International Journal of Pediatric Otorhinolaryngology (2005) 69, 1629—1633

www.elsevier.com/locate/ijporl

Day-case adenoidectomy: Outcomes areimproved using suction coagulation andprophylactic anti-emetic treatment§

Alison Hunt a, Maria Karela a, Peter J. Robb b,*

aDepartment of Otolaryngology, Royal Surrey County Hospital HNS Trust,Guildford GU2 7XX, UKbDepartment of Otolaryngology, Epsom & St. Helier University Hospitals NHS Trust,Epsom KT18 7EG, UK

Received 17 January 2005; received in revised form 23 March 2005; accepted 23 March 2005

KEYWORDSAdenoidectomy;Day-case;Suction coagulation;Ondansetron;Complications;Audit

SaoaacbopadBobdtod# 2005 Elsevier Ireland Ltd. All rights reserved.

§ Paper presented at the 5th Extraordinary International Sym-posium on Recent Advances in Otitis Media, Amsterdam, 24—27April 2005.* Corresponding author. Tel.: +44 1372 735226;

fax: +44 1372 277494.E-mail address: peter.robb@epsom-sthelier.nhs.uk

(P.J. Robb).

0165-5876/$ — see front matter # 2005 Elsevier Ireland Ltd. All rigdoi:10.1016/j.ijporl.2005.03.043

1. Introduction

Adenoidectomy is a common operation carried outin childhood predominantly to treat upper airwayobstruction or as part of the surgical management ofotitis media with effusion (OME).

ummary In 2004, the Department of Health published 10 High Impact Changescross the NHS. Of these, the first was treating day surgery as the norm for electiveperations, releasing up to half a million in-patient beds each year. Adenoidectomy isn operation commonly performed in children for upper respiratory tract obstructionnd as part of the surgical management of otitis media with effusion. Many surgeonsonsider the traditional curettage adenoidectomy as an unsatisfactory operationecause it is performed blind, and is associated with varying reported levels of post-perative bleeding. Concern about the risk of bleeding and the frequent occurrence ofost-operative nausea and vomiting have discouraged many surgeons from adoptingdenoidectomy as a day-case procedure. We have audited the management andischarge of a cohort of 72 children undergoing traditional curettage adenoidectomy.ased on the results, we have completed the audit loop, by managing a second cohortf 77 children by suction coagulation adenoidectomy. An anaesthetic protocol haseen designed to reduce post-operative nausea and vomiting, and facilitate same dayischarge from hospital. The rate of post-operative nausea and vomiting fell from 21o 1.3%, and the post-operative bleeding from 9.7% to nil. Discharge on the day ofperation rose from 40.3 to 100%. Our audit confirms that these measures permit safe,ay-case adenoidectomy.

hts reserved.

1630 A. Hunt et al.

In the UK, for the last 50 years, adenoidectomyhas been performed as a predominantly in-patientprocedure. Last year, the Department of Healthlisted day surgery as the first of its 10 High ImpactChanges across the NHS [1]. In the UK, day surgery isany procedure carried out where the patient doesnot occupy a hospital bed at midnight on the day ofoperation.

ENT day surgery has steadily increased from 21%of ENT procedures in 1991 to 33% in 1998. Of theseENT day-cases, 27% were adenoidectomies [2]. In1993, the Chief Medical Officer of England andWalesset a target aiming for 50% of all surgery to be day-cases by 2000 [3]. Several studies support day-caseadenoidectomy as a safe and cost-effective proce-dure [4—7].

Benefits of day surgery include cost-effective-ness, reduced pressure on in-patient beds and lesspsychological trauma for parents and for childrenundergoing surgery. Limitations on day-case surgeryinclude resource problems regarding unplannedadmissions and consequences of delayed treatmentof complications. There are however medical, socialand geographical constraints that may precludeeligibility for day-case adenoidectomy.

Admission to hospital following ENT day surgery isdue to vomiting (30%), inadequate recovery fromanaesthetic (22%), bleeding (20%), inadequate paincontrol (14%) and pyrexia (9%) [2].

