ORIGINAL ARTICLE

Postoperative Complications After

Tonsillectomy and Adenoidectomy
in Children With Down Syndrome
Nira A. Goldstein, MD; Derek R. Armfield, MD; Lawrence A. Kingsley, DrPH;
Lawrence M. Borland, MD; Gregory C. Allen, MD; J. Christopher Post, MD

Objective: To compare the postoperative course and
complications after tonsillectomy or tonsillectomy and
adenoidectomy in children with Down syndrome (group
1) with the postoperative course and complications in
children in a control group (group 2).
Design: Retrospective review of medical records for the
period January 1, 1986, through March 30, 1996.
Setting: Tertiary care children’s hospital.
Patients: The study included 87 children in group 1 and
64 children in group 2 matched for age, sex, and year of
surgery.
children in group 2 (1.6 vs 0.80 days; P=.001, Mann-
Whitney U test). Twenty-two children (25%) in group 1
required airway management or observation in the pedi-
atric intensive care unit compared with no children in
group 2 who required such care (P,.001, Fisher exact
test). None of the children in either group required rein-
tubation, continuous positive airway pressure, or trache-
otomy. Respiratory complications requiring intervention
were 5 times more likely in group 1 (22 [25%] vs 3 [5%];
P,.001, Fisher exact test). The median time until intake
of clear liquids and duration of intravenous therapy were
significantly increased in group 1 compared with group 2
(5.0 vs 4.0 hours, P=.03; 23.5 vs 16.0 hours, P=.001, re-
spectively; Mann-Whitney U test).

Intervention: Tonsillectomy and adenoidectomy Conclusions: Although tonsillectomy and adenoidec-

(group 1, 79 children; group 2, 57 children) and tonsil-
lectomy (group 1, 8 children; group 2, 7 children).
Main Outcome Measures: Length of hospitalization
and postoperative complications.
Results: The length of hospitalization was significantly in-
creased for the children in group 1 compared with that of
tomy can be performed safely in children with Down syn-
drome, the rate of postoperative respiratory complica-
tions is higher and the duration until adequate oral intake
is resumed is longer. We therefore recommend that chil-
dren with Down syndrome be admitted to the hospital over-
night after undergoing tonsillectomy and adenoidectomy.
Arch Otolaryngol Head Neck Surg. 1998;124:171-176

From the Departments of
Pediatric Otolaryngology
(Drs Goldstein, Armfield, Allen,
and Post) and Anesthesiology
(Dr Borland), Children’s
Hospital of Pittsburgh, and the
Departments of Otolaryngology
(Drs Goldstein, Armfield,
Allen, and Post), Infectious
Diseases and Microbiology/
Epidemiology, Graduate School
of Public Health (Dr Kingsley),
and Anesthesiology
(Dr Borland), University of
Pittsburgh School of Medicine,
Pittsburgh, Pa. Dr Post is now
with the Department of
Pediatric Otolaryngology,
Allegheny General Hospital,
Pittsburgh.
D
OWN SYNDROME occurs in
1 in 800 live births and is
the most common autoso-
mal chromosomal disor-
der causing mental retar-
dation.1 Most children with Down syndrome
have trisomy 21 (95%), while 3% to 4% have
an unbalanced translocation for all or part
of chromosome 21. Down syndrome is char-
acterized by aberrant craniofacial features,
including microbrachycephaly, flat occi-
put, short neck, oblique palpebral fissures,
epicanthal folds, Brushfield spots, flat na-
sal dorsum, small low-set auricles, ste-
notic ear canals, prominent furrowed
tongue, and microdontia with fused teeth.
Associated anomalies include congenital car-
diac disease, gastrointestinal disease, hypo-
tonia, delayed growth, developmental de-
lays, hearing loss, cervical spine disorders,
thyroid disease, and obesity.
Upper-airway obstruction and ob-
structive sleep apnea syndrome (OSAS) are
increasingly recognized problems in chil-
dren with Down syndrome.2,3 In fact, OSAS
may contribute to the noncardiac pulmo-
nary hypertension that occurs in these chil-
dren.4,5 Predisposing factors for OSAS in
Down syndrome include midfacial hypo-
plasia; micrognathia;6 narrow nasopharynx;
small oral cavity; macroglossia; relative ton-
sil and adenoid hyperplasia; increased
secretions; hypotonia of the palatal, lin-
gual, and pharyngeal muscles; laryngotra-
cheal abnormalities; and obesity.1,7 There
is an increased incidence of chronic rhino-
sinusitis in children with Down syn-
drome. Recurrent and chronic tonsillitis
also affect these children, as they do other
children.
Tonsillectomy and adenoidectomy
(T&A) may be required in children with
Down syndrome for treatment of upper-
airway obstruction, OSAS, recurrent or
chronic tonsillitis, recurrent peritonsillar
abscesses, dentofacial abnormalities, and,

