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International Journal of Pediatric Otorhinolaryngology (2003) 67, 453 /460

A retrospective study of tonsillectomy in the under 2-year-old child: indications, perioperative management, and complications
Andreas H. Werlea,*, Pamela J. Nicklausa,b, Daniel J. Kirsea,b, Daniel E. Brueggera,b

Department of Otolaryngology-Head and Neck Surgery, University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, KS 66160, USA b Department of Otolaryngology-Head and Neck Surgery, Childrens Mercy Hospital, 2401 Gilham Road, Kansas City, MO 64108, USA
Received 18 April 2002; received in revised form 30 October 2002; accepted 2 November 2002

Tonsillectomy; Perioperative management

Summary Objective: To retrospectively review the experience with tonsillectomy in the under 2-year-old child at an urban childrens hospital. Methods: The medical records of 94 patients under 2 years old undergoing tonsillectomy between May 1, 1995, and May 31, 2000, were reviewed. The methods of tonsil and adenoid excision were noted, as was the use of perioperative steroids, antibiotics, and antiemetics. Outcome measures studied included the duration of postoperative inpatient observation, complications, time to first oral intake, prevalence of postoperative vomiting, type and duration of respiratory support, and improvement relative to operative indications. Results: Eighty-two patients (87%) underwent tonsillectomy and adenoidectomy (T&A). Twelve patients (13%) underwent tonsillectomy without adenoidectomy. Patient ages ranged from 12 to 23 months (mean 19.69/3.1). Indications included obstructive sleep apnea (OSA) in 51 patients (54%), chronic or recurrent tonsillitis in 30 (32%), both OSA and infection in 11 (12%), and acute tonsillitis with airway obstruction in two (2%). Comorbid conditions were numerous. Preoperative polysomnograms were obtained for eight patients (8%). Hospital stays ranged from 4 h to 16 days. Complications included hemorrhage in four patients (4%) and pneumonia in two (2%). Oxygen was required after discharge from the recovery room in 27 patients (29%), with seven more (7%) requiring either reintubation, continuous positive airway pressure, or nasopharyngeal airways. Of the 88 patients on oral diets, only five (5%) took longer than 24 h to resume oral intake. Two patients (2%) experienced significant emesis after surgery. Four patients (4%) required treatment for dehydration after discharge. Conclusions: Tonsillectomy is a procedure with low morbidity in the otherwise healthy child under 2 years of age. However, we advocate routine postoperative overnight inpatient observation in this age group. We found that young children with comorbid conditions had a higher incidence of complications and required special postoperative management strategies. 2003 Published by Elsevier Science Ireland Ltd.

*Corresponding author. Present address: Clinical Care Center, Baylor College of Medicine, Texas Childrens Hospital, 6701 Fannin Street, Suite 540, Houston, TX 77030, USA. Tel.: /1-913-588-6701; fax: /1-913-588-6708. E-mail address: (A.H. Werle). 0165-5876/03/$ - see front matter 2003 Published by Elsevier Science Ireland Ltd. doi:10.1016/S0165-5876(02)00387-7


A.H. Werle et al.

1. Introduction
As one of the most common surgical procedures performed on children, tonsillectomy has generated a wealth of discussion. While older studies revealed a reluctance to perform tonsillectomy in very young children, the more recent trend towards performing tonsillectomy for airway obstruction has led to younger and younger patients being considered for surgery [1 /4]. Recent contributions to the literature on tonsillectomy have focused largely on outpatient management of postoperative patients. Essential to this ongoing discussion has been the identification of patients at increased risk for complications, especially those occurring within the first 24 h after surgery. Frequently, patients under 3 years of age are considered higher risk patients and are excluded from consideration for outpatient surgery. This higher risk status is generally based on one of two premises: (1) that young children are at increased risk of having postoperative problems; or (2) that these young children have such little hemodynamic reserve that complications become more dangerous. In addition, many studies regard obstructive sleep apnea (OSA) to be a contraindication to outpatient tonsillectomy, regardless of age [5 /16]. No studies in the literature have focused on the under 2-year-old tonsillectomy patient. The present study was performed to investigate a number of variables involved in patient selection, operative technique, and postoperative management of these youngest of patients undergoing tonsillectomy at a large urban pediatric hospital. The review was designed to identify the make-up of our patient population requiring tonsillectomy at such an early age, the difficulties encountered during their management, and a limited evaluation (in the form of parental assessment at first follow-up) of the procedures success in addressing its indications.

up including sleep studies, X-rays, and laboratory tests were documented. Surgical indications, operative technique, and blood loss were recorded. The administration of steroids, antibiotics, and antiemetics was noted both during and after surgery. Finally, postoperative variables studied included duration and location of hospital stay, type and duration of respiratory support, time to first significant oral intake, vomiting, hemorrhage, readmission rate, and other complications occurring during recovery from surgery.