Post-operative haemorrhage is rare but can belife threatening. Since haemorrhage usually occurswithin the first 6 h post-operatively, some wouldadvocate overnight stay as the minimum [8,9].Afternoon operating sessions limit the ability todischarge children after surgery. The Royal Collegeof Surgeons [10] has published guidance for daysurgery, including anaesthetic, analgesic and dis-charge protocols to maximise safety and efficiency.A maximum readmission rate of 2—4% is consideredthe benchmark.

We have undertaken audit of adenoidectomylooking at complications and readmission followingtraditional curettage technique and overnightstay, and based on the outcomes, have completedthe audit cycle with a cohort undergoing suctioncoagulation and routine pre-operative anti-emetic.

2. Patients and methods

A clinical audit of complications following paedia-tric adenoidectomy in a secondary care generalhospital (referral population 350,000) was carriedout between 1999 and 2001. All children were ASA 1or 2 (American Society of Anaesthesiologists), and

admitted to a dedicated children’s day surgery unit,staffed by pediatric nursing staff, with immediateaccess to pediatric medical support. Experiencednon-trainee surgeons carried out all surgery. Allanesthesia was administered by consultant or con-sultant-supervised trainees in accordance with thelocal Epsom Protocol (Appendix A). The differencebetween the first and second groups was that thefirst group had no prophylactic ondansetron.

In addition to adenoidectomy, some childrenunderwent insertion of ventilation tubes (VTs),sub-mucosal diathermy of inferior turbinates(SMD) or release of tongue-tie under the same gen-eral anaesthetic. Prior to 2000, all children under-went curettage adenoidectomy with an overnightstay. No prophylactic anti-emetic medication wasused.

In the first cycle group, there were 72 children, 37male and 35 female, with a mean age of 5.1 years(range 2.0—12.5 years) who underwent curettageadenoidectomy with overnight stay. Of these 15.0%underwent adenoidectomy alone, 78.0% VTs, 4.0%SMD, and 3.0% release of tongue-tie in addition toadenoidectomy.

Prior to the second cycle, the suction coagulatorwas introduced as a new mode of adenoidectomy.Surgeons used the suction coagulator for more than1 year before the second cycle of the audit loop toavoid an observed learning-curve effect with thesuction coagulation group.

In the second cycle of the audit after 2000, allchildren underwent suction coagulation adenoi-dectomy as a day-case, with the routine prophy-lactic use of an anti-emetic (ondansetron 0.1 mg/kg). Routine antibiotics were prescribed (azithro-mycin 10 mg/kg) to reduce the well-recognisedpost-operative fetor associated with diathermyadenoidectomy. Children in the latter group weredischarged via a nurse-led protocol if recoverywas satisfactory at the time of the post-operativeward round. Following day-case discharge therewas a telephone follow-up within 72 h to monitorany complications arising from same day dis-charge.

In the second cycle group, there were 77 chil-dren, 44 male and 33 female with a mean age of 4.8years (range 2.0—11.5 years). This group underwentsuction coagulation adenoidectomy as day-casewith routine prophylactic anti-emetic treatment.Of this group, 14.3% underwent adenoidectomyalone, 83.0% with VTs and 2.7% with SMD.

The clinical records were reviewed, and compli-cations including: post-operative nausea and vomit-ing (PONV), haemorrhage, transfusion, unplannedovernight stay, pain preventing discharge (PPD) andpyrexia were recorded.

Day-case adenoidectomy 1631

Table 1 Post-operative bleeding between the groupthat had curettage adenoidectomy and the group thathad suction coagulation adenoidectomy

Curettage Suctiondiathermy

Number of patients 72 77Bleeding 7 * 0 *

* p < 0.001.

Table 3 Day-case discharges in the two groups

Curettageand noondansetron(%)

Suctioncoagulationand ondansetron(%)

Number of patients 72 (100) 77 (100)Day-case 29 (40.3) 77 (100)Overnight stay 43 (59.7) 0 (0)

3. Results

A standard personal computer (Acer Intel PentiumCentrino) with SPSS 11.5 software was used for thestatistical evaluation of the results. Significancewas evaluated by the independent-samples Stu-dent’s t-test, and the paired-samples Student’st-test: p-values less than 0.05 were consideredstatistically significant.

The mean of age was 4.95 � 2.04 years (range1.5—12.5 years). Eighty-two (55.03%) were maleand 67 (44.97%) were female.