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METHODS
The medical records of 87 children with Down syn-
drome (group 1) who underwent T&A or tonsillec-
tomy at Children’s Hospital of Pittsburgh, Pittsburgh,
Pa, between January 1, 1986, and March 30, 1996, were
identified by International Classification of Diseases, Ninth
Revision, Clinical Modification8 codes. Of the 87, 64 were
randomly matched for age, sex, and year of surgery with
control patients (group 2) who did not have Down syn-
drome, underwent T&A or tonsillectomy, and were as-
signed an American Society of Anesthesiologists Physi-
cal Status of 1 by the anesthesia service. All medical
records were reviewed to determine the admitting di-
agnosis, more remote and antecedent medical his-
tory, physical examination findings, results of ancil-
lary studies, operative procedure performed, anesthetic
complications, length of hospitalization, respiratory
complications, required medical interventions, time af-
ter the operation until resumption of adequate oral in-
take, duration of intravenous therapy, duration of post-
operative emesis, occurrence of postoperative bleeding,
and the need for readmission. Before 1991, children
were routinely admitted to the hospital for 1 night af-
ter T&A. By matching group 1 and group 2 by the year
of surgery, we accounted for changes in established prac-
tices. All comparisons of dichotomous data were made
with the Fisher exact test, which was especially appro-
priate because of the very low cell size for many of the
232 tables. Continuous variables were compared be-
tween groups by using the Mann-Whitney U test.
rarely, for malignant neoplasms, spontaneous tonsil hem-
orrhage, and refractory halitosis. Because of their mul-
tiple underlying medical problems, especially cardiac dis-
ease, increased incidence of OSAS, and developmental
delays, we suspected that children with Down syn-
drome would have an increased rate of respiratory com-
plications and a more protracted postoperative course.
With increasing economic pressure to perform T&As on
an ambulatory basis, high-risk patients who are inap-
propriate candidates for ambulatory surgery must be as-
certained. Our aim was to perform a review of the post-
operative course and complications after tonsillectomy
or T&A in children with Down syndrome to determine
whether these children are at high risk for postopera-
tive complications.
RESULTS
The demographics of our patient population are given in
Table 1. There were no significant differences in age, sex,
or race in groups 1 and 2. Clinically significant medical his-
tory data for the children are given in Table 2. Forty-two
children in group 1 (48%) had congenital cardiac disease,
with 28 (32%) requiring cardiac surgery compared with
only 1 child in group 2 (2%) with congenital cardiac dis-
ease who did not require cardiac surgery. No child had clini-
cal pulmonary hypertension or congestive heart failure at
the time of adenotonsillar surgery, and all were consid-
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Table 1. Demographics of Children Undergoing
Tonsillectomy With or Without Adenoidectomy*
Characteristics Group 1 Group 2 Total
No. of patients 87 64 151
Mean age (range), y 6.6 (0.92-18.4) 6.1 (1.8-16.6) 6.4 (0.92-18.4)
Male 51 38 89
Female 36 26 62
Race
White 74 59 133
Black 11 5 16
Hispanic 2 0 2
*At Children’s Hospital of Pittsburgh, Pittsburgh, Pa, January 1, 1986,
through March 30, 1996. Children in group 1 had Down syndrome; children
in group 2 did not.
ered, by their cardiologists or pediatricians, to be healthy
enough to undergo surgery. Gastrointestinal disease, hy-
pothyroidism, developmental delay, growth retardation, and
hypotonia were, as expected, relatively common in the chil-
dren in group 1. Only 3 children in group 1 had atlanto-
axial instability. Other otolaryngologic manifestations fre-
quently found in children with Down syndrome, including
chronic otitis media, rhinosinusitis, recurrent croup, sub-
glottic stenosis, and recurrent pneumonia, were also found
in children in group 1. Two children in group 1 had tra-
cheotomies in place; of these, 1 had a history of right vo-
cal cord paralysis and subglottic stenosis and 1 had a his-
tory of choanal atresia and subglottic stenosis.
Of the 151 children in both groups, 136 (90.0%) had
a tonsillectomy and a full or upper-half adenoidectomy
(Table 3). An upper-half adenoidectomy was per-
formed if the child had a submucous cleft palate or bifid
uvula. A tonsillectomy alone was performed in children
with recurrent tonsillitis without obstructive symptoms
or in children who had previously undergone adenoid-
ectomy. Upper-airway obstruction and OSAS were the
indications for surgery in 82 children (94%) in group 1
and 36 children (56%) in group 2.
Of the children in group 1, 80 (92%) had a history
of snoring, and 46 (53%) had a history of nighttime breath-
ing pauses. In group 2, 52 children (81%) also had a his-
tory of snoring, and 15 (23%) had a history of nighttime
breathing pauses. Percentile weights for age at the time
of surgery were comparable between the 2 groups ex-
cept that 18 children (21%) in group 1, but no children
in group 2, weighed less than the 5th percentile for age.
Preoperative nocturnal polysomnograms (NPSGs) were
performed in 7 children (8%) in group 1 and only 1 child
(2%) in group 2. In group 1, 5 studies demonstrated ob-
structive sleep apnea, the results of 1 study were nor-
mal, and the results of 1 study, which had been per-
formed at an outside institution, were not recorded. The
NPSG from the 1 child in group 2 demonstrated obstruc-
tive sleep apnea.
Rigid bronchoscopy was performed in 6 children (7%)
in group 1 (Table 3); of these 6 children, 4 required inter-
val bronchoscopy (2 had tracheotomies, 1 had a history of
subglottic stenosis, and 1 had a history of tracheal steno-
sis), 1 had a history of recurrent croup, and 1 had OSAS
and suspected multilevel airway obstruction that required
 Table 2. Clinically Significant Medical History* Table 3. Diagnosis and Operative Procedure*