3. Results
There were 55 males (59%) and 39 females (41%) in the study group. Ages ranged from 12 to 23 months (mean 19.69/3.1). Weight percentage ranged from less than the 5th percentile to greater than the 95th percentile (mean 479/33.7, calculated assigning all those less than the 5th percentile a value of 5% and those greater than the 95th percentile a value of 95%). There were 17 children (18%) in the group weighing less than the 5th percentile and 15 (16%) in the group weighing greater than the 95th percentile. Snoring was the most common symptom described, followed by observed apneas and/or gasping for breath during sleep, mouth breathing or nasal obstruction, recurrent or chronic tonsillitis, recurrent or chronic otitis, restless sleep, and dysphagia (Table 1). Failure to thrive, defined in this study as weight less than the 5th percentile, and rhinorrhea were also common. Symptoms rarely seen included speech delay, sinusitis, chronic cough, drooling, chronic fatigue, and the exacerbation of seizure and cardiopulmonary conditions linked to airway obstruction during sleep. Forty-seven patients (50%) had no significant comorbidities. The other 47 patients (50%) comorbidities are summarized in Table 2. This group includes 21 (22%) with asthma, eight (9%) with cardiac anomalies, seven (7%) with seizure disorders, and three (3%) with Down syndrome. Also included are those who were inpatients prior to their tonsillectomies. Ten patients (11%) had previously had adenoidectomies, 31 (33%) had tympanostomy tubes placed, and six patients (6%) had undergone fundoplication and feeding gastrostomy. One patient (1%) had signs of severe OSA following resection of a cervical lymphatic malformation and underwent tonsillectomy 3 days later. Laboratory studies, including coagulation profile and complete blood count, were obtained in 58 patients (62%) with five revealing abnormalities (5%). All abnormal laboratory values involved

2. Materials and methods

A retrospective chart review was performed involving 96 consecutive patients under the age of 2 years who underwent tonsillectomy alone or in combination with other minor procedures between May 1995 and 2000. Two patients who had concurrent major procedures were excluded from the study, leaving a study group of 94 patients. Data collected included patient variables such as age, gender, symptoms, past medical history, past surgical history, and tonsil size. Additional work-

Tonsillectomy in the under 2-year-old child


Table 1 Symptoms described preoperatively Symptom Snoring Apnea/gasping Mouth breathing Tonsillitis Otitis Restless sleep Dysphagia Failure to thrive Rhinorrhea Speech delay Sinusitis Chronic fatigue Chronic cough Drooling Increase in seizures Worsened cardiac/pulmonary conditions N 76 59 54 42 38 26 26 17 14 7 4 2 2 2 1 1 % 81 63 57 45 40 28 28 18 15 7 4 2 2 2 1 1

(1%). Intraoperative intravenous medications administered included steroids in 68 patients (72%), antibiotics in 11 (12%), and antiemetics in 83 (88%). Blood loss exceeded 25 cc in only 16 patients (17%) with no procedures resulting in blood loss of

Table 2 Comorbid conditions in complex patients Complex patient no. 1 2 3 4a Description of comorbidities Cardiac anomaly, craniosynostosis, choanal atresia, asthma, GERD Cerebral palsy, hypotonia, GERD Cerebral palsy, spina bifida, cardiac anomaly Cardiac anomaly, gestational drug exposure, bronchopulmonary dysplasia Neonatal asphyxia, aspiration, seizures, asthma Cardiac anomaly, prematurity, asplenia Pulmonary hypertension, prematurity, asthma Prematurity, seizures, GERD Down syndrome, cardiac anomaly Down syndrome, neonatal jaundice Down syndrome, cardiac anomaly Gestational drug exposure, aspiration, asthma Cardiac anomaly, seizures Hypotonia, seizures Prematurity, bronchopulmonary dysplasia, asthma, GERD Neonatal meningitis Recurrent pneumonia, asthma Craniosynostosis IgA deficiency Retinoblastoma Meconium aspiration Prematurity Anemia NOS Aortic valve stenosis Seizures, asthma Seizures Laryngomalacia Prematurity, herpes stomatitis (nasogastric tube in place) von Willebrand disease Acute tonsillitis with airway obstruction Cervical lymphatic malformation resection Asthma, GERD Asthma, GERD Asthma

