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There are many uncertainties in the medical process itself. Whether the failure of the operation is related to the medical operation itself and how much responsibility the doctor has, all require subsequent medical appraisals to determine. Before the final results come out, no conclusion can be drawn.

Written by | Yan Xiaoliu, Ling Jun

Today, the news that "10-year-old girl died during minimally invasive tonsil surgery" became a hot topic.

According to reports from Red Star News and other media, a mother posted a video saying that her 10-year-old daughter underwent a minimally invasive tonsillectomy and adenoidectomy in the hospital at noon on August 6. At around 17:00, the parents were called into the operating room to "see their child for the last time."

Surgeon @蓝梅博士, who is certified as one of the "Top Ten Influential Health and Medical Celebrities of 2019-2021" on Weibo, pointed out in a post that tonsillectomy is actually very risky. He claimed that he had conducted legal appraisals on two children who died after tonsillectomy, both of which were related to postoperative bleeding.

Medical World found that such tragedies have also been reported abroad. In 2006 and 2007, Austria reported five children under the age of six who died of severe bleeding after tonsillectomy. In June this year, a children's hospital in Canada reported two similar deaths in succession. Subsequently, the hospital suspended elective tonsillectomy and adenoids removal for patients under the age of 18 out of caution.

"Any surgery is a traumatic treatment. Bleeding during surgery is generally related to the human anatomical structure, including whether there are blood vessels or important organs around the surgical site. Although the occurrence of complications is only a matter of probability, objective risks always exist." Professor Wang Yu, chief physician of head and neck surgery at the Affiliated Cancer Hospital of Fudan University, told "Medical World".

Do I need to have my tonsils removed if I snore while sleeping?

"Red Star News" quoted the child's mother as saying that the girl in question sometimes snored when she slept, and she suspected that she had swollen tonsils, so she was taken to the hospital for examination and underwent a tonsillectomy.

With the widespread media coverage, one of the most discussed details is: Is minimally invasive tonsillectomy considered a "minor surgery"? Should it be removed if you snore while sleeping?

In 2021, the Journal of Clinical Otolaryngology and Head and Neck Surgery published my country's "Clinical Practice Guidelines", stating that low-temperature plasma radiofrequency ablation is the mainstream minimally invasive method for the removal of tonsils and adenoids in children. This technology has been used in my country for more than 10 years, and its advantages are precise removal and low bleeding.

"This is one of the most common surgeries in the otolaryngology department," the Department of Otolaryngology-Head and Neck Surgery at the Affiliated Hospital of Yangzhou University once wrote. According to media reports in July this year, some hospitals perform 300 tonsillectomies on children each year, and summer vacation is usually the peak period for surgery. In the United States, there are about 300,000 outpatient-related surgeries on children aged 15 or younger each year.

Details such as the duration of the operation also indicate that the operation is relatively easy. According to a 2023 article in "Healthy Chengdu", a simple adenoids ablation operation takes about 10 minutes. If tonsillectomy is also included, it takes about 30 minutes.

A search on the "Medical World" website found that my country, the United Kingdom, the United States, France and other countries all have detailed and clear clinical practice guidelines for related surgical indications. The unified recommendation is that when excessive hypertrophy of adenoids and tonsils leads to moderate to severe obstructive sleep apnea syndrome (OSA) in children, surgical resection is the first choice for treatment.

The aforementioned article in the Journal of Clinical Otolaryngology-Head and Neck Surgery believes that if OSA is not detected and intervened early, it will lead to a series of serious complications, such as neurocognitive damage, learning disabilities, growth and development retardation, maxillofacial abnormalities, endocrine and metabolic disorders, pulmonary hypertension, and even an increased risk of cardiovascular events in adulthood.

However, there has been controversy in clinical practice about how to judge the severity of OSA.

In 2019, the American Academy of Otolaryngology-Head and Neck Surgery updated the clinical practice guidelines for pediatric tonsillectomy, clearly stating that polysomnography (PSG) should be performed before surgery to confirm the indications and appropriateness of surgical resection and reduce unnecessary surgery. The guidelines also stated that for recurrent throat infections, "watchful waiting" is strongly recommended rather than surgery as soon as possible.

