INTRODUCTION — Tonsillectomy and/or adenoidectomy (T&A) is one of the most common surgical procedures performed in children [1-3]. Preparing children and their families appropriately can improve safety and recovery following surgery.
The indications, contraindications, complications, and details of intraoperative and postoperative care for T&A are reviewed separately, as are issues specific to T&A in children with obstructive sleep apnea:
●(See "Tonsillectomy and/or adenoidectomy in children: Indications and contraindications".)
●(See "Anesthesia for tonsillectomy with or without adenoidectomy in children".)
●(See "Tonsillectomy (with or without adenoidectomy) in children: Postoperative care and complications".)
●(See "Adenoidectomy in children: Postoperative care and complications".)
PREOPERATIVE MEDICAL EVALUATION
General health assessment — The preoperative medical evaluation includes a standard history and physical examination. In addition, the evaluation should include assessment for potential velopharyngeal, hematologic, or medical contraindications and/or conditions associated with increased risk of complications. (See "Tonsillectomy and/or adenoidectomy in children: Indications and contraindications", section on 'Contraindications'.)
Indications for postponing surgery (eg, acute pharyngitis, fever, cough/wheezing) and management of preoperative anxiety and postoperative pain should also be discussed with the patient/caregivers during this evaluation. (See "Anesthesia for the child with a recent upper respiratory infection" and 'Preoperative emotional and pain preparation' below and "Anesthesia for tonsillectomy with or without adenoidectomy in children", section on 'Reduction of anxiety'.)
Anatomic assessment — Preoperative assessment should include examination of the oropharynx (uvula and palate) for submucous cleft and tonsil size (figure 1). Children in whom submucous cleft of the palate is detected and those in whom velopharyngeal insufficiency is suspected (even if the examination is normal) should be referred to an individual or a team skilled in cleft palate evaluation and management. (See "Tonsillectomy and/or adenoidectomy in children: Indications and contraindications", section on 'Velopharyngeal' and "Tonsillectomy and/or adenoidectomy in children: Indications and contraindications", section on 'Infectious'.)
Additional evaluation in select patients
Hematologic evaluation — A hematologic evaluation is not routinely necessary for children undergoing T&A unless there is a personal or family history of significant bleeding problems [4]. This approach is consistent with other consensus statements and guidelines, including those published by the American Academy of Otolaryngology-Head and Neck Surgery and the French Society of Otorhinolaryngology and Head and Neck Surgery [1,2].
If there is clinical concern for an underlying bleeding disorder, laboratory evaluation and/or referral to a pediatric hematologist is appropriate. Completion of a standardized bleeding questionnaire can assist in this assessment (table 1) [5]. The approach to evaluating for bleeding disorders in children is reviewed separately. (See "Approach to the child with bleeding symptoms".)
One of the most feared complications following tonsillectomy is post-tonsillectomy hemorrhage. Severe post-tonsillectomy hemorrhage (ie, hemorrhage requiring blood transfusion or repeat surgery) is rare, occurring in approximately 2 to 3 percent of cases. Bleeding after adenoidectomy can also occur but is less common. (See "Tonsillectomy (with or without adenoidectomy) in children: Postoperative care and complications", section on 'Hemorrhage' and "Adenoidectomy in children: Postoperative care and complications", section on 'Postoperative hemorrhage'.)
Occult bleeding disorders are rarely diagnosed in children who experience severe bleeding after T&A [6,7]. In the rare instances when a bleeding disorder is identified, the most commonly diagnosed condition is von Willebrand disease (VWD). Routine screening laboratory tests such as the platelet count and coagulation studies (prothrombin time [PT], activated partial thromboplastin time [aPTT]) have a poor sensitivity for detecting VWD. Thus, routinely performing these tests prior to surgery is unlikely to identify patients at risk for significant bleeding. (See "Clinical presentation and diagnosis of von Willebrand disease", section on 'Laboratory testing'.)
Cardiac evaluation — Preoperative cardiac evaluation (eg, electrocardiogram and/or echocardiogram) is not routinely performed in children undergoing T&A unless there are known cardiac abnormalities or comorbidities [8-11]. (See "Suspected heart disease in infants and children: Criteria for referral".)
Polysomnogram — Polysomnogram (PSG) in not necessary for all children prior to T&A but is suggested for those with conditions associated with increased risk of upper airway obstruction and/or central apnea in the postoperative period (table 2). Indications for PSG in children undergoing T&A are discussed in greater detail separately. (See "Adenotonsillectomy for obstructive sleep apnea in children", section on 'Polysomnography'.)
PREOPERATIVE CARE IN SPECIFIC PATIENT POPULATIONS — Certain patients, such as those with a bleeding disorder, sickle cell disease, or Down syndrome, may require additional preoperative screening and management.
