Children suffering from obstructive sleep apnea due to craniofacial abnormalities, hypotonia, obesity, or “kissing” tonsils are at increased risk of developing acute airway maintenance difficulties after tonsillectomy. Prolonged obstruction of the upper airway from the obstructing tonsils can increase intrathoracic pressure and decrease venous return and pulmonary blood volume. After removal of the tonsils, there is a sudden increase in venous return, pulmonary blood volume, and pulmonary hydrostatic pressure. These rapid changes cause a fluid shift from pulmonary vessels into the lungs’ interstitial spaces and alveoli. The complication is sometimes referred to as “negative-pressure pulmonary edema.”22,23
Appropriate management includes close monitoring and the use of continuous positive airway pressure ventilation, as needed. The same approach is appropriate in children with right-sided cardiac insufficiency or pulmonary hypertension.
Fever and infection
Fever may occur within 18 to 36 hours after tonsillectomy as a result of lung atelectasis, a response to anesthetic agents, or a transient bacteremia. A postop fever lasting more than 24 hours, accompanied by severe throat pain, suggests an emerging pharyngeal infection.
Some surgeons prescribe prophylactic postop antibiotics to reduce the risk of infection in the traumatized region, decrease pain, and enable the patient to return quickly to a normal oral diet.24 A meta-analysis suggests, however, that postop oral antibiotics don’t reduce infection rates, posttonsillectomy pain, or secondary hemorrhage rates; the drugs do facilitate a return to normal activity and diet about a day sooner.25,26
Pneumonia used to be a common complication due to aspirated blood during the procedure. With the advent of improved surgical and anesthetic techniques, however, this complication rarely occurs.2 Neck infection, including suppurative lymphadenitis, is also a rare complication.27
Dehydration
While postop dehydration may be uncommon in the “average” patient, the risk is more common among dysphagic children. Post-tonsillectomy vomiting worsens this situation. With that in mind, encourage patients to resume oral intake of fluids and, when necessary, provide analgesia to facilitate the process. You will need to readmit patients who are unable to drink to achieve better pain relief and restore hydration.28
Some reports suggest that severe post-tonsillectomy hyponatremia can result from excessive hypovolemia-induced antidiuretic hormone secretion, disproportionate administration of hypotonic fluids, or inadequate postop fluid intake.29,30
Encouraging patients to consume soft and cold foods after tonsillectomy will comfort patients and help restore hemostasis. Because pain is the major obstacle for a return to an oral diet, coupling analgesia and timing of oral intake is crucial for a quick recovery.
Injuries from a forceful surgical technique
Because tonsillectomy requires forceful insertion of instruments into the mouth, a loose tooth may become dislodged, or even aspirated. We don’t recommend routine pre-operative dental consultation, but do urge a watchful eye. (See TABLE 3 for details on tonsillectomy techniques.)
Temporary uvular or tongue edema can develop if the tissues were forcefully manipulated during surgery, causing the patient to feel like he or she is choking. This edema usually subsides within a few days. Additional steroid dosing can be helpful.
If the glossopharyngeal nerve is damaged during dissection or electrocautery, the patient may develop a taste disorder.31 Spontaneous healing often occurs within several weeks.
An inadvertent eye injury such as keratitis may occur from exposure or friction from surgical covers. Skin, lip, and buccal mucosa lacerations or burns may also occur, often with the use of electrocautery needles and probes.
Mandibular condyle fracture is a rare complication that can be caused by forceful opening of the mouth. Forceful opening and the use of muscular relaxants lead to dislocation or stress injury of the temporomandibular joint (TMJ).32 This TMJ disorder is treated with analgesia, soft diet, and possible surgical reduction.
Excessive hyperextension of the neck can cause muscular tension and severe neck pain after the surgery. The atlanto-axial joint is at highest risk for dislocation or subluxation, especially in patients with Down syndrome—10% of whom already have atlanto-axial joint hyperlaxity.33 With that in mind, neck radiographs should be taken prior to surgery to assess the atlanto-axial joint stability in patients with Down syndrome.
In the rare Grisel’s syndrome, patients complain of severe neck pain about a week after surgery, with limitation in neck movements and torticollis. This is due to an impaired venous drainage from the joint, local infection, and injury to the paraspinal ligaments.34 Treatment consists of rest, neck immobilization, and antibiotics.