Alasdair Robertson MRCS, Research Fellow in ENT, Leicester Royal Infirmary, Leicester
Bill Wallace, Clinical Audit Department, Royal Alexandra hospital, Paisley
Aileen White FRCS, Consultant Otolaryngologist, Royal Alexandra Hospital, Paisley
Correspondence to: alasdair@robertsonz.freeserve.co.uk
SMJ 2004 49(3): 70
Abstract
Objective : To assess the practice of tonsillectomy in Inverclyde and Renfrewshire area of Argyll and Clyde Health Board.
Design : an audit
Setting : Royal Alexandra Hospital, Paisley
Subjects : all patients undergoing tonsillectomy were prospectively audited over a four year period. Information audited included: age, sex, length of stay, operator grade, complications, readmissions and prophylactic antibiotic use.
Results : 1582 cases were audited. 64% were women. The mean age of the patients was 16. 76% of patients were discharged on the first post operative day. The majority of operations were carried out by staff grades and associate specialists. The primary complication rate was very low (1.33%). 3% of patients were readmitted, mostly because of secondary haemorrhage. Prophylactic post operative antibiotics were used in 39% of cases.
Conclusions: it is safe to discharge patients on the first day post tonsillectomy, even if they live some distance from the hospital. Prophylactic post operative antibiotic use does not decrease the rate of readmission. Tonsillectomy is carried out safely in Argyll and Clyde.
Introducution
Tonsillectomy is one of the most commonly performed elective operations performed in the UK and accounts for 20% of all operations performed by otolaryngologists (1). The main indication for tonsillectomy is recurrent tonsillitis although it can also be performed for obstructive sleep apnoea in children and for diagnosis of tonsillar malignancies as well as part of an uvulopalatopharyngoplasty operation for snoring.
The operation is associated with significant morbidity, primary and secondary haemorrhages being the most dangerous complications of this procedure. The tonsillectomy practice in Inverclyde and Renfrewshire districts of the Argyll and Clyde Health board area was audited prospectively, over a four-year period (from1996-2000) with particular regard to complications of surgery.
Argyll and Clyde Health Board area has a population of 423,500, and covers 2,880 square miles (2). Argyll and Clyde is a region of contrasts. It comprises of rural and urban areas, mainland and island locations and has areas of affluence and of considerable deprivation. The ENT service for the Inverclyde and Renfrewshire districts of Argyll and Clyde (population 360,000) is provided by Inverclyde Royal Hospital, the Royal Alexandra hospital and out reach clinics. Inpatient ENT for Inverclyde and Renfrewshire districts is based in the Royal Alexandra hospital in Paisley, and it was this service, which was examined.
AIM
The aim of this study was to examine the practice and safety of tonsillectomy in the Inverclyde and Renfrewshire Districts of the Argyll and Clyde Health Board area.
Method
All tonsillectomies carried out at the Royal Alexandra Hospital in Paisley between March 1996 and February 2000 were audited prospectively. A proforma was completed at the time of surgery on all patients undergoing a tonsillectomy including those patients who also had other procedures at the same time, e.g. adenoidectomies and palatoplasties. Post operative complications were also noted on this form. Data pertaining to management on readmission following discharge for a complication of tonsillectomy was also recorded on this data form. The data was collated when the period of the study had finished. To ensure completeness of the Dataset, cross checking with admission and readmission patient lists ensured that no patient who had undergone tonsillectomy was excluded from this audit.
Results
General data
A total of 1582 tonsillectomies were performed over the four-year period. Men accounted for 36% of the cases and women 64%. The age of the patients varied between 2 and 73 years old. The mean age was 16, the median 15 and the mode was 5 (106 patients in the mode group).
Length of stay
Most patients were discharged home on the day following their tonsillectomy: 1206 (76%) went home on day one, 291 patients (18%) on day 2 and 45 on the third day post tonsillectomy (TABLE 1). The longest stay was for one patient who went home 6 days after the tonsillectomy. The mean number of days post operation that patients were discharged was 1.26.
Operator grade
Consultants performed 347 of the tonsillectomies (24%), 828 (57%) were performed by staff grades or associate specialists and 285 (19%) by junior surgeons (registrars and SHO’s).
Primary Complications
A total of 35 patients (1.33%) had some form of complication in the 24 hours after the operation. Primary haemorrhage accounted for 21 of the complications. The non-haemorrhagic complications are listed in TABLE 2.
17
of the primary haemorrhages were from the tonsillar fossae and 4 from adenoids.
6 of the tonsillectomy bleeds and 1 of the adenoid bleeds were taken back to
theatre.
Readmissions
47 patients (3%) required readmission to hospital, 4 patients were readmitted twice. The commonest cause for readmission was secondary haemorrhage (42 patients, 2.65%), 3 patients were readmitted with pain and fever and 2 had fever and a rash. Conservative treatment (antibiotics and rehydration) was effective in 35 patients with a secondary haemorrhage, but 8 (0.5% of all tonsillectomies) had to return to theatre and 3 required blood transfusions. The number of days post discharge for the readmissions were between 1 and 16 days with the average being 5.63 days post discharge (TABLE 3). The patients who were readmitted for non haemorrhagic complications were readmitted earlier than the patients with secondary haemorrhages with the average day post discharge of readmission being 1.8 and 6.0 days respectively.