The difference in post-operative bleeding,between the first subgroup that had adenoidectomyperformed by curettage and the second subgroupthat had adenoidectomy performed by suction dia-thermy, was statistically significant (p < 0.001).None of the patients that had adenoidectomy pre-formed by suction diathermy, bled post-operatively(Table 1).

In the first group, complications includedPONV, of which 14.0% vomited clear fluid and7.0%, blood stained fluid. No significant differencewas found in both post-operative bleeding, andpost-operative nausea or vomiting between malesand females.

9.7% suffered some observed post-operativebleeding during the period of admission. None ofthe children required transfusion or return to theoperating room for arrest of haemorrhage. As aresult of these complications, overnight stay wasrequired for 59.7% of the children. 40.3% weredischarged on the day of surgery (Table 2).

In the second group, after the introduction ofsuction coagulation adenoidectomy and routine pro-phylactic anti-emetic treatment, the PONV rate fell

Table 2 Post-operative nausea and vomiting compar-ing prophylactic ondansetron and no ondansetron

No ondansetron Ondansentron

Number of patients 72 77PONV 15* 0 *

* p < 0.001.

to 1.3%. None of these children produced bloodstained fluid. No child in this group developedpost-operative bleeding. All patients were dis-charged on the day of surgery (Table 3). The singlepatient who did suffer PONV did so at day three post-operatively, and this was felt to be due to unrelatedviral infection (Probable Norwalk virus).

4. Discussion

Routine practice for adenoid surgery has undergonea complete circle in the last century. Initially a day-case procedure, sometimes with no anaesthetic, ithas become an operation under general anaesthesiawith an overnight admission [11]. Current pres-sures, largely financial, but facilitated by improvedsurgical techniques and anesthesia, have movedadenoidectomy again towards day-case manage-ment. The post-operative period of observationhas been safely reduced further from 6 to 4 h [4].In the UK in 1990, less than 1.5% of adenoidectomiesalone were carried out as day-case procedures [5].However, published data has confirmed that day-case adenoidectomy is not only a safe procedure,but has a high level of parental acceptability andlow degree of parental anxiety and concern[6,7,12,13]. The current constraints to day-caseadenoidectomy are limited to patient fitness orunfavourable social circumstances and rural geo-graphical limitations.

In this audit, of the curette group, 9.7% sufferedpost-operative bleeding, although no significant orserious haemorrhage requiring transfusion or returnto the operating room occurred. In the suctioncoagulation group, however, 0% suffered post-operative bleeding of any description. During theoperation, there was minimal blood loss using suc-tion coagulation.

Our audit supports the published data on theefficacy of the suction coagulator over the tradi-tional curettage method of adenoidectomy,with minimal blood loss and post-operative dis-comfort [14—17]. With suction coagulation, thereis an absence of significant complications and

1632 A. Hunt et al.

there are cost benefits in contrast to adenoidect-omy using the curettage, or the microdebrider[18,19].

Post-operative nausea and vomiting was a rela-tively common complication in the curettage group(14.0% clear fluid and 7.0% blood stained). In thisgroup no anti-emetic was routinely given. In thesuction coagulation group there were no cases ofimmediate PONV, but one patient was readmittedwith nausea and vomiting 3 days after surgery. Thissettled with administration of anti-emetic andintravenous fluids overnight. The patient was dis-charged the following day with no serious adverseeffect. Because of the delayed presentation, webelieve that the cause of vomiting was viral in originrather than a direct result of surgery. Our auditsupports the routine use of ondansetron as a pro-phylactic anti-emetic medication [20,21]. (Sincethe audit, we have modified the Epsom Protocol(Appendix A), with the introduction of pre-opera-tive dexamethasone.) [22].

Published data concludes that while post-opera-tive analgesia is required, over 90% of childrenare back to normal daily activities within 3 daysof adenoidectomy. Paracetamol and non-steroidalanti-inflammatory drugs provide satisfactory anal-gesia during this period [23,24].

5. Conclusions

Adenoidectomy is a generally safe operation withminimal risk of serious morbidity or of mortality [9].In an unselected group of nearly 8000 patients, post-operative bleeding after adenoidectomy occurred in0.21%, usually in the first hours after surgery. Noneof these required transfusion, and there were nomortalities [25].