Children with a bleeding disorder — Children with known bleeding disorders are at increased risk of perioperative and postoperative bleeding. von Willebrand disease (VWD) and platelet function defects are the most common hematologic disorders leading to perioperative bleeding.
Children with a known bleeding disorder should have a preoperative hematologic assessment (eg, prothrombin time [PT], international normalized ratio [INR]. activated partial thromboplastin time [aPTT], , complete blood count, and other relevant studies specific to their diagnosis). These patients should have a perioperative management plan formulated by their hematologist. (See 'Hematologic evaluation' above and "Approach to the child with bleeding symptoms", section on 'Initial laboratory evaluation'.)
For children with mild bleeding disorders (eg, mild VWD), who receive appropriate prophylactic medical intervention, rates of postoperative hemorrhage approach those of unaffected children. However, children with more severe bleeding disorders, such as hemophilia A, can have significant postoperative bleeding problems [12-16]. Perioperative management of VWD and hemophilia are discussed separately. (See "von Willebrand disease (VWD): Treatment of major bleeding and major surgery" and "Acute treatment of bleeding and surgery in hemophilia A and B", section on 'Tonsillectomy'.)
Children with sickle cell disease — Children with sickle cell disease are at risk for pain crises, acute chest syndrome, priapism, or stroke if they become hypoxic, acidotic, hypothermic, or hypovolemic in the perioperative period [17]. A preoperative polysomnogram (PSG) is recommended for patients with sickle cell disease [18]. In addition, a pediatric hematologist should be involved in the perioperative care of patients with sickle cell disease. Strategies to reduce risk of stroke and other vaso-occlusive complications include preoperative transfusions and hydration [19]. Postoperative observation as an inpatient is planned in order to observe for hypoxia and to administer oxygen therapy as needed. (See "Red blood cell transfusion in sickle cell disease: Indications and transfusion techniques", section on 'Indications for preoperative transfusion' and "Perioperative management of adults with sickle cell disease or thalassemia".)
Children with Down syndrome — Children with Down syndrome are at increased risk of anesthesia-related complications, primarily due to soft tissue and skeletal alterations. (See "Down syndrome: Clinical features and diagnosis".)
Obstructive sleep apnea is a common problem in children with Down syndrome, and many of them will require T&A. A PSG is recommended prior to surgical intervention [18]. (See "Down syndrome: Clinical features and diagnosis", section on 'Sleep apnea' and "Down syndrome: Management", section on 'Sleep apnea'.)
Children with Down syndrome are at increased risk of atlantoaxial subluxation; however, routine screening radiographs are not necessary in the asymptomatic child [20]. The clinical findings suggestive of symptomatic atlantoaxial instability and its management in patients with Down syndrome are discussed in greater detail separately. (See "Down syndrome: Clinical features and diagnosis", section on 'Atlantoaxial instability' and "Down syndrome: Management", section on 'Atlantoaxial instability'.)
Children with Down syndrome are more likely to require an inpatient stay postoperatively due to an increased likelihood of respiratory complications and the possibility of delayed oral intake [21,22]. Patients and their families/caregivers should be prepared for the possibility of a postoperative hospitalization. (See "Tonsillectomy (with or without adenoidectomy) in children: Postoperative care and complications", section on 'Setting of care'.)
PREOPERATIVE EMOTIONAL AND PAIN PREPARATION — It is common for children to experience preoperative anxiety before undergoing any surgery [23]. In addition, parents are often anxious about the surgery, further increasing the anxiety level of their children.
Prospective studies of children undergoing T&A found that the children who were more anxious preoperatively experienced significantly more pain postoperatively [24,25]. These children consumed more pain medication, had a higher incidence of emergence delirium after anesthesia, and had a higher incidence of postoperative anxiety and sleep problems. In addition, it has been shown that preoperative caregiver anxiety is associated with increased postoperative pain in the child [26].
Various pre-tonsillectomy education tools are available and are commonly used in an effort to reduce patient and parent anxiety, improve patient pain management, and decrease post-tonsillectomy emergency department visits. The available reports on such education tools have reached variable conclusions, with some finding improved perioperative outcomes and others finding little benefit [23,27-33].
Parental presence during induction of anesthesia may improve parental satisfaction with the experience; however, it has not consistently been shown to decrease anxiety in the child and can sometimes increase parental and patient anxiety [34-36]. If available, a child life specialist can be a valuable resource to optimize nonpharmacologic interventions aimed at reducing the child's anxiety in the preoperative setting. (See "Procedural sedation in children: Approach", section on 'Nonpharmacologic interventions'.)
Pharmacologic intervention to reduce anxiety in the preoperative setting is discussed separately. (See "Anesthesia for tonsillectomy with or without adenoidectomy in children", section on 'Reduction of anxiety'.)