Post-operative antibiotics
Postoperative oral antibiotics were used for prophylaxis against secondary infection in 613 (39%) of our patients. Secondary infection post tonsillectomy is thought to be the cause of secondary haemorrhage. We therefore looked to see if the use of post op antibiotics was effective in preventing secondary haemorrhage and readmissions. We found no difference in the incidence of secondary haemorrhages, with 2.8% of the antibiotic group and 2.6% of the non-antibiotic group having bleeds TABLE 4. There did not appear to be any difference in the readmission rates between the antibiotic and non-antibiotic groups (3.1% and 2.9 % respectively).
Discussion
This study is a prospective audit, which because of its long time span contains a large number of patients. The following points highlighted by the data were felt to be of interest.
The tonsillectomy patients were usually discharged on the first post operative day, however patients from the remote parts of the health board, requiring aeroplane or ferry transport to home, were routinely kept in an extra day post-tonsillectomy. Patients from these remote areas therefore account for most of the patients staying in for two days post operation. However only 4 (0.25%) patients needed to be readmitted on the day after discharge from hospital and only one of these was for a secondary haemorrhage, therefore the policy of an extra night stay for distant patients benefits only a very small number of them. The patients with complications arising during the initial admission were also kept in longer. From the audit data, the unit’s discharge policy appears to have worked well as the readmission rate was low (3%).
Some units have promoted Day case tonsillectomy, but its use is dependant upon favourable population characteristics. A recent publication from a large urban Scottish unit (3) found that only 27% of patients fitted the criteria for day case tonsillectomy. Day case tonsillectomy is not offered in the area served by this unit because of the distances involved in travelling to the inpatient site for a majority of the patients in this far flung area.
Staff grades and associate specialists performed most of the tonsillectomies. A previous audit of tonsillectomies in Scotland (1) found that it was mostly consultants and senior registrars performing tonsillectomies. The increase in tonsillectomies performed by middle grades in this study reflects their growing importance in service commitments in the NHS.
The
rate of primary complications in this study is remarkably low and compares
favourably with previously reported series (1,4,5). Only seven patients had to
be taken back to theatre in the immediate post operation period (0.4%).
Readmission after tonsillectomy was found to be relatively uncommon (3%). The
vast majority of readmissions were for secondary haemorrhages. The peak days for
readmission were from 3-8 days post discharge, which equates to 4-9 days post
tonsillectomy. Secondary haemorrhage is caused by a secondary bacterial
infection that develops in the raw surface of the tonsillar fossae. This post
operative infection take about one week to develop from inoculation to clinical
infection and this explains the peak of secondary haemorrhages at 6 days post
discharge. Most secondary haemorrhages were treated conservatively (83%). Blood
transfusion or surgical interventions to achieve arrest
of haemorrhage were rarely required.
Prophylactic antibiotic post tonsillectomy was initially thought to decrease the amount of post operative discomfort, fever and secondary haemorrhage (6), however this theory has fallen out of favour as more recent studies have showed no benefit in prophylactic antibiotic use (8). We did not measure post operative pain in our patients, but the rate of secondary haemorrhage was not affected by the use of prophylactic antibiotics.
As expected, in view of the mortality rate from tonsillectomy, no mortalities occurred in the period of this study.
Recently there have been controversies of disposable instruments. The standard sterilising process for instruments does not kill the BSE prions. BSE prions have been identified in tonsillar tissue and therefore there is a theoretical risk of contamination. Disposable instruments were introduced to combat this risk, however there may have been an increase in secondary haemorrhage with their use. The use of disposable instruments has been suspended in England and Wales but in Scotland their use is compulsory. Our study was carried before the introduction of the disposable instruments and it shows that the practice with the non-disposable instruments was safe. We are currently repeating the audit on tonsillectomies carried out with disposable instruments and will be able to compare the new practice with the old once completed.
Conclusions And Actions
The practise of keeping patients from far flung regions in for 2 days post tonsillectomy was initiated in order that if the patients experienced any complications on the second post operative day, they would not have to travel a long way for treatment. Given that only 0.25% of patients require readmission on the second day post tonsillectomy, and that the peak for readmissions was 5.63 days post discharge, this policy does not seem to make any sense and should be discontinued.
Routine antibiotic use post tonsillectomy is another contentious issue. This was not a randomised trial of prophylactic antibiotics and the antibiotics were prescribed purely on the surgeon’s preference, so definite conclusions cannot be drawn from this data. The ENT department feels that, although the scientific basis of the audit of antibiotic prophylaxis may be flawed, the number of patients is large and has therefore discontinued the use of post operative antibiotic prophylaxis.
Overall we have found that tonsillectomy in the Inverclyde and Renfrewshire districts of the Argyll and Clyde Health board area is a common procedure which is performed safely with minimal risks of post operative complications.
References
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Argyle and Clyde Health Board website. http://www.show.scot.nhs.uk/achb/index.htm
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Telian HA, Handler SD, Fleischer GR, Baranak CC, Wetmore RF, Patsic WP. The effect of antibiotic therapy on recovery after tonsillectomy in children, a controlled study. Archives of Otolaryngology – Head and Neck Surgery. 112(6):610-5 1986
Lee WC, Duignan MC, Walsh RM, McRae-Moore JR. An audit of prophylactic antibiotic treatment following tonsillectomy in children. Journal of Laryngology and Otology. 110(4):357-9 1996