By Letitia Stein, Times staff writer
Thursday, August 26, 2010
The recent death of a seemingly healthy, 12-year-old Pinellas County girl following a tonsillectomy may have many parents worried about one of the most common surgical procedures performed in children.
Few details have been revealed about exactly what caused Carly Jane Liptak's death on Aug. 15 following a tonsillectomy at Mease Countryside Hospital in Safety Harbor.
Whether it was bleeding following the surgery, a reaction to medication, an infection, or some other cause that killed Carly hasn't been announced. What experts do know is that such deaths are incredibly rare, and that no surgery is without risk.
Why tonsils are removed
Since the Roman era, doctors have been surgically removing the tonsils, the glands at the back of the throat that are part of the body's immune system.
The number of American children who get tonsillectomies has been declining over the past 50 years. Still, more than a half million U.S. children get the surgery annually, according to national health statistics. Deaths are extremely rare: Medical literature places the mortality rate from tonsillectomy between one in 15,000 and one in 35,000 procedures, mostly from anesthesia complications and blood loss.
Thirty years ago, most tonsillectomies were performed to treat repeat infections, but now about 80 percent of procedures address obstructive sleep problems, according to the American Academy of Otolaryngology-Head and Neck Surgery. Antibiotics are the first treatment option for infections.
In obstructive sleep problems, blocked airways can result in low oxygen levels at night, which can be harmful to a developing brain and hamper growth. The child may snore loudly and occasionally seem to stop breathing before awakening with a snort, said Dr. Alec Beningfield, an assistant professor in the Department of Otolaryngology-Head and Neck Surgery at the University of South Florida.
"Thirty or forty years ago, people probably got their tonsils out because they were 'big,' now we recognize that the big tonsils are contributing to sleep problems," said Beningfield, who does several tonsillectomies a week.
No surgery is minor
"In general, (tonsillectomy) is very, very safe,'' Beningfield said.
"It's very unfortunate when something like this happens,'' he said of the Liptak case, in which he was not involved, "but for a number of reasons bad things do occasionally happen in surgery."
Adverse reaction to anesthesia is among the risks that he discusses with parents before surgery. Another is bleeding, which Beningfield said can occur either in the first 24 hours after surgery or about a week later, when the scab at the back of the throat falls off.
Death is exceedingly rare following removal of tonsils and adenoids, also part of the oral-nasal immune system, said Dr. Craig Derkay, past president of American Society of Pediatric Otolaryngology. Generally, just the tonsils are removed for serious recurring infections, while both the tonsils and adenoids are removed to treat sleep apnea, he said.
"Because a lot of times tonsillectomies are the first operation (a child ever receives), you wouldn't be aware there is an anesthesia allergy until they go under anesthesia the first time," Derkay said.
Post-operative drugs can also lead to complications. The New England Journal of Medicine last year reported on a 2-year-old boy who died after he was given codeine syrup for pain following a adenotonsillectomy. Investigation revealed the child's body metabolized codeine at a faster rate than normal, building to a deadly concentration.
Locally, Bill Pellan, director of the Pinellas-Pasco Medical Examiner's Office, couldn't recall another death following a recent tonsillectomy in the last 10 years. He said Carly Jane Liptak's autopsy results likely won't be completed for six to eight weeks.
Her family members have not provided details on what happened. Mease Countryside Hospital still is reviewing the circumstances surrounding her death, said hospital spokeswoman Beth Hardy.
Benefits vs. risks
Most tonsillectomies take about 30 minutes to an hour, said Ramzi Younis, chief of pediatric otolaryngology at the University of Miami's Miller School of Medicine. Patients usually go home the same day.
"You want the benefits of the surgery to outweigh the risks," said Derkay, who is also a professor of otolaryngology and pediatrics at Eastern Virginia Medical School in Norfolk, Va.
That's generally the case. For children with sleep apnea, removing tonsils and adenoids is effective about 95 percent of the time, Younis said.
And many parents tell USF's Beningfield that the procedure completely changes children who were hyperactive because they were tired due to poor sleep. Those with chronic infections also can experience fewer or less severe episodes of sore throat after surgery, although they may still get some.
But even with a seemingly simple surgery that carries clear benefits, Beningfield said, doctors always consider risk.
"These are things that, as surgeon, we all think about in our day-to-day work."
Times researcher Shirl Kennedy contributed to this report. Lorri Helfand can be reached at lorri@sptimes.com or (727) 445-4155. Letitia Stein can be reached at lstein@sptimes.com or (813) 226-3322.