CARE SETTING — Most T&As are performed in an outpatient setting, and children are discharged a few hours after surgery. However, certain children are considered at higher risk of postoperative complications or respiratory compromise after T&A and may benefit from management in a tertiary care setting with availability of pediatric intensive care units and personnel. Children with obstructive sleep apnea are at particularly high risk for respiratory complications following T&A. (See "Adenotonsillectomy for obstructive sleep apnea in children", section on 'Complications of adenotonsillectomy' and "Tonsillectomy (with or without adenoidectomy) in children: Postoperative care and complications", section on 'Respiratory complications'.)
Indications for inpatient admission are discussed separately. (See "Tonsillectomy (with or without adenoidectomy) in children: Postoperative care and complications", section on 'Setting of care'.)
INTRAOPERATIVE INTERVENTIONS — The following intraoperative interventions are discussed in detail separately:
●Antiemetics – An intraoperative dose of dexamethasone is effective in decreasing postoperative nausea, vomiting, pain, and time to first oral intake [1]. Serotonergic antagonists (ondansetron, granisetron, tropisetron, dolasetron, and ramosetron) are also effective in preventing postoperative nausea and vomiting. (See "Anesthesia for tonsillectomy with or without adenoidectomy in children", section on 'Antiemetics'.)
●Antibiotics – Intraoperative prophylactic antibiotics do not improve outcomes in the postoperative period and are not recommended [1]. (See "Tonsillectomy (with or without adenoidectomy) in children: Postoperative care and complications", section on 'No role for antimicrobial prophylaxis'.)
●Local anesthesia – Studies reporting on the effectiveness of local anesthetics for reducing postoperative pain are inconsistent [37,38]. (See "Anesthesia for tonsillectomy with or without adenoidectomy in children", section on 'Local anesthesia'.)
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Preoperative medical evaluation and risk assessment" and "Society guideline links: Tonsillectomy and adenoidectomy in children".)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or email these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient education" and the keyword[s] of interest.)
●Basics topic (see "Patient education: Tonsillectomy and adenoidectomy in children (The Basics)")
SUMMARY AND RECOMMENDATIONS
●Preoperative health assessment – The preoperative medical evaluation for tonsillectomy and/or adenoidectomy (T&A) includes a standard history, review of medications, and physical examination with careful attention to the airway. This includes assessment of tonsil size (figure 1) and identification of any craniofacial or airway abnormalities. (See 'General health assessment' above and 'Anatomic assessment' above.)
●Additional selective testing in at-risk patients – Patients with certain underlying conditions (eg, bleeding disorder, sickle cell disease, Down syndrome) may require additional preoperative screening and management prior to T&A. (See 'Preoperative care in specific patient populations' above.)
•Hematologic evaluation – Preoperative laboratory studies to evaluate for bleeding disorders are warranted only if there is a personal or family history of bleeding symptoms concerning for a bleeding disorder. Completion of a standardized bleeding questionnaire can assist in this assessment (table 1). (See 'Hematologic evaluation' above and "Approach to the child with bleeding symptoms".)
•Cardiac evaluation – Preoperative cardiac evaluation in children undergoing T&A is not necessary unless there are known cardiac abnormalities or comorbidities. (See 'Cardiac evaluation' above and "Suspected heart disease in infants and children: Criteria for referral".)
•Polysomnogram (PSG) – PSG is not necessary for all children prior to T&A but is recommended for those with conditions associated with increased risk of upper airway obstruction and/or central apnea in the postoperative period (table 2). (See 'Polysomnogram' above and "Adenotonsillectomy for obstructive sleep apnea in children", section on 'Polysomnography'.)
●Preoperative emotional preparation – It is common for children and their parents to experience preoperative anxiety before undergoing any surgery. Preoperative anxiety in the child and/or parents/caregivers can influence their postoperative pain experiences. Thus, whenever possible, children and their families should be educated about the T&A procedure to reduce anxiety and improve postoperative recovery. (See 'Preoperative emotional and pain preparation' above.)
●Surgical setting – Most T&As are performed in an outpatient setting, and children are discharged a few hours after surgery. However, children who are at risk for complications should be monitored in a tertiary care setting with availability of pediatric intensive care units and personnel. Children with obstructive sleep apnea are at particularly high risk for respiratory complications following T&A. (See 'Care setting' above and "Tonsillectomy (with or without adenoidectomy) in children: Postoperative care and complications", section on 'Setting of care'.)
●Intraoperative interventions – Intraoperative interventions aimed at improving postoperative pain, nausea, and vomiting (eg, dexamethasone, serotonergic antagonists) are discussed in a separate topic review. (See "Anesthesia for tonsillectomy with or without adenoidectomy in children", section on 'Antiemetics'.)
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