Tonsillectomy and/or Adenoidectomy is one of the most common surgical procedures peformed annually in the US, especially in the pediatric population. Although it is a common surgical procedure, there are still risks such as bleeding, pain, and even death (with the mortality rate following the surgery approximately 1 in 30,000). For years in the US, Otolaryngologists have prescribed Tylenol with Codeine for pain control in pediatric patients who underwent a tonsillectomy. However, the FDA Adverse Event Reporting System had identified 8 deaths due to overdoses between 1969 and 2012 in this group of patients. This has prompted further investigation into the matter, and recently the FDA has contraindicated Tylenol with Codeine for patient following a Tonsillectomy and/or Adenoidectomy.
Codeine is a prodrug, meaning that it is in an inactive form that requires converted by the body into its active form, Morphine. It is this “converter”, enzyme CYP2DC, where the variability, and potential problems, reside. There is a small group of patients, roughly 5-10% in the general population, who do not have the functional enzyme in their body required for this conversion and, thus, have no effect from Codeine. However, there is another small group in the general population (estimated to be 1-10%) that convert the Codeine to Morphine at a higher rate. In these patients, abnormally elevated levels of Morphine builds up in the blood stream and can cause central respiratory depression, apnea with depressed oxygen levels, and even death. It is this situation that has led the FDA and the AAOHNS to strongly encourage the elimination of Codeine for pediatric patients following a Tonsillectomy and/or Adenoidectomy.
Other opiod pain medications, such as Hydrocodone and Oxycodone, have not seen this association when compared to Codeine. However, in younger pediatric patients who are having the surgery for Obstructive Sleep Apnea, many otolaryngologists are attempting to avoid all opiod pain medications due to these recent findings. The most common regimen used for postoperative pain control now will likley be with an alternating schedule (every 3 hours) of Acetominophen (plain Tylenol) and Ibuprofen.
Since learning of these reports a few weeks ago, I have given it a great deal of thought. On one hand, I have performed well over a thousand tonsillectomies and/or adenoidectomies and never had a problem with either Tylenol with Codeine or Tylenol with Hydrocodone. I recently spoke to a retiring colleague who practiced for nearly 40 years and treated these patients with Tylenol with Codeine and never had a problem either. I also noted that during my mission trip to Barahona in the Dominican Republic that the children who underwent a Tonsillectomy +/- Adenoidectomy were treated only with Tylenol and Ibuprofen, and they had a good outcome. There is another consideration when using NSAIDs (Aspirin, Ibuprofen, Naproxen, etc) and it’s the blood thinning effects of these medications. While studies show no increased risk of postoperative bleeding with Ibuprofen use following Tonsillectomy, I am concerned that if bleeding did occur (which does in 2-4% of tonsillectomy patients) that it would be more difficult to control and likely require surgical control. As a surgeon, I am always trying to balance limiting the risk of postoperative bleeding with appropriate and effective pain control.
While I have not witnessed something like this situation, only one of these horrible and devestating complications ever occurring would be too many. Because of this, I will be changing my practice in this situation, treating younger pediatric patients with a combination of Tylenol and Ibuprofen as needed. There will be further research studies performed to yield information so we as surgeons and parents can continue to treat our children as safely as possible.