What are the preoperative and postoperative management recommendations for a pediatric or adult patient with recurrent tonsillitis or sleep disorders undergoing adenoids and tonsillectomy?

Adenotonsillectomy: Preoperative and Postoperative Management

For pediatric patients undergoing adenotonsillectomy, administer a single intraoperative dose of IV dexamethasone, avoid perioperative antibiotics entirely, and use only ibuprofen/acetaminophen for postoperative pain—never codeine in children under 12 years. 1

Preoperative Assessment and Planning

Indications Documentation

• Document specific frequency criteria for recurrent tonsillitis: at least 7 episodes in the past year, at least 5 episodes per year for 2 years, or at least 3 episodes per year for 3 years, with documentation of temperature >38.3°C, cervical adenopathy, tonsillar exudate, or positive strep testing. 1
• For obstructive sleep-disordered breathing (oSDB): assess and document tonsillar hypertrophy, snoring, witnessed apneas, mouth breathing, and associated comorbidities including growth retardation, poor school performance, enuresis, asthma, and behavioral problems. 1

Polysomnography Requirements

Mandatory PSG is required for children with oSDB who are: 1

• <2 years of age
• Obese
• Down syndrome
• Craniofacial abnormalities
• Neuromuscular disorders
• Sickle cell disease
• Mucopolysaccharidoses

Advocate for PSG in children without these comorbidities when: 1

• The need for surgery is uncertain
• Discordance exists between physical examination and reported symptom severity

Preoperative Laboratory Testing

• Do not routinely order coagulation studies (PT/PTT) or blood typing/cross-matching in otherwise healthy children with negative bleeding history—these provide no additional predictive value for post-tonsillectomy hemorrhage. 2, 3, 4
• Obtain coagulation studies only when: personal or family history suggests bleeding disorder. 2, 4

Intraoperative Management

Mandatory Interventions

Administer a single intraoperative dose of IV dexamethasone to all pediatric patients—this is a strong recommendation that decreases postoperative nausea/vomiting, reduces time to first oral intake, and lowers pain scores. 1, 5

Prohibited Interventions

Do not administer or prescribe perioperative antibiotics—this is a strong recommendation against routine use, as antibiotics provide no benefit and contribute to antibiotic resistance. 1, 5

Postoperative Management

Pain Control Protocol

Recommend ibuprofen, acetaminophen, or both for pain control—this is a strong recommendation for first-line analgesia. 1, 5

Never prescribe codeine or any codeine-containing medication to children younger than 12 years—this is a strong recommendation against use due to FDA black box warning regarding respiratory depression and death in ultra-rapid metabolizers. 1, 5

Inpatient Monitoring Criteria

Arrange mandatory overnight inpatient monitoring for: 1, 5

• All children <3 years of age (regardless of OSA severity, as they have 9.8% respiratory complication rate vs. 4.9% in older children)
• Children with severe OSA defined as:
  • Apnea-hypopnea index (AHI) ≥10 obstructive events/hour, OR
  • Oxygen saturation nadir <80%

Monitoring requirements include: continuous pulse oximetry and availability of respiratory support. 5

Patient/Caregiver Counseling

Provide comprehensive perioperative pain counseling emphasizing the need to anticipate, reassess, and adequately treat pain after surgery—reinforce this at the time of surgery. 1

Counsel families that oSDB may persist or recur after tonsillectomy—complete resolution of OSA occurs in only 25% of children with severe preoperative disease, and obesity significantly reduces success rates. 1, 6, 7

Arrange postoperative PSG to assess for residual OSA, particularly in patients with obesity and multiple anatomical factors. 6

Bleeding Surveillance

Follow up with patients/caregivers and document: 1

• Primary bleeding (within 24 hours of surgery)
• Secondary bleeding (>24 hours after surgery)
• Track your bleeding rates at least annually for quality improvement

Common Pitfalls to Avoid

• Failing to administer intraoperative dexamethasone—this single intervention has strong evidence for reducing multiple postoperative complications. 1, 5
• Prescribing perioperative antibiotics "just in case"—this practice is explicitly contraindicated and contributes to antibiotic resistance. 1, 5
• Using codeine for postoperative pain in children <12 years—this can be fatal in ultra-rapid metabolizers. 1
• Discharging high-risk patients (age <3 years or severe OSA) on the day of surgery—these patients require overnight monitoring. 1, 5
• Assuming surgery will completely resolve OSA—families must understand that additional interventions (weight management, CPAP) may be needed, with overall success rates around 79%. 6, 7

Adult Considerations

For adults with OSA and tonsillar hypertrophy: tonsillectomy is recommended as a single intervention, though evidence shows significant improvements in AHI with residual sleep-disordered breathing remaining common. 1

Tonsillectomy in adults may increase CPAP tolerance in patients with tonsillar hypertrophy who are CPAP-intolerant or require high pressures. 1