No. (%) of Children No. (%) of

Children
Group 1 Group 2
Medical History (n=87) (n=64) Group 1 Group 2
(n=87) (n=64)
Congenital cardiac disease 42 (48) 1 (2)
Ventricular septal defect 29 (33) 0 Diagnosis
Atrial septal defect 26 (30) 1 (2) Obstructive sleep apnea syndrome 31 (36) 4 (6)
Pulmonary hypertension 10 (12) 0 Upper-airway obstruction 38 (44) 20 (31)
Patent ductus arteriosus 4 (5) 0 Recurrent tonsillitis 5 (6) 28 (44)
Pulmonic stenosis 4 (5) 0 Upper-airway obstruction and 13 (15) 12 (19)
Endocardial cushion defect 3 (3) 0 recurrent tonsillitis
Patent foramen ovale 2 (2) 0 Procedure
Other† 8 (9) 0 Tonsillectomy and adenoidectomy 76 (87) 56 (88)
None 45 (52) 63 (98) Tonsillectomy and upper-half 3 (3) 1 (2)
Previous cardiac surgery 28 (32) 0 adenoidectomy
Gastrointestinal disease 9 (10) 1 (2) Tonsillectomy 8 (9) 7 (11)
Duodenal atresia 3 (3) 0 Additional procedures performed during surgery
Gastrointestinal reflux 2 (2) 0 Myringotomy and tube placement 41 (47) 11 (17)
Annular pancreas 1 (1) 0 Direct laryngoscopy and rigid 6 (7) 0
Pyloric stenosis 0 1 (2) bronchoscopy
Hirschsprung disease 1 (1) 0 Direct laryngoscopy, rigid bronchoscopy, 1 (1) 0
Imperforate anus 1 (1) 0 and rigid esophagoscopy
Necrotizing enterocolitis 1 (1) 1 (1) Replacement of gastrostomy tube 1 (1) 0
None 78 (90) 62 (97) Dilatation of choanae 1 (1) 0
Hypothyroidism 10 (12) 0 Orchiopexy 1 (1) 0
Developmental delay 63 (72)‡ 1 (2)
Growth retardation 24 (28)§ 0 *At Children’s Hospital of Pittsburgh, Pittsburgh, Pa, January 1, 1986,
Hypotonia 19 (22)§ 0 through March 30, 1996. Children in group 1 had Down syndrome; children
Atlantoaxial instability 3 (3) 0 in group 2 did not.
Chronic otitis media 67 (77) 24 (38)
Sensorineural hearing loss 15 (17) 4 (6)
anticholinergics, antiemetics, and benzodiazepines. Anti-
Diffuse pulmonary hypoplasia 0 0
Rhinosinusitis 21 (24) 4 (6) biotic prophylaxis for subacute bacterial endocarditis was
Asthma 8 (9) 0 administered to all children with congenital cardiac dis-
Seizure disorder 4 (5) 2 (3) ease. This study included medical records for operations
Recurrent croup 5 (6) 0 performed before the routine use of intraoperative corti-
Subglottic stenosis 3 (3) 0 costeroids to prevent oropharyngeal edema and shorten the
Tracheal stenosis 1 (1) 0
time until oral intake is resumed.
Previous tracheotomy\ 2 (2) 0
Recurrent pneumonia 6 (7) 0
Choanal atresia 1 (1) 0 INTRAOPERATIVE COURSE
Leukemia¶ 2 (2) 0
Congenital left hemiparesis 1 (1) 0 Data about the treatment and hospital course for the chil-
