What should be noted during a tonsillectomy operation?

Key Elements to Note During Tonsillectomy Operation

During a tonsillectomy operation, clinicians should document bleeding complications, administer a single intraoperative dose of intravenous dexamethasone, and prepare for appropriate post-operative monitoring based on patient risk factors. 1

Preoperative Documentation and Assessment

• Document the indication for tonsillectomy, whether for recurrent throat infection (meeting specific frequency criteria) or obstructive sleep-disordered breathing 1, 2
• Note any comorbid conditions that may improve after tonsillectomy, including growth retardation, poor school performance, enuresis, asthma, and behavioral problems 1
• Document results of polysomnography for patients with obstructive sleep-disordered breathing, especially if they are <2 years of age or have specific risk factors (obesity, Down syndrome, craniofacial abnormalities, neuromuscular disorders, sickle cell disease, or mucopolysaccharidoses) 1

Intraoperative Management

• Administer a single intraoperative dose of intravenous dexamethasone to all patients undergoing tonsillectomy (strong recommendation) 1
• Do not administer perioperative antibiotics (strong recommendation against) 1
• Document any intraoperative complications, particularly primary bleeding 1
• Note the surgical technique used, as this may impact postoperative pain and bleeding risk 3, 4

Postoperative Planning and Documentation

• Determine if overnight inpatient monitoring is required based on:

  • Age <3 years (mandatory monitoring regardless of OSA severity) 1, 5
  • Presence of severe OSA (AHI ≥10 obstructive events/hour, oxygen saturation nadir <80%, or both) 1, 5
  • Presence of comorbidities requiring more intensive monitoring 5

• Document pain management plan:

  • Recommend ibuprofen, acetaminophen, or both for pain control (strong recommendation) 1
  • Must not administer or prescribe codeine or any medication containing codeine to children younger than 12 years (strong recommendation against) 1

• Plan for follow-up to document:

  • Presence or absence of primary bleeding (within 24 hours of surgery) 1
  • Presence or absence of secondary bleeding (occurring later than 24 hours after surgery) 1

Risk Factors to Note During Operation

• Male patients have higher risk of requiring reoperation (odds ratio 2.30) 6
• Inpatient status is associated with increased risk of reoperation (odds ratio 1.52) 6
• Patients undergoing tonsillectomy for infection have an increased incidence of postoperative bleeding compared to those undergoing the procedure for obstruction (6% vs 4%) 4
• Document any anatomical variations or technical difficulties encountered during the procedure that may affect recovery 7

Common Pitfalls to Avoid

• Failure to administer intraoperative dexamethasone, which has both analgesic and anti-emetic effects 1, 5
• Inappropriate prescription of perioperative antibiotics, which is not recommended 1
• Failure to arrange appropriate postoperative monitoring for high-risk patients 5
• Prescribing codeine for postoperative pain management in children under 12 years 1
• Inadequate documentation of bleeding complications, which should be tracked at least annually 1