elevated partial thromboplastin time, including one patient (1%) who was eventually diagnosed with von Willebrand disease. Sleep studies were obtained in eight patients (9%). Of these polysomnographies, five (5%) revealed severe OSA, while three (3%) revealed mild OSA. Indications for tonsillectomy were OSA in 51 patients (54%), recurrent or chronic tonsillitis in 30 (32%), both OSA and chronic or recurrent infection in 11 (12%), and acute tonsillitis with airway obstruction in two (2%). Except for the eight patients who underwent sleep studies, the diagnosis of OSA was made based on symptoms and parental observation, which did not allow for an objective assessment of sleep apnea severity. The diagnosis of chronic or recurrent tonsillitis was made based on the frequency and duration of previous treatments for infections, as instituted by primary care physicians. Work up for other potential causes of recurrent pharyngitis was not generally performed. Surgery on patients in this series was performed by nine different otolaryngologists. Fifty-five tonsillectomies (59%) were done using electrocautery dissection while 38 (40%) were performed using cold techniques. The final patient underwent tonsillectomy using the harmonic scalpel. Adenoids were removed in 82 patients (87%) using a variety of methods. Other procedures performed on patients in this series at the time of tonsillectomy included minor ear procedures in 41 (44%) patients, direct laryngoscopy and bronchoscopy in three (3%), nasal endoscopy with maxillary sinus irrigation or septal cauterization in three (3%), insertion or removal of central venous catheter in two (2%), palate lesion biopsy in one (1%), and frenulectomy in one

5 6 7 8 9a 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26, 27 28 29a 30 31a, 32a 33a 34 35 36 /47


Denotes those admitted prior to tonsillectomy.


A.H. Werle et al.

greater than 75 cc. No patients required blood transfusion. Ninety-three patients (99%) were extubated immediately after surgery, either in the operating room (38, or 40%), the recovery room (54, or 57%), or the pediatric intensive care unit (1, or 1%, in a patient who bypassed the recovery room postoperatively). One patient (1%) with a complex medical history was extubated on postoperative day 1 (complex patient 5). Six patients (6%) were inpatients at the time of their surgeries (Table 2). This group includes those with acute tonsillitis with airway obstruction (2), herpes stomatitis and failure to thrive (1), severe OSA discovered via polysomnography the day before tonsillectomy (1), resection of cervical lymphatic malformation 3 days prior to tonsillectomy (1), and one patient whose admission was planned for the day prior to tonsillectomy due to multiple complicating medical problems. These patients all required postoperative admissions longer than 24 h as well. Twenty patients (21%) were discharged home on the day of surgery. This included 11 (12%) discharged within 4 h and an additional nine (9%) observed for up to 8 h. This outpatient group contained five of the complex patients described in Table 2 (patients 17, 22, 24, 42, and 45). The majority of patients (56, or 60%) were observed after surgery for one night. Selection of unit was largely based on physician bias and comorbid conditions. Patients were observed in the intensive care unit, an intermediate care (i.e. step-down) unit with fully-monitored beds, and on a standard ward with continuous pulse oximetry. Eighteen patients (19%) were admitted for more than 24 h (Table 3). This list includes 13 complex patients, one otherwise healthy child who developed pneumonia postoperatively and required supplemental oxygen for a prolonged period, and four otherwise healthy children who were monitored for one night in the intensive care unit and the following night in a standard ward without developing complications. In addition to medication for pain control, 26 patients (28%) received postoperative antibiotics alone, eight (9%) received intravenous steroids, and 42 (45%) received both antibiotics and steroids after surgery. Complications consisted of hemorrhage and postoperative pneumonia. Bleeding occurred in four patients (4%), all of whom had comorbid conditions and underwent tonsillectomy due to OSA without a history of tonsillitis. One patient bled in the recovery room and was the only patient to require treatment in the operating room under a second general anesthetic. Three other patients experi-

