgeon "kept the children in the hospital overnight - something within his power and a standard practice for children under 3 and for those with a history of breathing trouble - their low oxygen levels could have been detected. Maybe they could have been saved..."

Tonsillectomy and adenoidectomy (T&A) is a very common surgery done on children for a variety of problems. However, this surgery does carry risks, especially as it relates to airway swelling that almost always occur to some degree after surgery, especially uvular swelling (see picture).

Due to this swelling and risk of airway problems, most (but not all) otolaryngologists are reluctant to perform this surgery on very young children (less than age 2 for adenoids and less than 4 years old for tonsil removal) unless absolutely essential. And when performed on such young children, most (but not all), otolaryngologists will admit into the hospital for overnight observation.

I personally take the extra step of warning parents of very young children undergoing T&A that given this airway risk, it is not unreasonable to not only be admitted overnight after surgery, but to also have the surgery done in a facility that has an ICU just in case airway loss occurs. Otherwise, if done in a community hospital without pediatric ICU capabilities, an airway loss event would require emergency intubation followed by helicopter life-flight transportation to a hospital that does have one.

By the age of 4 for tonsillectomy and 2 for adenoidectomy, the airway risk for most children becomes negligible and it is safe to discharge home same day of surgery unless other medical problems/concerns are present.

Why at those particular ages is it fine? It is mainly because the child would be much bigger with a correspondingly larger airway that can accomodate the swelling. Furthermore, a child who is older can communicate what they are feeling better which leads to the other risk that is present in very young children.

The other risk involved is over-administration of narcotics which are prescribed after surgery. When the child is too young to communicate their feelings, any signs of discomfort could be erroneously misinterpreted as pain by the parents. And with suspicion of pain, parents often will give prescription narcotics. If too much is given when the child is not truly in pain, the narcotics can suppress breathing resulting in respiratory arrest.

Read the full story here.

References:
Surgical management of obstructive sleep apnea in infants and young toddlers. Otolaryngol Head Neck Surg. 2009 Jun;140(6):912-6. Epub 2009 Mar 9.

Ambulatory pediatric otolaryngologic procedures in the United States: characteristics and perioperative safety. Laryngoscope. 2010 Apr;120(4):821-5.

Postoperative respiratory complications of adenotonsillectomy for obstructive sleep apnea syndrome in older children: prevalence, risk factors, and impact on clinical outcome. J Otolaryngol Head Neck Surg. 2009 Feb;38(1):49-58.

Avoiding airway obstruction after pediatric adenotonsillectomy. Int J Pediatr Otorhinolaryngol. 2009 Jun;73(6):803-6. Epub 2009 Mar 14.

Clinical Guidelines For Tonsillectomy in Children Published

This month, the American Academy of Otolaryngology-Head & Neck Surgery published clinical guidelines for tonsillectomy in kids. No big surprises in the guidelines, but everything is nicely summarized in one document.

In summary:
• Strong recommendation that clinicians should administer a single, intraoperative dose of intravenous dexamethasone to children undergoing tonsillectomy.
• Strong recommendation against clinicians routinely administering or prescribing perioperative antibiotics to children undergoing tonsillectomy.
• Recommendations for:

1. watchful waiting for recurrent throat infection if there have been fewer than 7 episodes in the past year or fewer than 5 episodes per year in the past 2 years or fewer than 3 episodes per year in the past 3 years
2. assessing the child with recurrent throat infection who does not meet criteria in statement 2 for modifying factors that may nonetheless favor tonsillectomy, which may include but are not limited to multiple antibiotic allergy/intolerance; PFAPA (periodic fever, aphthous stomatitis, pharyngitis and adenitis); or history of peritonsillar abscess
3. asking caregivers of children with sleep-disordered breathing and tonsil hypertrophy about comorbid conditions that might improve after tonsillectomy
4. counseling caregivers about tonsillectomy as a means to improve health in children with abnormal polysomnography who also have tonsil hypertrophy and sleep-disordered breathing
5. counseling caregivers that sleep-disordered breathing may persist or recur after tonsillectomy and may require further management
6. advocating for pain management after tonsillectomy and educating caregivers about the importance of managing and reassessing pain
7. clinicians who perform tonsillectomy should determine their rate of primary and secondary post-tonsillectomy hemorrhage at least annually.

References:
Clinical Practice Guideline: Tonsillectomy in Children. Otolaryngology– Head and Neck Surgery 144(1S) S1–S30