What are the indications, complications, and major neurovascular structures to identify during tonsillectomy and adenoidectomy procedures?

Tonsillectomy and Adenoidectomy: Indications, Complications, and Important Neurovascular Structures

Tonsillectomy and adenoidectomy are among the most common surgical procedures performed in children, with specific indications including recurrent throat infections and sleep-disordered breathing (SDB), both of which can significantly impact morbidity, mortality, and quality of life. 1

Indications for Surgery

Tonsillectomy Indications:

• Recurrent throat infections (pharyngitis, tonsillitis) 1
• Sleep-disordered breathing (SDB) and obstructive sleep apnea (OSA) 1
• Peritonsillar abscess 2, 3
• Tonsillar hypertrophy causing upper airway obstruction 2, 3
• Suspicion of malignancy 2, 3
• Hemorrhagic tonsillitis 3

Adenoidectomy Indications:

• Nasal airway obstruction due to adenoidal enlargement 2, 4
• Recurrent or chronic adenoiditis 3, 4
• Otitis media (relative indication) 3, 4
• Recurrent or chronic rhinosinusitis 3

Combined Tonsillectomy and Adenoidectomy Indications:

• Sleep-disordered breathing with both tonsillar and adenoidal hypertrophy 1
• Upper airway obstruction causing respiratory distress, dysphagia, or speech impairment 2, 3
• Failure to thrive related to obstructive symptoms 3
• Abnormal dentofacial growth 3

Complications of Tonsillectomy and Adenoidectomy

Hemorrhage:

• Primary hemorrhage (within 24 hours): 0.2% to 2.2% of cases 1
• Secondary hemorrhage (more than 24 hours after surgery): 0.1% to 3% of cases 1
• Hemorrhage is the most frequent complication and accounts for approximately one-third of tonsillectomy-related deaths 1

Operative Complications:

• Trauma to teeth, larynx, pharyngeal wall, or soft palate 1
• Difficult intubation, laryngospasm, laryngeal edema 1
• Aspiration, respiratory compromise 1
• Endotracheal tube ignition and cardiac arrest (rare) 1
• Direct vascular injury during adenoidectomy (rare but potentially fatal) 5

Postoperative Complications:

• Pain, nausea, vomiting, dehydration 1
• Referred otalgia (ear pain) 1
• Postobstructive pulmonary edema 1
• Velopharyngeal insufficiency 1
• Nasopharyngeal stenosis 1
• Taste disorders (hypogeusia, ageusia, dysgeusia, phantogeusia) 1
• Persistent neck pain (Eagle syndrome) 1
• Subcutaneous emphysema, jugular vein thrombosis, atlantoaxial subluxation (Grisel syndrome) 1

Mortality:

• Current US mortality rates: 1 per 2,360 in inpatient settings and 1 per 18,000 in ambulatory settings 1
• Historical estimates: between 1 in 16,000 to 1 in 35,000 1
• Death causes include bleeding, aspiration, cardiopulmonary failure, electrolyte imbalance, and anesthetic complications 1

Major Neurovascular Structures to Identify/Be Careful Of

Critical Vascular Structures:

• Carotid artery – located lateral and posterior to the tonsillar fossa 1, 5
• Facial artery – branches supply the inferior pole of the tonsil 5
• Lingual artery – supplies the tongue base and can be at risk during lower pole dissection 5
• Aberrant vessels in the nasopharynx during adenoidectomy 5

Important Neural Structures:

• Glossopharyngeal nerve (IX) – provides sensation to the posterior third of the tongue and pharynx 5
• Vagus nerve (X) – branches supply the pharyngeal muscles 5
• Hypoglossal nerve (XII) – motor innervation to the tongue 5

Surgical Considerations and Risk Mitigation

Preoperative Assessment:

• Evaluate for bleeding disorders or family history of bleeding problems 2
• Assess for velopharyngeal insufficiency risk factors 2
• Screen for family anesthetic intolerance 2
• Identify concurrent diseases that may enhance operative risks 2

Intraoperative Precautions:

• Careful inspection of the nasopharynx before adenoidectomy 5
• Piecemeal curettage under visual control during adenoidectomy to prevent vascular injury 5
• Complete control of the airway with endotracheal anesthesia 2
• Meticulous surgical technique to minimize bleeding 2, 5

Postoperative Management:

• Consider inpatient observation for cases with repeated bleeding episodes 5
• Focus follow-up on wound healing assessment 5
• Have rigid instruments and tracheotomy equipment available for potential airway emergencies 5
• Administer a single, intraoperative dose of intravenous dexamethasone to reduce postoperative pain and nausea 1
• Avoid routine perioperative antibiotics as they provide no significant benefit 1