enced delayed hemorrhages after discharge (two on postoperative day 7 and one on day 5), none of which requiring treatment other than inpatient observation. Pneumonia occurred in two patients (2%) postoperatively, one each from the groups with and without significant comorbidities. Besides the use of oxygen, respiratory support was, in nearly all cases, associated with complex past medical histories. One such patient (1%) required reintubation (complex patient 2). Three patients (3%), including two who were otherwise healthy and complex patient 8, required continuous positive airway pressure (CPAP) for short periods of time in the recovery room. Three patients (3%), all with significant comorbidities (complex patients 9, 14, and 28) required nasopharyngeal airways after surgery, one for 20 h and two for 48 h. All of these nasal trumpets were placed in recovery. Oxygen alone was used in all children immediately after extubation, most generally being weaned to room air before discharge from the recovery room. Twenty-seven patients (29%) required oxygen after discharge from recovery, with 20 of these patients having significant comorbidities (Table 4). Ten of these patients required oxygen for more than 24 h. Of the four patients who were discharged on oxygen, two (or 50%) had required oxygen before surgery. It was not possible to precisely quantify oral intake in most cases. Fifty-seven patients (61%) were identified as having taken sufficient oral intake in less than 4 h to justify discharge from the hospital on this criterion alone (Table 5). An additional nine patients (10%) had significant oral intake documented within 8 h, three more (3%) were drinking well by 12 h, and 14 more (15%) by 24 h. Given that five patients (5%) were gastrostomy tube dependent both pre- and postoperatively and one patient (1%) was fed both preoperatively and on discharge by nasogastric tube (due to herpes stomatitis), only five patients (5%) required more than 24 h to resume adequate oral intake (range 31 h to 5 days). All but one of this group was among the patients with complex medical histories. Interestingly, only two patients (2%) experienced troublesome nausea and vomiting, defined in this series as more than one episode in the entire postoperative period or any episodes occurring after discharge from the recovery room. In both of these patients, adequate oral intake was seen within 4 h. After discharge, four patients required treatment for dehydration, two of which were among those with comorbid conditions. Readmission occurred in three cases on postoperative days 1, 3, and 8. The remaining patient was treated on

Tonsillectomy in the under 2-year-old child


Table 3 Patients with postoperative admission greater than 24 h Total days 1.5 2 3 3 4 4 4 6 7 9 16 Total Days in PICU 1 1 2 1 3 2 1 3 0 3 4 Days in ward 0.5 1 1 2 1 2 3 3 7 6 12 N (total) 1 8 1 1 1 1 1 1 1 1 1 18 N (complex) 1 4 1 1 1 1 1 1 0 1 1 13 Complex patient no. 32 1, 9, 12, 25 6 31 28 5 29 14 4 2

Table 5 Oral intake Time to oral intake B/4 h 4 /8 h 8 /12 h 12 /24 h 24 /48 h /48 h Tube feeds Total N 57 9 3 14 4 1 6 94 % 61 10 3 15 4 1 6

4. Discussion
Tonsillectomy is among the most commonly performed procedures in children. In the past, the literature has reflected a reluctance to perform tonsillectomy on young children. This opinion was based on the beliefs that the procedure was unnecessary in this age group and that tonsillectomy in young children is more dangerous, given its risks of postoperative bleeding, dehydration, and airway compromise [1,17]. The young patients in this series, in general, did well, especially those without significant comorbidities. Nine different physicians utilized a variety of surgical techniques and perioperative management strategies, an obvious source of bias with regard to planned duration of hospital stay, ward choice for postoperative observation, and routine use of medications during surgery. These variables preclude the drawing of any definitive conclusions from this series regarding the optimal treatment plan for young patients undergoing tonsillectomy. Although indications for tonsillectomy have included a large number of conditions over the years, most procedures have traditionally been performed to address infection, either recurrent or chronic. More recently, a trend towards airway obstruction as a common indication for tonsillect-

postoperative day 7 with intravenous hydration in the emergency department and was released. Follow-up data collected consisted of parental assessment of clinical improvement relative to the condition(s) necessitating tonsillectomy. Of the 62 patients with OSA, 17 (27%) were lost to follow-up and 41 (66%) had no further apneic episodes witnessed during sleep. When parents were unsure regarding improvement, which occurred in four patients, polysomnograms were obtained. Two of these (3%) were on oxygen at the time of follow-up and one (1%) required CPAP during sleep. One patient had a follow-up sleep study which demonstrated resolution of OSA.