Histiocytosis X 0 1 (2) dren studied are given in Table 4. There were no sig-
nificant differences in operative or anesthesia time be-
*At Children’s Hospital of Pittsburgh, Pittsburgh, Pa, January 1, 1986,
through March 30, 1996. Children in group 1 had Down syndrome; children
tween groups. The estimated amount of intraoperative
in group 2 did not. Column totals exceed 87 for group 1 and 64 for group 2 blood loss was significantly higher in group 2.
because a child could have more than 1 disorder. Anesthetic complications occurred in 7 children (8%)
†One child each with mitral valve prolapse, mitral insufficiency, cleft mitral in group 1 compared with none in group 2 (P=.02). The
valve, tricuspid insufficiency, aortic insufficiency, double aortic arch, aberrant
subclavian artery takeoff, and Wolff-Parkinson-White syndrome. complications were all respiratory, and the most com-
‡Not evaluable from the medical records of 19 children (22%). mon complication was postextubation stridor. The in-
§Not evaluable from records of 51 children (59%). dication for surgery for all 7 children with anesthetic com-
\One child with right vocal cord paralysis after cardiac surgery and
subglottic stenosis and 1 child with choanal atresia and subglottic stenosis.
plications was OSAS or upper-airway obstruction. None
¶One child with mixed myelogenous leukemia and 1 child with acute had preoperative cardiac or pulmonary disease, and none
lymphocytic leukemia; both were in remission. had a history of recurrent croup or subglottic stenosis.
Three of the 4 children with postextubation stridor were
complete airway evaluation. One child in group 1 with sus- intubated with an endotracheal tube of the appropriate
pected gastroesophageal reflux disease underwent bron- size for age as calculated by a standard formula,9 while
choscopy and esophagoscopy at the time of the T&A. Ton- the endotracheal tube size used for 1 child was not re-
sillectomies were performed by electrocautery dissection corded in the anesthetic record. An endotracheal tube of
in 143 children (94.7%), while blunt and sharp dissection the appropriate size should allow some leaking around
were used in the remainder. Adenoidectomy was per- the tube at 20 to 25 cm of water of airway pressure. Re-
formed by curettage. The anesthetic technique was vari- sults of a gas leak test were recorded in only 1 anes-
able, but children received a combination of inhalational thetic record. One child with postextubation stridor had
agents, opioid or barbiturate narcotics, muscle relaxants, undergone bronchoscopy and esophagoscopy for evalu-

