Complications of Tonsillectomy
Tonsillectomy carries a well-defined spectrum of complications, with hemorrhage being the most common and clinically significant, occurring in 0.2-2.2% for primary bleeding and 0.1-3% for secondary bleeding, while mortality remains rare at approximately 1 per 18,000 in ambulatory settings. 1
Hemorrhagic Complications
Bleeding is the most frequent and important complication following tonsillectomy. 1, 2
Primary vs. Secondary Hemorrhage
- Primary hemorrhage (within 24 hours): occurs in 0.2-2.2% of cases 1
- Secondary hemorrhage (after 24 hours): occurs in 0.1-3% of cases 1
- Bleeding may require readmission for observation or return to the operating room for surgical control 1
Risk Factors for Hemorrhage
- Male gender is associated with higher bleeding risk 3, 4
- Older age: 69% of bleeding occurs in patients over 11 years 5
- History of recurrent acute tonsillitis: 3.7% bleeding rate 3
- Previous peritonsillar abscess: 5.4% bleeding rate 3
- Hot surgical techniques (diathermy, coblation): 3-fold increased secondary hemorrhage risk compared to cold steel 3
- Elevated postoperative mean arterial pressure: 14% bleeding rate in affected patients 5
- Excessive intraoperative blood loss (>50 cm³) 5
Respiratory Complications
Respiratory complications occur in 5.8-26.8% of children with obstructive sleep apnea undergoing tonsillectomy. 3
High-Risk Populations
- Children under 3 years of age 1, 3
- Severe OSA patients 3
- Craniofacial disorders 1, 3
- Down syndrome 1
- Cerebral palsy 1
- Neuromuscular diseases 1
Specific Airway Complications
- Laryngospasm 1
- Laryngeal edema 1, 6
- Postobstructive pulmonary edema 1
- Aspiration 1
- Tongue swelling causing airway obstruction 1, 6
- Difficult intubation 1
Operative Complications
Traumatic Injuries
- Dental trauma 1
- Pharyngeal wall injury (constrictor muscle or arterial structures) 1
- Soft palate trauma 1
- Carotid artery injury 1
- Mandibular condyle fracture 1, 7
- Eye injury 1
- Lip burn 1
Anesthetic Complications
Postoperative Complications
Common Symptoms
- Pain and throat discomfort: lasts 7-10 days, may extend to 2 weeks 6
- Referred otalgia (ear pain) 1, 6
- Nausea and vomiting 1
- Dehydration: requiring intervention in some cases 1, 6
- Fever 1
- Uvular edema: common and usually self-limited 8
Structural Complications
- Velopharyngeal insufficiency 1, 7
- Nasopharyngeal stenosis 1, 6, 7
- Altered taste 1
- Eustachian tube injury 7
Mortality and Severe Morbidity
Mortality rates are 1 per 2,360 in inpatient settings and 1 per 18,000 in ambulatory settings. 1, 3
Causes of Death
- Approximately one-third of deaths are attributable to bleeding 1, 3
- Airway compromise is the major cause of death or major injury in malpractice claims 1, 3, 8
- Other causes include aspiration, cardiopulmonary failure, electrolyte imbalance, and anesthetic complications 1
Readmission and Delayed Discharge
- 1.3% of patients experience delayed discharge of 4-24 hours during initial hospital stay 1
- Up to 3.9% require readmission for secondary complications 1
- Primary reasons for readmission include pain, vomiting, fever, and tonsillar bleeding 1
Critical Pitfalls to Avoid
Pain Management Failures
- Only 35% of parents administer the prescribed number of analgesic doses despite receiving specific instructions 6
- Pain medication should be given on a regular schedule, not just as needed, particularly in the first few days 6
Medication Considerations
- Aspirin should be avoided postoperatively as it increases hemorrhage risk 3
- Non-aspirin NSAIDs do not significantly increase bleeding and are recommended 3
- Perioperative antibiotics do not reduce hemorrhage rates and should not be used routinely for this purpose 3
Monitoring Requirements
- Continuous pulse oximetry monitoring is recommended for high-risk patients 3
- Availability of respiratory support for high-risk patients 3