Table 4 Oxygen use after discharge from the recovery room Time oxygen required B/4 h 4 /12 h 12 /24 h /24 h On discharge from the hospital Total N (total) 5 8 4 6 4 27 N (complex) 4 6 1 5 4 20 Complex patient no. 23, 30, 34, 46 8, 13, 21, 25, 32, 38 11 4, 5, 12, 14, 28 1, 2, 9, 33


A.H. Werle et al.

omy has emerged because of increasing information about the causes and sequelae of OSA. Additionally, fewer surgeries are being performed for infectious reasons due to improved antibiotic therapy [3,18]. In our population, OSA was present in the majority of patients, as expected; but a surprising number underwent tonsillectomy for chronic, recurrent, or acute tonsillitis. Additional work-up for other conditions causing or mimicking pharyngitis, such as gastroesophageal reflux, may have reduced the number of procedures performed for infection. In addition, the two procedures performed for acute tonsillitis with airway obstruction may have been avoidable with the placement of artificial airways and aggressive medical management. The long-term effects of OSA in young children include developmental delay, facial growth aberration, failure to thrive, neurologic sequelae, and cardiopulmonary problems including cor pulmonale [19 /22]. Potsic further suggests that chronic upper airway obstruction that does not meet criteria for OSA can also lead to negative sequelae [23]. Refinement of diagnostic techniques and increased awareness of OSA has resulted in both earlier identification of children with this disorder and an appreciation for the increased morbidity associated with delay in its treatment [19]. In our population with OSA, subjective improvement was reported in the vast majority of patients who returned for follow-up evaluations. Only three of our complex patients needed oxygen or CPAP therapy after surgery. Several studies have indicated that young children, often defined as those less than 3 years old, are at increased risk of posttonsillectomy complications, most notably airway compromise [4,6,9,14,24 /27]. In a related group of studies, several authors have identified groups of patients at higher risk for complications after tonsillectomy, based on aspects of their medical histories [11,21,23,28,29]. Many of these disorders */which include failure to thrive, hypotonia, craniofacial anomalies, prematurity, and cor pulmonale */have been shown to be more common in young children undergoing tonsillectomy. Therefore, one would expect that a population of patients under 2 years of age undergoing tonsillectomy would experience a large number of complications, especially those involving the airway, and that many of these patients would have significant comorbidities. In our series, however, such complications were uncommon. There were two cases of pneumonia, one each among those with and without significant comorbidities. Extubations occurred immediately after the completion of surgery in all but one case,

and only one complex patient failed extubation initially. Few children required more than oxygen for respiratory support perioperatively, and most children requiring additional respiratory support (in the form of reintubation, nasopharyngeal airways, or CPAP) were from the group with complex medical histories. In comparison to older children and adults, increased difficulty in young children with posttonsillectomy oral intake has not been definitively established. Some authors have reported delayed resumption of adequate oral intake in their youngest patients while others indicate that this is less problematic in this population [12,14,26,29]. Most patients in our series resumed oral intake quickly, and only four patients required treatment for dehydration after surgery. One of the most interesting findings in this study was the rarity of perioperative nausea and vomiting, which was reported in only two patients. Bleeding, when reported according to patient age, is perhaps slightly less common in young children [14,26,30]. This could be a reflection of the prevalence of airway obstruction as an indication for tonsillectomy in these patients, with chronic or recurrent infection thought to predispose patients to hemorrhage from inflamed tonsillar fossae [31,32]. Our series included four posttonsillectomy hemorrhages, all of which occurred in patients with significant comorbid conditions but without histories of tonsillitis. Despite conflicting conclusions in the literature about the frequency of delayed oral intake and bleeding in young children undergoing tonsillectomy, several authors have emphasized that younger children have less reserve when considering these important hemodynamic variables [14,26,30,33]. As such, they are more likely to have poor outcomes from complications which would be less serious for older children and adults. Since 1968, when Chiang et al. published their experience with a large series of outpatient tonsillectomies, there has been an ongoing debate about which patients can be managed in the outpatient setting [5 /16,34 /36]. A complete discussion of this body of work is beyond the scope of this study. However, it is significant to note that many authors have listed as exceptions to consideration for outpatient surgery patients with OSA, age less than three, and/or complicating medical conditions [5 /16,27]. Some have recommended intensive care unit monitoring postoperatively for those with OSA [7,11]. In our series, complex patients were uniformly scheduled for inpatient management, with most requiring monitored beds.

