Is There a Misperception of The Risks of Tonsillectomy?
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Steven T Kmucha, MD, JD, FACS Board certified in Otolaryngology – Head & Neck Surgery and in the subspecialty of ear, nose and throat allergy. About the author: Dr. Kmucha is board certified in otolaryngology and allergy, completed an otology fellowship and have additional certification in sleep medicine. He completed law school in 2007 and received a JD with emphasis in health/healthcare law. He has a Masters degree in Medical Management presented by the American College of Physician Executives. |
Tonsillectomy remains a common operation, with approximately 737,000 procedures performed annually in the U.S. The two most common indications for tonsillectomy include sleep-disordered breathing and recurrent tonsillitis. These indications have changed from being a surgery performed primarily for recurrent infections in the 1970s to a surgery performed more commonly for sleep-disordered breathing today. A large number of recent clinical trials and medical reports have repeatedly confirmed that adenotonsillectomy improves quality of life, behavior outcomes, quality
of sleep and polysomnographic findings, especially in children with documented obstructive sleep apnea.
Relatively minor surgical complications such as minor hemorrhage, soft tissue injuries, abnormal taste, TMJ dysfunction and others are well-recognized and reported following tonsillectomy. Prior analyses of post-tonsillectomy malpractice claims has documented that hemorrhage is a predominant cause of mortality following tonsillectomy. Based upon data from the 1970s, total post-tonsillectomy mortality has been estimated at between 1:16000 and 1:35000. A 2009 European documented a post-tonsillectomy mortality rate again of approximately 1:16000. Therefore, posttonsillectomy mortality appears unchanged over more than 4 decades of monitoring and numerous studies/reports despite significant improvements in surgical technique, surgical technology, anesthesia equipment and monitoring and an intense system-wide focus on surgical quality and patient safety.
Perioperative arrhythmiae, cardiac death and other anesthesia complications are also associated with tonsillectomy surgery. A 2008 malpractice claims review documented that when monetary awards were paid to plaintiffs associated with perioperative or postoperative tonsillectomy claims, monetary awards against anesthesiologists were more frequent and higher than against otolaryngologists.
The role of obstructive sleep apnea in tonsillectomyrelated malpractice claims remains somewhat controversial. With an increase in obesity, with an increase in the diagnosis of sleep apnea, with an increase in ambulatory surgeries, otolaryngologists and anesthesiologists would appear to be increasingly exposed to new areas of liability. Also, with the shift in the indications for tonsillectomy from recurrent infections in the 1970s to treatment of sleep apnea more recently, it would appear that both otolaryngologists and anesthesiologists are similarly being exposed to increasing liability when treating this growing population of patients with documented sleep apnea.
For those patients without documented sleep apnea, only formal polysomnography (PSG) can provide such documentation; due to the (geographic and financial) inaccessibility of PSG for many patients, such a study may not be available. As there are no clinical metrics that diagnosis OSAS other than PSG, a diagnosis based on patient reporting, family reporting and other clinical symptoms alone may under-diagnose a significant proportion of patients with true OSAS.
While most otolaryngologists and anesthesiologists are familiar with postoperative post-obstructive “flash” pulmonary edema that often occurs after tonsillectomy in a patient with OSAS, some studies also suggest that the frequent episodes of hypoxemia associated with OSAS result in increased opioid sensitivity of mu-receptors such that a normal dose of opioid can be a relative overdose in patients with OSAS. Posttonsillectomy complications also appear to be more commonly associated with OSAS in younger children. The obvious fact that smaller children have smaller and more difficult airways is another important factor. Another recent report published in Pediatrics in 2012 documented that while younger white children received less opioid doses after tonsillectomy than black children, white children had higher numbers of opioidrelated adverse events.
The most commonly reported opioids associated with post-tonsillectomy claims were codeine, morphine, fentanyl and meperidine. Despite its well-known efficacy and safety problems, codeine remains one of the mostly commonly prescribed opioids for home pain management after adenotonsillectomy in the US likely due to cost, availability and perceived safety. Black box warnings were issued in 2013 by the FDA against the use of codeine following tonsillectomy in children. Ultra-rapid metabolizers of codeine have greatly enhanced rate of conversion of codeine to morphine in the blood stream rapidly increasing the possibility of morphine toxicity with associated respiratory depression and death. These risks are not limited to codeine but are associated with all other opioids.
Many otolaryngologists have already switched to protocols which maximize analgesia provided by non-opioids administered on a scheduled basis (choosing medications which do not simultaneously increase the risk of bleeding such as acetaminophen) while reserving the lowest effective dose of opioids not dependent upon pathways present in “ultrametabolizers” on a limited and as needed basis such as hydromorphone, oxycodone and morphine with detailed safety instructions to parents and patients about potential side effects and appropriate use.
Many studies suggest less pain and postoperative nausea is associated with a pre-operative dose of dexamethasone; a recent 2014 report suggests that significant variations persists around the US in the use of perioperative antibiotics, dexamethasone and analgesics.
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