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 Table 4. Treatment and Hospital Course of Children Undergoing Tonsillectomy With or Without Adenoidectomy*

Group 1 (n=87) Group 2 (n=64) P

Intraoperative period
Operative time, mean±SD, median (range), min 39.8±19.0, 35.0 (6.0-120.0) 37.1±14.7, 34.0 (9.0-86.0) .72
Anesthesia time, mean±SD, median (range), min 72.9±22.5, 65.0 (35.0-155.0) 67.9±18.6, 65.0 (35.0-130.0) .28
Anesthetic complications, No. (%)
Postextubation stridor 4 (5) 0 .11
Upper-airway obstruction 2 (2) 0 .33
Laryngospasm 1 (1) 0 .58
Apnea 1 (1) 0 .58
Total† 7 (8) 0 .02
Estimated blood loss, mean±SD, median (range), mL 31.9±30.3, 20.0 (0.0-150.0) 54.8±54.2, 40.0 (0.0-225) .02
Hospital stay
Length of hospital stay, mean±SD, median (range), d 1.6±1.5, 1.0 (0.0-10.0) 0.80±0.88, 1.0 (0.0-6.0) .001
No. (%) admitted to pediatric intensive care unit 22.0 (25) 0 ,.001
Length of intensive care unit stay, mean±SD, median (range), d‡ 1.4±1.1, 0 (0.0-5.0) ... ...
No. (%) discharged from same-day surgery unit 4.0 (5) 22.0 (34) ,.001
Postoperative period, mean±SD, median (range), h
Duration of intravenous therapy 27.8±23.1, 23.5 (0.0-142.0) 15.3±11.4, 16.0 (0.0-49.0) .001
Time until intake of clear liquids 9.0±15.6, 5.0 (1.0-119) 8.0±25.1, 4.0 (1.0-200.0) .03
Duration of intravenous morphine sulfate administration 1.4±8.1, 0 (0.0-72.0) 0.35±1.5, 0 (0.0-9.0) .75
Time until out of bed 16.1±17.2, 14.0 (1.0-135.0) 10.0±8.8, 6.0 (1.0-30.0) .004
Duration of postoperative emesis 3.2±6.2, 0 (0.0-27.0) 2.3±4.3, 0 (0.0-24.0) .84
Readmission, No. (%)
Patients readmitted for treatment of dehydration 4 (5) 2 (3) .49
Patients readmitted for treatment of bleeding 3 (3) 1 (2) .43
Total 7 (8) 3 (5) .32
No. (%) of patients with postoperative bleeding 4 (5) 1 (2) .29

*At Children’s Hospital of Pittsburgh, Pittsburgh, Pa, January 1, 1986, through March 30, 1996. Children in group 1 had Down syndrome; children in group 2
did not.
†Total equals 7 because 1 child had stridor and upper-airway obstruction.
‡Ellipses indicate not applicable.