Tonsillectomy in the under 2-year-old child

[4] L.W.C. Tom, R.M. DeDio, D.E. Cohen, R.F. Wetmore, S.D. Handler, W.P. Potsic, Is outpatient tonsillectomy appropriate for young children?, Laryngoscope 102 (1992) 277 /280. [5] E.C. Gabalski, K.F. Mattucci, M. Setzen, P. Moleski, Ambulatory tonsillectomy and adenoidectomy, Laryngoscope 106 (1996) 77 /80. [6] M.E. Gerber, D.M. OConnor, E. Adler, C.M. Myer, Selected risk factors in pediatric adenotonsillectomy, Arch. Otolaryngol. Head Neck Surg. 122 (1996) 811 /814. [7] R.A. Guida, K.F. Mattucci, Tonsillectomy and adenoidectomy: an inpatient or outpatient procedure?, Laryngoscope 100 (1990) 491 /493. [8] A.J. Maniglia, H. Kushner, L. Cozzi, Adenotonsillectomy: a safe outpatient procedure, Arch. Otolaryngol. Head Neck Surg. 115 (1989) 92 /94. [9] S.A. McColley, M.M. April, J.L. Carroll, R.M. Naclerio, G.M. Loughlin, Respiratory compromise after adenotonsillectomy in children with obstructive sleep apnea, Arch. Otolaryngol. Head Neck Surg. 118 (1992) 940 /943. [10] R.B. Mitchell, K.D. Pereira, N.R. Friedman, R.H. Lazar, Outpatient adenotonsillectomy: is it safe in children younger than 3 years, Arch. Otolaryngol. Head Neck Surg. 123 (1997) 681 /683. [11] E. Truy, F. Merad, P. Robin, B. Fantino, A. Morgon, Failures in outpatient tonsillectomy policy in children: a retrospective study in 311 children, Int. J. Pediatr. Otorhinolaryngol. 29 (1994) 33 /42. [12] M.A. Rothschild, P. Catalano, H.F. Biller, Ambulatory pediatric tonsillectomy and the identication of high-risk subgroups, Otolaryngol. Head Neck Surg. 110 (1994) 203 / 210. [13] J.M. Ruboyianes, R.M. Cruz, Pediatric adenotonsillectomy for obstructive sleep apnea, ENT-Ear Nose Throat J. 75 (1996) 430 /433. [14] B.J. Wiatrak, C.M. Myer, T.M. Andrews, Complications of adenotonsillectomy in children under 3 years of age, Am. J. Otolaryngol. 12 (1991) 170 /172. [15] G.J. Wiet, C. Bower, R. Seibert, M. Griebel, Surgical correction of obstructive sleep apnea in the complicated pediatric patient documented by polysomnography, Int. J. Pediatr. Otolaryngol. 41 (1997) 133 /143. [16] E.F. Williams, P. Woo, R. Miller, R.M. Kellman, The effects of adenotonsillectomy on growth in young children, Otolaryngol. Head Neck Surg. 104 (1991) 509 /516. [17] B. Tolczynski, Tonsillectomy, its hazards and their prevention, Eye Ear Nose Throat Monthly 48 (1969) 71 /80. [18] K.M. Grundfast, D.J. Wittich, Adenotonsillar hypertrophy and upper airway obstruction in evolutionary perspective, Laryngoscope 92 (1982) 650 /656. [19] R.T. Brouillette, S.K. Fernbach, C.E. Hunt, Obstructive sleep apnea in infants and children, J. Pediatr. 100 (1982) 31 /40. [20] D.B. Kearns, S.M. Pransky, A.B. Seid, Current concepts in pediatric adenotonsillar disease, Ear Nose Throat J. 70 (1991) 15 /19. [21] J. Leach, J. Olson, J. Hermann, S. Manning, Polysomnographic and clinical ndings in children with obstructive sleep apnea, Arch. Otolaryngol. Head Neck Surg. 118 (1992) 741 /744. [22] L.P. Singer, P. Saenger, Complications of pediatric obstructive sleep apnea, Otolaryngol. Clin. North Am. 23 (1990) 665 /676. [23] W.P. Potsic, P.S. Pasquariello, C.C. Baranak, R.R. Marsh, L.M. Miller, Relief of upper airway obstruction by adenotonsillectomy, Otolaryngol. Head Neck Surg. 94 (1986) 476 /480.

