What causes fever after an adenoidectomy?

Postoperative Fever After Adenoidectomy

Fever after adenoidectomy is typically a benign, self-limiting inflammatory response to surgical trauma that occurs within the first 48-72 hours and does not require extensive workup or antibiotics unless accompanied by specific warning signs.

Primary Mechanism: Normal Inflammatory Response

• Surgery triggers a systemic inflammatory response (SIR) characterized by fever, somnolence, fatigue, and anorexia, with the magnitude corresponding to the extent of surgical injury 1
• Fever commonly occurs during the initial 48 hours after surgery and is usually non-infectious in origin 2, 1
• This early postoperative fever typically resolves spontaneously within 2-3 days without intervention 1
• The inflammatory response involves increased production of acute phase proteins by the liver, including C-reactive protein 1

Timeline for Distinguishing Benign vs. Infectious Fever

• Fever within the first 48-72 hours is typically non-infectious and benign 2, 1
• Fever occurring after 96 hours (4 days) postoperatively is more likely to represent true infection and warrants investigation 2, 1
• Most postoperative fevers in adenoidectomy patients occur on postoperative day one and subside after removal of nasal packing material without antibiotics 3

When to Investigate Further

Red Flags Requiring Evaluation:

• Persistent fever beyond 72 hours that does not resolve after packing removal 3, 4
• Fever accompanied by neck stiffness, which may indicate rare but serious complications like skull base osteomyelitis involving the spheno-occipital synchondrosis 4
• Temperature ≥38.5°C with tachycardia (heart rate ≥110 beats/min) 2
• Signs of dehydration, persistent rhinorrhea, or systemic toxicity 5
• Purulent drainage or spreading erythema at the surgical site 2, 1

What NOT to Do:

• Do not obtain chest radiographs, urinalysis, or cultures during the initial 72 hours if fever is the only indication 2, 1
• Avoid overzealous evaluation of early postoperative fever, as considerable money can be wasted 2
• Do not routinely prescribe antibiotics for uncomplicated early postoperative fever 1, 3

Risk Factors for Postoperative Fever

• History of asthma (OR 2.3) 3
• Prolonged operation time ≥108 minutes (OR 4.6) 3
• Type of intraoperative antibiotic used (cefazolin vs. cefmetazole, OR 2.0) 3

Management Algorithm

Days 0-3 Post-Adenoidectomy:

• Observe and provide supportive care (hydration, pain control, antipyretics) 1
• Remove nasal packing as scheduled; fever typically resolves after removal 3
• Examine the surgical site daily, but do not culture unless signs of infection are present 2, 1

Day 4+ with Persistent Fever:

• Perform thorough wound inspection for purulent drainage, erythema, or necrosis 1, 6
• Obtain cultures if purulent drainage is present 1, 6
• Consider imaging (CT scan) if concerned about deep infection or abscess 6
• Initiate targeted antibiotic therapy only if true infection is identified 1, 6

Rare but Serious Complications

• Spheno-occipital synchondrosis infection (skull base osteomyelitis) presents with persistent fever and neck stiffness; requires imaging and prolonged antibiotic therapy 4
• Meningitis can occur if fever persists after packing removal 3
• These complications are exceedingly rare but should be considered if fever does not follow the typical benign pattern 4

Common Pitfalls to Avoid

• Mistaking normal inflammatory fever for infection and initiating unnecessary antibiotics in the first 48-72 hours 2, 1
• Delaying evaluation when fever persists beyond 96 hours or is accompanied by warning signs 1, 6
• Failing to remove nasal packing promptly, as retained packing can perpetuate fever 3
• Missing rare complications like skull base osteomyelitis by not considering them in patients with persistent fever and neck stiffness 4