ation of gastroesophageal reflux at the time of the T&A.
All anesthetic complications were successfully man-
aged with supplemental oxygen, positioning of the child,
positive pressure ventilation, nebulized racemic epineph-
rine, intravenous corticosteroids, or naloxone hydro-
chloride. Two of the 7 children were admitted to the pe-
diatric intensive care unit (PICU) for 1 night after surgery,
and all but 1 were hospitalized for 1 or 2 nights. The con-
dition of 1 child with postextubation stridor responded
to nebulized racemic epinephrine, and the child was dis-
charged from the same-day surgery unit.
HOSPITAL STAY
The length of hospitalization was significantly longer in
group 1 than in group 2. A significantly higher number
of the children in group 1 (25%) required either airway
management or observation in the PICU compared with
the children in group 2. The mean±SD length of stay in
the PICU was 1.4±1.1 days. Of the 22 children admitted
to the PICU, 11 (50%) were electively admitted for ob-
servation, while 11 (50%) required admission because
of intraoperative or postoperative complications. Signifi-
cantly more children in group 2 than in group 1 were
discharged from the same-day surgery unit.
POSTOPERATIVE COURSE
Recovery from incisional pain was longer in group 1 than
in group 2. The median duration of intravenous therapy,
median time until intake of clear liquids, and median time
until out of bed were all significantly longer in group 1 than
in group 2. The mean duration of intravenous morphine
sulfate administration and mean duration of postopera-
tive emesis were also longer in group 1, but the differ-
ences were not statistically significant. Although there was
an increased rate of readmission for the treatment of de-
hydration in children in group 1, the difference was not
statistically significant. No significant difference was found
in the rate of postoperative bleeding between the 2 groups.
RESPIRATORY COMPLICATIONS
The occurrence of the postoperative respiratory complica-
tions of upper-airway obstruction and arterial oxygen de-
saturation to less than 90% was significantly more frequent
in group 1 than in group 2(Table 5). The mean±SD num-
ber of oxygen desaturations to less than 90% per child was
4.1±6.6 (range, 1.0-30.0; P,.001). Oxygen desaturation to
less than 70%, hypoventilation, and bradycardia occurred
infrequently in both groups. Respiratory complications re-
quiring intervention occurred significantly more often in
group 1 than in group 2. The most frequent interventions
were supplemental oxygen therapy, positioning of the child,
the insertion of a nasal airway, treatment with nebulized
racemic epinephrine, and administration of intravenous cor-
ticosteroids. In group 1, the mean±SD duration for various
interventionswasasfollows:supplementaloxygen,25.7±35.7
hours (range, 1.0-120.0 hours); positioning, 9.7±10.7 hours
(range, 1.0-43.0 hours); and nasal airway placement,

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10.4±17.1 hours (range, 1.0-48.0 hours). One child in group
1 remained intubated for 19.0 hours after surgery, but this Table 5. Postoperative Respiratory Complications and
elective intubation was planned preoperatively. No child Interventions Required for Children Undergoing
Tonsillectomy With or Without Adenoidectomy*
in either group required reintubation, continuous positive
airway pressure, or tracheotomy during the postoperative
No. (%) of Children
period. Of the children in group 1 with respiratory com-
plications, mean±SD hospital stay was 2.4±2.7 days (range, Group 1 Group 2
0.0-10.0 days), with 11 children requiring admission to the (n=87) (n=64) P
PICU for a mean±SD of 1.8±1.5 days (range, 1.0-5.0 days). Complication
Only 1 child in group 1 required continued intervention Upper-airway obstruction 15 (17) 3 (5) .01
once discharged from the hospital. Because of persistent ob- Oxygen desaturation, between 19 (22) 0 (0) ,.001
71% and 90%
struction and arterial oxygen desaturation documented by Oxygen desaturation, ,70% 1 (1) 0 (0) .58
NPSG 6 days after T&A, a 6-year-old girl required home Hypoventilation 1 (1) 2 (3) .39
nighttime supplemental oxygen therapy for 1 month un- Bradycardia 0 (0) 0 (0) ...
til her symptoms resolved. Intervention required
A total of 24 children in group 1 required interven- Supplemental oxygen 19 (22) 3 (5) .002
tion for anesthetic or postoperative respiratory complica- Positioning 21 (24) 3 (5) ,.001
Nasal airway insertion 10 (12) 0 (0) .003
tions because 5 of these children exhibited both types of Racemic epinephrine nebulizer 7 (8) 0 (0) .02
complications. These children did not constitute a younger Intravenous corticosteroids 5 (6) 0 (0) .06
group; the mean±SD age was 5.8±3.5 years (range, 2.0- Albuterol sulfate nebulizer 1 (1) 0 (0) .58
14.7 years). No significant differences were found in sex, Reintubation 0 (0) 0 (0) ...
race, admitting diagnosis, surgical procedure, medical his- Continuous positive 0 (0) 0 (0) ...
tory, obstructive symptoms, or results of preoperative stud- airway pressure
Tracheotomy 0 (0) 0 (0) ...
ies between these 24 children and the entire group 1. Total† 22 (25) 3 (5) ,.001