Despite the low incidence of complications seen in this series, it is our opinion that tonsillectomy in all very young children should be planned with an overnight stay. This is in keeping with several authors who have suggested that admission be planned in these children, with evaluation 4 /6 h after surgery resulting in the discharge of a small percentage [4,29,35]. Because of their small size, these patients, even when otherwise healthy, have little reserve to combat the effects of a general anesthetic and a surgery that simultaneously introduces the risks of bleeding, dehydration, and airway distress. Most of our patients who required prolonged postoperative respiratory support or experienced delays in oral intake had significant comorbidities. We feel that such patients clearly warrant close observation after surgery, and some may require intensive care monitoring. Extra vigilance is especially important outside of the childrens hospital setting, where care of young, complex patients is not routine. This study is a retrospective chart review which presents the recent experience with tonsillectomy in under 2-year-old children at a large urban pediatric hospital. We began the study assuming that the majority of patients would have complicated medical histories, necessitating early surgical intervention for upper airway obstruction. However, we found that approximately 50% of these patients were otherwise healthy. We also found that tonsillectomy in this age group has been a rewarding procedure. At the initial postoperative visit, the vast majority of patients with OSA symptoms had resolved. Further, we found that tonsillectomy has met with relatively few complications in this young population. Specifically, delays in oral intake, vomiting, and the need for respiratory support were infrequent and, in most cases, predictable based on patient comorbidities. Management decisions should always, however, take into account the diminished capacity of these young and often complex patients to deal with hemodynamic insults, airway swelling, and anesthetic effects.

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[24] M.J. Biavati, S.C. Manning, D.L. Phillips, Predictive factors for respiratory complications after tonsillectomy and adenoidectomy in children, Arch. Otolaryngol. Head Neck Surg. 123 (1997) 517 /521. [25] J.S. Carithers, D.E. Gebhart, J.A. Williams, Postoperative risks of pediatric tonsilloadenoidectomy, Laryngoscope 97 (1987) 422 /429. [26] W.S. Crysdale, Complications of tonsillectomy and adenoidectomy in 9409 children observed overnight, CMAJ 135 (1986) 1139 /1142. [27] G.M. Rosen, R.P. Muckle, M.W. Mahowald, G.S. Goding, C. Ullevig, Postoperative respiratory compromise in children with obstructive sleep apnea syndrome: can it be anticipated?, Pediatrics 93 (1994) 784 /788. [28] W.P. Potsic, R.R. Marsh, Snoring and obstructive sleep apnea in children, in: D.N.F. Fairbanks, et al. (Eds.), Snoring and Obstructive Sleep Apnea, Raven Press, New York, NY, 1987, pp. 245 /257. [29] S.D. Price, D.B. Hawkins, E.J. Kahlstrom, Tonsil and adenoid surgery for airway obstruction: perioperative respiratory morbidity, ENT J. 72 (1993) 526 /531.

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[30] C. Helmus, Tonsillectomy and adenoidectomy in the one and two-year-old child, Laryngoscope 89 (1979) 1764 / 1771. [31] D. Carmody, T. Vamadevan, S.M. Cooper, Posttonsillectomy haemorrhage, J. Laryngol. Otol. 96 (1982) 635 /638. [32] D. Myssiorek, A. Alvi, Post-tonsillectomy hemorrhage: an assessment of risk factors, Int. J. Pediatr. Otorhinolaryngol. 37 (1996) 35 /43. [33] N.L. Shapiro, A.B. Seid, S.M. Pransky, D.B. Kearns, A.E. Magit, P. Silva, Adenotonsillectomy in the very young patient: cost analysis of two methods of postoperative care, Int. J. Pediatr. Otorhinolaryngol. 48 (1999) 109 /115. [34] T.M. Chiang, A.E. Sukis, D.E. Ross, Tonsillectomy performed on an outpatient basis: report of a series of 40,000 cases performed without a death, Arch. Otolaryngol. 88 (1968) 307 /310. [35] M.L. Lalakea, I. Marquez-Biggs, A.H. Messner, Safety of pediatric short-stay tonsillectomy, Arch. Otolaryngol. Head Neck Surg. 125 (1999) 749 /752. [36] S.A. Reiner, W.P. Sawyer, K.F. Clark, M.W. Wood, Safety of outpatient tonsillectomy and adenoidectomy, Otolaryngol. Head Neck Surg. 102 (1990) 161 /168.