The "Guidelines for the Diagnosis and Treatment of Obstructive Sleep Apnea in Chinese Children (2020)" also emphasizes and highlights the status of PSG, and states that it is not recommended to use indicators such as tonsil size to grade the severity of OSA. However, in relevant popular science articles published by some children's specialized hospitals in my country, if the degree of tonsil hypertrophy reaches Ⅲ° or above, causing obvious narrowing of the pharynx, causing snoring and mouth breathing, surgical removal is recommended.

"In China, PSG is still not widely used before surgery due to factors such as economic costs. Clinicians tend to use the results of laryngoscopy or AP and lateral head and neck radiographs as the basis for diagnosis, and determine whether to perform surgery based on the morphology of tonsils or adenoids." This is how a document interprets the 2019 American version of the Children's Tonsillectomy Guidelines.

The mother of the deceased girl said that the doctor believed that her child had enlarged tonsils and adenoids through adenoids films and recommended removing them together.

Bleeding after tonsillectomy and adenoidectomy is not uncommon

Why does tonsillectomy lead to severe bleeding? This is another issue that has attracted widespread public attention after the above incident.

A large number of literatures show that postoperative bleeding after tonsillectomy is one of the common complications of surgery, accounting for 1/3 of all postoperative complications. In theory, the older the age, the higher the rate of postoperative bleeding. Some studies have shown that age > 6 years old is a risk factor for postoperative bleeding in children. In addition, the postoperative bleeding rate in adults is 8.6%-14.5%, much higher than the 2.1%-5% in those under 12 years old. The incidence in men is often higher than that in women.

Wang Yu told the Medical World that this is because the area where the tonsils are located has a rich blood supply and multiple arteries supply blood. At the same time, since the wound after tonsillectomy cannot be sutured, it relies on the body's own scar tissue to repair. After the operation, the patient's eating, strenuous exercise, or high blood pressure may cause "secondary damage" to the wound and induce bleeding.

The "Advances in Risk Factors and Preventive Measures for Postoperative Bleeding after Tonsillectomy" states that surgical indications and techniques can also affect the postoperative bleeding rate. Children with recurrent infections are more likely to bleed than those who undergo tonsillectomy for OSA. This may be because recurrent infections, inflammatory stimulation, and scarring can aggravate surgical trauma.

Wang Yu said that generally more serious bleeding is common after surgery for oropharyngeal malignant tumors. At this time, the scope of tonsillectomy is large and sometimes involves larger blood vessels. There have also been reports of sudden massive bleeding one week after surgery. The corresponding measures are mainly tracheotomy to expose the trachea. In this way, even if the patient bleeds, ventilation can still be maintained and suffocation due to blood blockage will not occur.

"For tonsillitis, tonsil hypertrophy and other reasons, severe bleeding generally does not occur during surgery. Even if it does occur, electric knife, ultrasonic knife and some anticoagulant drugs can be used to stop bleeding." Wang Yu explained that the relevant hemostasis methods are very mature. After the operation, medical staff will provide detailed rehabilitation guidance to patients, including the need to fast for a period of time.

In 2013, the Austrian Society of Otolaryngology, Head and Neck Surgery and Pediatrics published a multicenter study proposing partial tonsillectomy as an alternative method to reduce the risk of bleeding. The society said that for all patients who have experienced postoperative bleeding, it is recommended to be admitted to the hospital for observation to avoid worsening of bleeding.

"It is important to note that even if everything is done in accordance with medical standards, there are still rare situations that doctors cannot avoid in advance." Wang Yu pointed out that, for example, the patient has been thoroughly examined before the operation, and all indicators such as coagulation function are normal, and there are no other underlying diseases, but the patient may be born with high vascular fragility, and no matter what surgery is performed, it is easy to have severe bleeding. At present, there is no quantifiable indicator to measure this type of risk.