*At Children’s Hospital of Pittsburgh, Pittsburgh, Pa, January 1, 1986,

COMMENT
Our results demonstrated that children in group 1 had a sig-
nificantly higher rate of postoperative complications com-
pared with children in group 2 after T&A or tonsillectomy.
The respiratory complications of acute upper-airway ob-
struction, arterial oxygen desaturation, and postextubation
stridor occurred frequently in children in group 1. Twenty-
two (25%) children in group 1 were admitted to the PICU,
half electively for observation and half because of periop-
erativerespiratory complications, while no children ingroup
2 required admission to the PICU. The children in group
1 experienced significant delay in resuming postoperative
oral intake. The need for care in the PICU and the delay in
resuming oral intake significantly lengthened the hospital
stay for children in group 1.
Children with Down syndrome have multiple predis-
posing factors for the development of complications after
tonsil and adenoid surgery. The high incidence of OSAS
in the children with Down syndrome places the children
at a higher risk for postoperative respiratory compromise.
McColley et al10 reported that in 23% of children with poly-
somnographically proved OSAS, severe respiratory com-
promise developed after T&A and required intervention;
the respiratory compromise involved intermittent or con-
tinuous oxygen saturation of 70% or less, hypercapnia, or
both. Rosen et al11 reported that in 27% of children with
OSAS documented by NPSG, postoperative respiratory com-
promise developed after tonsillectomy, adenoidectomy, or
both, with symptoms ranging from oxygen desaturation to
less than 80% to respiratory failure. At our institution, chil-
dren with obstructive symptoms do not routinely have a
preoperative NPSG. The prevalence of OSAS in our study
groups is unknown because only 7 children in group 1 and
1 in group 2 underwent an NPSG. Yet, according to pa-
rental reports, more than 90% of the children in group 1
through March 30, 1996. Children in group 1 had Down syndrome; children
in group 2 did not. Ellipses indicate not applicable.
†The total is less than the sum of individual interventions because some
children required multiple interventions.
snored and more than 50% had a history of nighttime
breathing pauses.
The midfacial and mandibular hypoplasia, narrow
nasopharynx, macroglossia, increased secretions, and hy-
potonia associated with Down syndrome contribute to
upper-airway obstruction, especially after the induction
of anesthesia. Intubation and airway management may
be difficult because of the craniofacial abnormalities and
associated laryngotracheal abnormalities. The preven-
tion of hyperextension and hyperflexion during laryn-
goscopy, intubation, and surgical procedures is impor-
tant because of the high incidence of atlantoaxial
instability.12 Children with Down syndrome often have
elevated pulmonary vascular resistance in response to car-
diac disease or hypoxemia secondary to upper-airway ob-
struction. Abnormal central nervous system control of
breathing has been demonstrated in children with Down
syndrome and contributes to the occurrence of sleep ap-
nea.4 As demonstrated by our study, children with Down
syndrome have a high incidence of lower and upper res-
piratory infections, which contribute to perioperative res-
piratory compromise.
Children with Down syndrome have a higher inci-
dence of laryngotracheal stenosis than the general popu-
lation. Jacobs et al13 found laryngeal or tracheal stenosis
in 2% of 518 children with Down syndrome. Miller et
al14 found that children with Down syndrome repre-
sented a high proportion (4%) of the children undergo-
ing laryngotracheal reconstructions at their institution.
Sherry15 reported that postextubation stridor developed
in 38% of the children with Down syndrome after car-

