New study examines why removing a child's tonsils can sometimes result in death
Removing a child’s tonsils for recurrent throat infections or obstructive sleep-disordered breathing is a common procedure. About 350,000 tonsillectomies are performed each year. But complications can occur in some cases, even death. KERA’s Sam Baker discussed a new study about this with Dr. Romaine Johnson, an Associate Professor of Pediatric Otolaryngology at UT Southwestern Medical Center who is Director of both the Children's Health Airway Management Program and the Pediatric Voice and Swallowing Clinic at Children's Medical Center Dallas.
Main complications of tonsillectomy
So the main complications we see are dehydration related to severe pain and bleeding.
Bleeding can occur at the time of surgery, which we call primary bleeding. So within the first 24 hours.
And then perhaps, more importantly, there's something called secondary bleeding. This occurs greater than 24 hours after the surgery, roughly day 5 to 10.
This is an open wound. You essentially remove the tonsils through the oral cavity, but you don't suture it close. And as a result, there's healing by secondary attention. And sometimes as there's healing, you get bleeding. And that bleeding doesn't stop.
And that secondary hemorrhage is a particular concern because we think that in the majority of patients who have a delayed complication after surgery, a major complication is related to the secondary hemorrhage.
Are those complications now considered rare?
The risk of mortality in an otherwise healthy child is absolutely rare. The study in question that came out in JAMA by Edmondson and colleagues showed that the mortality risk was .007, much less than 1%. There were only 36 deaths out of about 504,000 tonsillectomies.
What kind of cases can lead to post-operative death?
They try to answer that in this study, and they concluded that those who are at the highest risk for post-living death are patients who have chronic, complex conditions. Let's say you have asthma and it affects you severely or you have end-stage renal disease or you have a neurologic disorder.
If you have one of those conditions, your risk of mortality goes up. And if you have three or more of those conditions, your risk of mortality goes way up.
Now there are some caveats. The number of deaths was small. There were only 36 patients. So that means the confidence interval that the confidence at which you're certain that the mortality rate is the number they quote is very wide. So we still have to be careful. But their data does suggest that if you have one of these complex chronic conditions, you're at more risk for mortality and perhaps, you know, complications in general.
Was that the purpose of the study? What were the researchers looking for?
Can we get better at risk reduction? We know that if you are an otolaryngologist - we do the majority, if not all, of the tonsillectomy in the country - the cumulative risk of having a major complication is there. And yet it's a very straightforward procedure.
But because it occurs so rarely, it's hard to figure out which patients are at the highest risk and which interventions can reduce those risks even further. So this study attempted to get a large enough number of patients to be able to answer some of those questions, and they did find some answers.
One, as I reiterate, research is very safe or otherwise healthy. Child risk of a major complication is less than 1%. However, for children who have chronic conditions, particularly those that affect them severely, the risk is higher in those patients and we may need to target them in particular.
Is there any takeaway for parents of children with chronic conditions regarding this?
I think you got to have an evidence-based discussion with your doctor about whether or not the surgery is needed. I think you should make sure the surgery is indicated. Don't just assume that the surgery is indicated.
You should probably also have the surgery done in a center that can handle complex chronic conditions like the ones your child may have. They probably need to be done in a facility that can monitor them overnight, for example.
Those are some of the conversations parents need to have among themselves, as well as with their physicians.
Interview highlights were lightly edited for clarity.
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