Patients who require urgent tonsillectomy without or with adenoidectomy (TA) tend to be younger, have elevated obstructive apnea-hypopnea indices, and more persistent desaturations below 80% than children who receive timely TA. Their desaturations also tend to be unresponsive to supplemental oxygen. After surgery, approximately half of children who receive urgent TA will no longer require supplemental oxygen because of a dramatic improvement in gas exchange.

Conan Liang, BA, from the University of Colorado School of Medicine in Aurora, and colleagues published the results of their retrospective medical record review online January 2 in JAMA Otolaryngology–Head & Neck Surgery. They report that at their institution, pediatric patients who receive urgent TA (n = 35) resemble those who meet hospital admission criteria for bronchiolitis. In particular, the decision to perform urgent TA was typically (85% of the time) based on persistent desaturation below 80% despite receipt at least 0.5 L of oxygen.

Patients receiving urgent TA had an average age of 3.8±2.1 years compared to the 6.6±4.2 years seen in the control group. Patients in the urgent TA group had average apnea-hypopnea indices of 39.4 events per hour.

TA is considered a relatively safe procedure with a low incidence of postoperative complications. Results from the current study are consistent with this, and the authors report that 94% of patients had a favorable postoperative course. The authors acknowledge, however, that that their hospital had a low (26%) follow-up rate for postoperative polysomnography.

The authors did not find an increased number of pulmonary comorbidities in the urgent TA cohort compared with the control cohort. This finding led the authors to suggest that children in the urgent TA group may have had subclinical findings that predisposed them to developing hypoxemia.

Urgent vs Timely TA
As more polysomnographies are performed, an increasing number of children are likely to be diagnosed with severe obstructive sleep apnea (OSA) with gas exchange abnormalities. The severity of OSA is correlated with adenotonsillar hypertrophy, and so, not surprisingly, TA is commonly performed in response to sleep-related breathing disorders.

OSA is now understood, however, to be a chronic as opposed to an acute condition, suggesting that it may not require urgent treatment. The study underscores that there are no clearly defined indications for urgent TA in the pediatric population.