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diac surgery, and de Jong et al16 reported that postextu-
bation stridor developed in 33% after cardiac surgery, with
a 6% incidence of subglottic stenosis. In the present study,
a 5% incidence of postextubation stridor was found af-
ter adenotonsillar surgery, even though endotracheal tubes
of the appropriate size were used. Care must be taken to
use an endotracheal tube of the appropriate size or smaller
than would be expected for age in children with Down
syndrome because these children are often smaller than
expected for age, their airways may be smaller, and they
may have unsuspected laryngotracheal stenosis. The
proper size should be confirmed by a gas leak test.
Previous studies have documented postoperative res-
piratory difficulty in children with Down syndrome. Bei-
lin et al17 reported that in 9 (14%) of 63 children with
Down syndrome undergoing facial reconstruction, post-
operative respiratory compromise developed; 5 re-
quired insertion of a nasal airway to maintain airway pa-
tency, and 3 with stridor and 1 with subglottic stenosis
required reintubation. Kobel et al18 reported that 13 (13%)
of 100 children with Down syndrome undergoing gen-
eral anesthesia for a variety of procedures had postop-
erative respiratory compromise; of these children, 10 had
difficulty maintaining an airway, 2 had postextubation
stridor, and 1 had marked respiratory depression.
In addition to postoperative respiratory complica-
tions, the children with Down syndrome in our study had
a significantly increased time until the resumption of oral
intake. Delayed postoperative oral intake, in addition to de-
hydration due to preoperative fasting and operative blood
loss, could contribute to perioperative discomfort and mor-
bidity, especially in small children with limited fluid re-
serves. Dehydration in the rare case is also life threaten-
ing. Delays in the resumption of adequate oral intake have
been reported in very young children undergoing T&A.19,20
Children with Down syndrome who are prematurely dis-
charged from the hospital after T&A, before the resump-
tion of adequate oral intake, are at risk for dehydration.
Several reviews of postoperative complications after
T&A have documented an increased rate in subsets of chil-
dren with additional medical conditions. Richmond et al21
reported that of 784 children undergoing tonsillectomy, ad-
enoidectomy, or both, 26 had Down syndrome, other types
of congenital disorders, cerebral palsy, seizures, or mental
retardation. Of the 26 children, 7 (27%) had a major res-
piratory complication involving admission to the PICU, in-
sertion of a nasal airway, or reintubation compared with
10 (1.3%) of the entire group. Tom et al20 found an in-
creased incidence of postoperative airway obstruction in
40 children with Down syndrome, other craniofacial anoma-
lies, cardiac disease, failure to thrive, or pulmonary dis-
ease. Gerber et al22 reported that the risk for respiratory com-
promise involving oxygen desaturation to less than 90%,
an obstructive breathing pattern, or respiratory distress that
occurred more than 2 hours after surgery and required in-
tervention was 8 times greater in 9 children with chromo-
somal anomalies and nearly 5 times greater in 9 children
with neuromuscular disorders.
Our review of the medical records of 87 children with
Down syndrome and 64 children in a control group dem-
onstrated that after T&A, children with Down syn-
drome are at significantly increased risk for postopera-
ARCH OTOLARYNGOL HEAD NECK SURG/ VOL 124, FEB 1998
176
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©1998 American Medical Association. All rights reserved.
tive respiratory complications and delayed resumption
of oral intake. Although T&A can be performed safely
in children with Down syndrome, we recommend inpa-
tient hospitalization with overnight measurement of pulse
oximetry and intravenous hydration until the resump-
tion of adequate postoperative oral intake. Observation
in an intensive care setting with capabilities for cardio-
pulmonary resuscitation and intubation should also be
considered for children with Down syndrome and sus-
pected OSAS, because these children are at risk for acute
upper-airway obstruction, arterial oxygen desaturation,
and respiratory failure.
Accepted for publication August 1, 1997.
Presented at the annual meeting of the American So-
ciety of Pediatric Otolaryngology, Scottsdale, Ariz, May 15,
1997.
We thank Susan Strelinski for assistance with data entry.
Reprints: Nira A. Goldstein, MD, Department of Pe-
diatric Otolaryngology, Children’s Hospital of Pittsburgh,
3705 Fifth Ave, Pittsburgh, PA 15213.
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