While the risk of serious post-operative bleedingis low, it is always a cause for concern. Bleeding andpost-operative nausea and vomiting may cause dis-tress and delay discharge from hospital. Despitethese potential problems, there is evidence of neg-ligible post-operative behavioural problems in chil-dren following adenoidectomy [26].

In children undergoing adenoidectomy, but nottonsillectomy, significant pain is less of an issue, andcan be adequately managed with a combination ofper-operative analgesics and regular paracetamoland non-steroidal anti-inflammatories to takehome.

This audit of two comparable groups illustrateshow a combination of improved surgical techniqueand change in pre-operative care has reduced mor-bidity and facilitated day-case management of chil-dren undergoing adenoidectomy.

We conclude that suction coagulation adenoi-dectomy in combination with prophylactic pre-operative anti-emetic treatment allows adenoi-dectomy to be safely performed as a day-case pro-cedure with minimal morbidity.

Acknowledgements

We thank Mary Raw, head nurse, and her team,Ebbisham children’s day surgery ward at Epsom &St. Helier University Hospitals, Epsom. We alsothank Dr. Anna-Maria Rollin and Dr. BernadetteEwah, consultant anesthesiologists as co-authors(with Mr. Peter Robb) of the Epsom Protocol forday-case children’s ENT surgery. Thanks are alsodue to Yvonne White for assistance with the dataretrieval.

Appendix A

Epsom Protocol for children undergoing day-caseadenoidectomy

1

Morning list–—admit on day of surgery at 07:30 Pre-op ward round Consultant anaesthetist and surgeon

2

No food from night before Clear fluids until 2 h pre-operatively–—excludesmilk/carbonated drinks or chewing gum

3

No premedication EMLA1 or Ametop1 on back of both handsand/or both antecubital fossae

4

Parent accompanies child to anaesthetic room untilinduction complete Induction with intravenous propofol (inhalationalinduction with sevoflurane if needle phobic orproblem veins) No narcotics/nitrous oxide

5

Sevoflurane/air or O2 inhalational maintenance(avoid N2O) Rectal diclofenac or paracetamol (consent pre-opis good practice) Intramuscular codeine 1 mg/kg Intravenous ondansetron 0.1 mg/kg Intravenous dexamethasone 150—200 mg/kg

6

Airway maintenance with LMA if possible. RAEETT uncuffed for smaller children or cuffed forolder children

7

IV fluids–—Hartman’s or normal saline 4 hpost-operation or until eating

Day-case adenoidectomy 1633

Fasting deficit/blood loss bolus plus: 4 ml/kg/hfor first 10 kg, 2 ml/kg/h for second 10 kg,1 ml/kg/hr thereafter

8

Free fluids on demand on return to ward for 1 h Then, food on demand if no nausea, vomitingor bleeding

9

Routine post-tonsillectomy nursing observationsfor 6 h Post-operative consultant anaesthetist andsurgeon ward round at 12:30 Nurse-led discharge after 6 h, if satisfactory

10

Discharge medications Azithromycin 10 mg/kg/od 3 days Paracetamol sugar-free elixir 15 mg/kg qdsfor 7 days Ibuprofen sugar-free elixir 5 mg/kg tds pcfor 7 days

References

[1] The PCT guide to applying the 10 High Impact Changes,Department of Health NHS Modernisation Agency, HMSO,London, 2004.

[2] P.M. Brown, S. Fowler, R. Ryan, R. Rivron, ENT day surgery inEngland and Wales–—an audit by the Royal College of Sur-geons (Eng.) Comparative Audit Service, J. Laryngol. Otol.112 (1998) 161—165.

[3] Department of Health, H93/977, HMSO, London, 1993.[4] E.C. Gabalski, K.F. Mattucci, M. Setzen, P. Moleski, Ambu-

latory tonsillectomy and adenoidectomy, Laryngoscope 106(1996) 77—80.

[5] J.N. Marshall, I. Sheppard, A.A. Narula, A prospective studyof day case adenoidectomy, Clin. Otolaryngol. 20 (1995)164—166.

[6] K. Ahmed, M.S. McCormick, A.K. Baruah, Day-case adenoi-dectomy–—is it safe? Clin. Otolaryngol. 18 (1993) 406—409.