Death from bleeding after tonsillectomy in children is extremely rare. In June 2022, JAMA published a study of five states in the United States, which found that among children undergoing tonsillectomy, the postoperative mortality rate was 7 cases per 100,000 surgeries. Children with complex chronic diseases had a higher mortality rate after surgery, at 117 cases per 100,000 surgeries. Further analysis showed that very few deaths were related to postoperative bleeding.

Why does pulmonary hemorrhage occur?

The diagnosis certificate of the deceased child showed pulmonary hemorrhage. Some netizens questioned why minimally invasive tonsil surgery would lead to pulmonary hemorrhage.

Medical World found that pulmonary hemorrhage after tonsillectomy is extremely rare. Only one similar case was reported by Korean doctors in 2012: a 25-year-old man underwent tonsillectomy to treat OSA. No obvious bleeding was observed during the operation. However, after the endotracheal tube was removed, the patient developed severe coughing and hemoptysis. After active anticoagulation and antibiotic treatment, the patient recovered after 1 week.

The Korean doctors who received the patient admitted in their report that they could not explain the cause of the pulmonary hemorrhage. They speculated that it might be because the patient was obese, had sleep apnea, and snored, which could damage the alveolar wall. The surgery required general anesthesia, and the anesthetic gas would exert pressure on the alveoli, causing barotrauma, which in turn caused diffuse alveolar hemorrhage.

This is similar to the explanation given by the hospital involved in the incident. "The hospital said it was diffuse alveolar hemorrhage, which was caused by obesity and years of snoring, which led to thin alveolar walls and caused sudden bleeding." The child's mother told the media.

Wang Yu proposed another possibility. The child had severe upper respiratory tract bleeding and could not cough it out completely. In this case, some of the blood was sucked into the trachea and then into the lungs and into the alveoli. But he also said that the diagnosis in this case would not be "pulmonary hemorrhage."

Wang Yu believes that what needs to be done now is to conduct a medical appraisal and autopsy according to the procedures. We cannot assume that it is a medical accident just because a death occurred during a minor operation.

He said that the medical process itself has many uncertainties. Whether the failure of the operation is related to the medical operation itself and how much responsibility the doctor has, all need to be determined by subsequent medical appraisals. Before the final results come out, no conclusion can be drawn.

At present, the child's parents have chosen the Heilongjiang Provincial Hospital Forensic Identification Center to conduct an autopsy. The identification center needs 60 working days to produce the results. The Harbin Daoli District Health Commission has initiated the investigation procedure.

References：

1.Stephanie Sarny, et al. What Lessons Can Be Learned from the Austrian Events?. ORL. doi.org/10.1159/000342319

2.Orlando Guntinas-Lichius, et al. Tonsillectomy versus tonsillotomy for recurrent acute tonsillitis in children and adults (TOTO): study protocol for a randomized non-inferiority trial. Trials. DOI:10.1186/s13063-021-05434-y

3. Mei Lin, Zhang Jie. Review: Adenoids and tonsils disease in children. Chinese Journal of Otorhinolaryngology Head and Neck Surgery. DOI:10.3760/cma.j.issn.1673-0860.2021.10.103

4. Ni Xin. Interpretation of the "Guidelines for the Diagnosis and Treatment of Obstructive Sleep Apnea in Chinese Children (2020)". Chinese Medical Information Herald. DOI:10.3760/cma.j.issn.1000-8039.2021.11.130.

5. Zhou Yuhao, et al. Interpretation of the 2019 American Academy of Otolaryngology-Head and Neck Surgery Guidelines for Tonsillectomy in Children. Journal of Wuhan University (Medical Edition). DOI:10.14188/j.1671-8852.2020.0771

6. Hu Xiandou, et al. Progress in risk factors and preventive measures for post-tonsillectomy bleeding. Chinese Medical Abstracts Otolaryngology. DOI:10.19617/j.issn1001-1307.2024.03.113

7.Jin Pyeong Kim, et al. A case of diffuse alveolar hemorrhage after tonsillectomy -A case report. Korean J Anesthesiol. doi:10.4097/kjae.2012.63.2.165