In the current study, 21.6% of patients were 3 years of age or younger. Electrodissection tonsillectomy was performed in 65.7% of children, while the remaining patients underwent sharp dissection tonsillectomy. Adenoidectomies were performed with a curette. Hemostasis was achieved with electrocautery and nasopharyngeal packs. Almost half of the patients received IV dexamethasone, typically at a dose of 0.5 mg/kg, before surgery.

Eleven (8.2%) of 134 planned outpatients required an unscheduled inpatient admission based on clinical evaluation in the PACU. Conversion to inpatient status was most commonly triggered by respiratory complications, including apnea, desaturation, and/or stridor. Respiratory complications were much more frequent in children 3 years or younger, and all patients experiencing respiratory difficulties had a preoperative diagnosis of obstructive sleep apnea syndrome (OSAS). Interestingly, there were no differences in operative technique, steroid administration, or indication for surgery in patients requiring unscheduled admission compared with the outpatient group. Four patients (3.2%) were readmitted to the hospital after discharge, two because of primary hemorrhage and two because of dehydration. No respiratory complications occurred after discharge.

Higher rates of respiratory complications in patients with OSAS [1,2] and in children 3 years of age or younger [2-4] are typically described in the literature, leading some authors to recommend posttonsillectomy admission for these categories of patients. Fortunately, postoperative respiratory complications characteristically appear early in recovery, allowing these patients to be admitted appropriately.

The most serious postdischarge concern is, of course, postoperative hemorrhage. In 1987 Carithers et al [5] recommended an 8 to 10 hr postoperative observation period. Subsequent reports suggested that many authors consider a minimum postoperative observation period of 6 to 8 hr to be standard.[6-9] However, Mitchell and colleagues [10] as well as Gabalski et al [11] have suggested that posttonsillectomy observation may be safely decreased to 4 hrs, and Colclasure and Graham [12] reported a complication rate of 1.4% among 3,340 children and adults observed for an average of 2.25 hr after tonsil and adenoid procedures. Clearly, the authors of the current paper are correct to state unequivocally that "careful patient section, with attention to the availability of transportation and proximity to the hospital, is critical to the safety of ambulatory adenotonsillectomy, regardless of the length of observation."

References:

1. Rosen GM, Muckle RP, Mahowald MW, Goding GS, Ullevig C. Postoperative respiratory comprise in children with obstructive sleep apnea syndrome: can it be anticipated? Pediatrics. 1994;93:784-8.
   
   
2. McColley SA, April MM, Carroll JL, Naclerio RM, Loughlin GM. Respiratory compromise after adenotonsillectomy in children with obstructive sleep apnea. Arch Otolaryngol Heal Neck Surg. 1992; 118:940-3.
   
   
3. Tom LWC, DeDio RM, Cohen DE, Wetmore RF, Handler SD, Potsic WP. Is outpatient tonsillectomy appropriate for young children? Laryngoscope. 1992; 102:277-80.
   
   
4. Biavati MJ, Manning SC, Phillips DL. Predictive factors for respiratory complications after tonsillectomy and adenoidectomy in children. Arch Otolaryngol Head Neck Surg. 1997; 123:517-21.
   
   
5. Carithers JS, Gebhart DE, Williams JA. Postoperative risks of pediatric tonsilloadenoidectomy. Laryngoscope. 1987: 97:422-9.
   
   
6. Reiner SA, Sawyer WP, Clark KF, Wood MW. Safety of outpatient tonsillectomy and adenoidectomy. Otolaryngol Head Neck Surg. 1990; 102:161-8.
   
   
7. Shott SR, Myer CM, Cotton RT. Efficacy of tonsillectomy and adenoidectomy as an outpatient procedure: a preliminary report. Int J Pediatr Otorhinolaryngol. 1987; 13:157-63.
   
   
8. Crysdale WE, Russel D. Complications of tonsillectomy and adenoidectomy in 9409 children observed overnight. CMAJ. 1986; 135:1139-42.
   
   
9. Guida RA, Mattucci KF. Tonsillectomy and adenoidectomy: an inpatient or outpatient procedure? Laryngoscope. 1990; 100:491-3.
   
   
10. Mitchell RB, Pereira RD, Friedman NR, Lazar RH. Outpatient adenotonsillectomy. Arch Otolaryngol Head Neck Surg. 1997;123:681-3.
    
    
11. Gabalski EC, Mattucci KF, Setzen M, Moleski P. Ambulatory tonsillectomy and adenoidectomy. Laryngoscope. 1996; 106:77-80.
    
    
12. Colclasure JB, Graham SS. Complications of outpatient tonsillectomy and adenoidectomy: a review of 3,3400 cases. Ear Nose Throat J. 1990; 69:155-60.

ABSTRACT Safety of pediatric short-stay tonsillectomy. AUTHORS: Lalakea ML; Marquez-Biggs I; Messner AH. SOURCE: Arch Otolaryngol Head Neck Surg. 1999 Jul;125(7):749-52 ABSTRACT: OBJECTIVE: To determine the safety of a relatively brief (<3-hour) period of postoperative observation prior to discharge in children undergoing outpatient tonsillectomy. DESIGN: Retrospective chart review. SETTING: Tertiary care children's hospital and public teaching hospital. PATIENTS: The records of all patients (12 years of age who underwent tonsillectomy or adenotonsillectomy from November 1995 through July 1997 were reviewed. A total of 143 patients scheduled for ambulatory treatment were identified; 9 were excluded owing to insufficient follow-up. The remaining 134 patients made up the study group. MAIN OUTCOME MEASURES: (1) Duration of observation prior to discharge; (2) complication rates. RESULTS: The mean age of the study population was 6.1+/-2.6 (mean+/-SD) years. Obstructive sleep apnea was an indication for surgery in 86.5%. Eleven (8.2%) of 134 planned outpatients were electively admitted from the recovery room for inpatient observation, most often because of respiratory compromise. Patients admitted from the recovery room were significantly younger (mean age, 4.0 years) than those who were discharged as planned (6.3 years, P<.001). One hundred twenty-three patients were discharged from the recovery room as anticipated, following a mean+/-SD duration of postoperative observation of 144+/-48 minutes. Overall, 5 (4.1%) of these 123 outpatients suffered complications after discharge. Two patients (1.6%) experienced primary bleeding, both at 8 hours after surgery. Four patients (3.2%) were readmitted. The complication rate did not vary significantly with the duration of postoperative observation (P= .71). CONCLUSION: A short postoperative observation period is safe, with a low rate of complications, in appropriately selected children scheduled for ambulatory tonsillectomy.