What are the causes and management of post-adenoidectomy fever?

Post-Adenoidectomy Fever: Causes and Management

Fever after adenoidectomy is most commonly a benign, self-limiting inflammatory response in the first 48-72 hours, occurring in approximately 13-20% of patients, but persistent fever beyond 96 hours warrants investigation for infectious complications.

Early Postoperative Fever (0-72 Hours)

Normal Inflammatory Response

• Surgery triggers a systemic inflammatory response (SIR) that commonly manifests as fever during the initial 48 hours and is typically benign and self-limiting 1
• The magnitude of fever corresponds to the extent of surgical tissue injury 1
• Approximately 80% of adenoidectomy patients remain afebrile, while 13% develop fever lasting 3-7 days 2
• This early fever is characterized by neuroendocrine changes including somnolence, fatigue, and anorexia 1

Management Approach for Early Fever

• Extensive workup is generally unnecessary for mild fever within 72 hours without other symptoms 1
• Chest radiography is not mandatory during the initial 72 hours if fever is the only indication 1
• Urinalysis and culture are not required during the initial 2-3 days unless specific urinary symptoms are present 1
• Daily wound inspection is essential, but cultures should not be obtained without signs of infection 1

Late Postoperative Fever (Beyond 96 Hours)

Infectious Causes to Consider

By postoperative day 4, fever is equally likely caused by surgical site infection or other infectious sources 1

Surgical Site Infections

• Examine the surgical site for purulent drainage, spreading erythema, or severe pain 1
• Rare but serious early infections include group A streptococcal and clostridial infections, which can develop 1-3 days after surgery 1
• Skull base osteomyelitis involving the spheno-occipital synchondrosis is a rare but morbid complication presenting with persistent fever and neck stiffness 3

Deep Infections

• Fever occurring 20 days post-surgery is highly concerning for infection, as non-infectious postoperative fever typically resolves within 72 hours 4
• Intra-abdominal or deep space infections may require imaging with CT scan to identify abscesses or collections 4

Other Infectious Sources

• Urinary tract infection, particularly if catheterization was performed 4
• Respiratory infections if accompanied by respiratory symptoms 1
• Meningitis in rare cases with persistent fever despite packing removal 5

Risk Factors for Postoperative Fever

Patient-Related Factors

• History of asthma increases odds of postoperative fever by 2.3 times 5
• Upper respiratory tract infections increase bleeding and fever complications threefold 2

Procedure-Related Factors

• Prolonged operation time (≥108 minutes) increases fever risk by 4.6 times 5
• Type of intravenous antibiotic used (cefazolin vs. cefmetazole) affects fever incidence 5
• Concurrent procedures such as tympanometry tube insertion may influence complication rates 2

Diagnostic Workup for Persistent Fever

Laboratory Studies

• Complete blood count with differential to assess for leukocytosis 4
• C-reactive protein and/or erythrocyte sedimentation rate to evaluate inflammatory response 4
• Blood cultures if sepsis is suspected 4

Imaging Studies

• Abdominal CT scan with intravenous contrast is the preferred modality to identify potential abscesses or collections 4
• Consider imaging of the skull base if neck stiffness is present 3

Cultures

• Obtain Gram stain and culture of any purulent drainage from the wound 4
• Urinalysis and urine culture if catheterization was performed 4

Treatment Algorithm

For Fever Within 72 Hours

• Observation and symptomatic management are appropriate if no other concerning symptoms are present 1
• Ensure adequate hydration, as dehydration can accompany postoperative fever 6
• Continue daily wound inspection 1

For Fever Beyond 96 Hours

• Immediate wound inspection for signs of infection 4
• If surgical site infection is identified, open infected wounds to allow drainage 4
• Initiate empiric antimicrobial therapy while awaiting culture results 4
• For head and neck clean wounds, start cefazolin (or vancomycin if MRSA risk is high) 1
• If intra-abdominal abscess is identified, source control with percutaneous drainage or surgical intervention is the primary management 4

Monitoring

• Daily assessment of fever curve, pain control, and clinical status 4
• Repeat imaging if clinical improvement is not observed within 48-72 hours of appropriate therapy 4
• Adjust antimicrobial therapy based on culture and susceptibility results 4

Critical Pitfalls to Avoid

• Delaying imaging studies in a child with persistent postoperative fever beyond 96 hours 4
• Failing to consider deep surgical site infections or organ space infections when superficial wound appears normal 4
• Attributing all early fever to atelectasis without considering other causes 1
• Inadequate source control when infection is identified 4
• Overuse of broad-spectrum antibiotics when targeted therapy would be more appropriate 4
• Missing rare complications such as skull base osteomyelitis in patients with neck stiffness 3

Special Considerations

Adenoidectomy-Specific Risks

• The procedure requires intubation anesthesia, which carries additional risks of postoperative nausea, vomiting, and pain control challenges 7
• Unique risks include velopharyngeal insufficiency, refractory bleeding, and Grisel's syndrome 7
• Recovery typically takes 1-2 days, with most minor complications (malodor, snoring, fever) resolving within 3-7 days 7, 2