Complications of Tonsillectomy in Children
Tonsillectomy in children carries significant morbidity with hemorrhage being the most common complication (0.2-3% overall), but airway compromise represents the leading cause of death and major injury in malpractice claims. 1
Hemorrhagic Complications
Bleeding is the most frequent complication requiring intervention:
- Primary hemorrhage (within 24 hours): occurs in 0.2-2.2% of cases 1, 2
- Secondary hemorrhage (after 24 hours): occurs in 0.1-3% of cases 1, 2
- Bleeding accounts for approximately one-third of all tonsillectomy-related deaths 1
- May require readmission for observation or return to operating room for hemostasis control 1
Risk Factors for Increased Bleeding:
- Male gender 2
- History of recurrent acute tonsillitis (3.7% bleeding rate) 2
- Previous peritonsillar abscess (5.4% bleeding rate) 2
- Hot surgical techniques (diathermy, coblation) increase secondary hemorrhage risk 3-fold compared to cold steel 2
- Cold steel with bipolar diathermy has 1.5 times higher secondary hemorrhage risk than cold steel with ties/packs alone 2
Respiratory Complications
Airway compromise is the major cause of death or major injury in malpractice claims after tonsillectomy: 1, 3, 2
- Respiratory complications occur in 5.8-26.8% of children with obstructive sleep apnea undergoing tonsillectomy 2
- Operative airway complications include: laryngospasm, laryngeal edema, aspiration, respiratory compromise, and cardiac arrest 1
- Postobstructive pulmonary edema can occur postoperatively 1
High-Risk Patients Requiring Enhanced Monitoring:
- Children under 3 years of age 1, 2, 4
- Severe OSA 2
- Craniofacial disorders 1
- Down syndrome 1
- Cerebral palsy 1
- Neuromuscular diseases 1
- Major heart disease 1
- Bleeding diatheses 1
Mortality Rates
Current mortality data demonstrates the serious nature of this procedure:
- Inpatient setting: 1 per 2,360 procedures 1, 2
- Ambulatory setting: 1 per 18,000 procedures 1, 2
- Ontario, Canada reported combined rate of 1 per 56,000 (2002-2013) 1
- Approximately one-third of deaths attributable to bleeding, remainder from aspiration, cardiopulmonary failure, electrolyte imbalance, or anesthetic complications 1
Operative Complications
Intraoperative injuries can affect multiple structures:
- Trauma to teeth, larynx, pharyngeal wall (constrictor muscle or underlying arterial structures), or soft palate 1
- Difficult intubation 1
- Endotracheal tube ignition 1
- Carotid artery injury 1
- Tongue swelling 1
- Altered taste 1
- Lip burn 1
- Eye injury 1
- Fracture of mandibular condyle 1
Common Postoperative Complications
Nearly all patients experience some degree of morbidity:
- Pain and prolonged throat discomfort (universal) 1, 2
- Nausea and vomiting 1, 2
- Dehydration 1, 2
- Referred otalgia (ear pain) 1, 2
- Fever 1
- Uvular edema (common, can contribute to airway compromise in severe cases) 3
Readmission and Delayed Discharge
Approximately 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 include:
Rare but Serious Structural Complications
Critical Pitfalls to Avoid
The American Academy of Otolaryngology-Head and Neck Surgery guidelines emphasize that complications are more common in specific populations, requiring heightened vigilance: 1
- Children under 3 years have the highest complication rates and most likely require overnight observation 1, 4
- Patients with underlying medical conditions (listed above) require continuous pulse oximetry monitoring and availability of respiratory support 2
- Avoid aspirin postoperatively as it increases hemorrhage risk, though non-aspirin NSAIDs do not significantly increase bleeding 2
- Perioperative antibiotics do not reduce hemorrhage rates and should not be used routinely for this purpose 2