[7] S.E.J. Leighton, J.M. Rowe-Jones, J.R. Knight, V.L. Moore-Gillon, Day case adenoidectomy, Clin. Otolaryngol. 18 (1993)215—219.

[8] A. Kishore, A.M. Haider-Ali, N.K. Geddes, Patient eligibilityfor day case paediatric adenotonsillectomy, Clin. Otolaryn-gol. 26 (2001) 47—49.

[9] M.P. Yardley, J.W. Fairley, L.H. Durham, A.J. Parker, Day casetonsil and adenoid surgery: howmany are eligible? J. R. Coll.Surg. Edinb. 39 (1994) 162—163.

[10] Royal College of Surgeons of England, Guidelines for day casesurgery, RCSEng, London, 1992.

[11] B.J. Bailey, Tonsils and adenoids: snapshots from theLaryngoscope scrapbook, Laryngoscope 107 (1997) 301—306.

[12] S. Browning, J. Blanshard, R. Baskerville, Day case adenoi-dectomy: is it acceptable to parents? J. R. Coll. Surg. Edinb.42 (1997) 347—348.

[13] V. Callanan, R. Capper, P. Gurr, D.L. Baldwin, Day-caseadenoidectomy, parental opinions and concerns, J. Laryn-gol. Otol. 108 (1994) 470—473.

[14] B.E.J. Hartley, B.C. Papsin, D.M. Albert, Suction diathermyadenoidectomy, Clin. Otolaryngol. 23 (1998) 308—309.

[15] P. Walker, Pediatric adenoidectomy under vision using suc-tion diathermy ablation, Laryngoscope 111 (2001) 2173—2177.

[16] R.G. Elluru, L. Johnson, C.M. Myer III, Electrocauteryadenoidectomy compared with curettage and power-assisted methods, Laryngoscope 112 (2002) 23—25.

[17] R. Wynn, R.M. Rosenfeld, Outcomes in suction coagulatoradenoidectomy, Arch. Otolaryngol. 129 (2003) 182—185.

[18] E. Yanagisawa, E.M. Weaver, Endoscopic adenoidectomywith the microdebrider, Ear Nose Throat J. 76 (1997) 72—74.

[19] C. Giannoni, M. Sulek, E.M. Friedmann, N.O. Duncan,Acquired nasopharyngeal stenosis: a warning and review,Arch. Otolaryngol. Head Neck Surg. 124 (1998) 163—167.

[20] C.D. Lawhorn, C. Bower, R.E. Brown Jr., M.L. Schmitz, P.J.Kymer, J. Stoner, Ondansetron decreases post-operativevomiting in pediatric patients undergoing tonsillectomyand adenoidectomy, Int. J. Pediatr. Otorhinolaryngol. 36(1996) 99—108.

[21] N.S. Morton, F. Camu, T. Dorman, K.E. Knudsen, O. Kvalsvik,P. Nellgard, Ondansetron reduces nausea and vomiting afterpaediatric adenotonsillectomy, Paediatr. Anaesth. 7 (1997)37—45.

[22] A.L. Pappas, R. Sukhani, A.J. Hotaling, M. Mikat-Stevens,J.J. Javorski, J. Donzelli, The effect of pre-operative dex-amethasone on the immediate and delayed post-operativemorbidity in children undergoing adenotonsillectomy,Anesth. Analg. 87 (1998) 57—61.

[23] H. Kokki, R. Ahonen, Pain and activity disturbance afterpaediatric day case adenoidectomy, Paediatr. Anaesth. 7(1997) 227—231.

[24] E. Nikanne, H. Kokki, K. Tuovinen, Post-operative pain afteradenoidectomy in children, Br. J. Anaesth. 82 (1999) 886—889.

[25] J.P. Windfuhr, Y.S. Chen, Post-tonsillectomy and adenoidect-omy hemorrhage in nonselected patients, Ann. Otol. Lar-yngol. Rhinol. 112 (2003) 63—70.

[26] H. Tuomilehto, H. Kokki, R. Ahonen, J. Nuttinen, Post-operative behavioural changes in children after adenoidect-omy, Arch. Otolaryngol. Head Neck Surg. 128 (2002) 1159—1164.