A devastating outcome after adenoidectomy and tonsillectomy: ideas for improved prevention and management

Abstract

Objective: To develop strategies that may assist the surgeon to prevent and manage severe bleeding complications after adenoidectomy and tonsillectomy.

Study design: Retrospective.

Subjects and methods: Expert reports for malpractice lawsuits or professional boards were reviewed. The review was restricted to "deaths" and "permanent generalized neurological deficiencies."

Results: Forty-three cases matched our search criteria, including 32 deaths. Adenoidectomy cases (2) were associated with immediate bleeding because of direct vascular injury resulting in one death. Tonsillectomy cases were associated with delayed and repeated episodes of bleeding resulting in 31 deaths, including 19 children. Autopsy verified predominantly aspiration and vascular injuries. An apallic syndrome prevailed in surviving patients.

Conclusion: Careful inspection of the nasopharynx immediately before adenoidectomy and curettage in a piecemeal fashion under visual control is helpful to prevent direct injury to aberrant arteries. Tonsillectomy cases are associated with delayed and episodic bleeding with spontaneous cessation and young age. Inpatient observation should be strongly considered in cases with repeated bleeding episodes to provide immediate treatment. The follow-up should be focused on disturbed wound healing. Outcome appears to be dependent on adequate airway management. Rigid instruments and tracheotomy in case of intubation failure are highly recommended to facilitate airway protection and ventilation.