Romanian Journal of Rhinology, Volume 9, No. 33, January-March 2019 DOI: 10.

2478/rjr-2019-0004

ORIGINAL STUDY
The ethical and moral responsibility of the surgeon,
hospital and government for the hospitalization
after adenotonsillectomy

Codrut Sarafoleanu1,2,3, Violeta Melinte1,2,3, Gabriela Musat1,3

1
ENT&HNS Department, “Sfanta Maria” Hospital, Bucharest, Romania
2
CESITO Center, “Sfanta Maria” Hospital, Bucharest, Romania
3
”Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania

ABSTRACT

Adenotonsillectomy is one of the most performed surgical procedures in otorhinolaryngology. When it comes to hospitalization
duration, there are no general available truths. Every patient is unique and only the physician should decide for how long he/
she has to remain in the hospital after adenotonsillectomy, taking into consideration the used technique, the intraoperatory
evolution and also the associated risk factors.
The authors present some general aspects of this theme and their own point of view in what adenotonsillectomy is concerned
in terms of ethics and moral responsibility of the surgeon, hospital and government for the hospitalization after the surgical
intervention.
KEYWORDS: ethics, moral responsibility, adenotonsillectomy, hospitalization.

INTRODUCTION HOSPITALIZATION AFTER

ADENOTONSILLECTOMY – ETHICAL
Regarding the interaction between the physician AND MORAL RESPONSIBILITY
and the patient, the ethical and moral responsibility
of the surgeon is one of the attributes that confer Ethical and moral responsibility has an important
the patient a good and healthy experience. But, role in each and every aspect of medical practice,
when the hospital management and the governmen- but most of all when it comes to surgical indications.
tal laws come into discussion, things get compli- From our point of view, it is ethical and, last but not
cated and it is not easy to make the best decisions. least, moral to establish a realistic surgical indica-
Today, deontology is dictated by the law and led tion for every type of pathology and patient.
by the judges. The laws of the sanitary democracy If we follow the guidelines and the studies found
represent the transition from the “idyllic” society in the literature, in what adenotonsillectomy is
to the developed society and establish the relation- concerned, there are absolute and relative indica-
ship authorities – physician – patient. tions, which can vary according to our patient’s

Corresponding author: Codrut Sarafoleanu, MD, PhD, Professor of Otorhinolaryngology, ENT&HNS Department, “Sfanta Maria” Hospital,
37-39 Ion Mihalache Blvd., District 1, Bucharest, Romania
e-mail: csarafoleanu@gmail.com
Received for publication: December 3, 2018 / Accepted: January 5, 2019
36 Romanian Journal of Rhinology, Volume 9, No. 33, January-March 2019

age 1. Absolute indications consist in: severe dys- parents who request a prolonged admission.
phagia, cor pulmonale, failure to thrive, adenoton- Even though the complications after adenoton-
sillar hyperplasia with obstructive sleep apnea or sillectomy are rare, bleeding is the most serious
abnormal dentofacial growth, suspicion of malig- one that can appear and it can lead to a tragic end
nant disease and (for tonsillectomy) hemorrhagic individually. The first spike in the bleeding event
tonsillitis. Speech impairment, halitosis, adenoton- was found within the first 24 hours after surgery. A
sillar hyperplasia with upper airway obstruction are second spike seems to occur between the 5th and
relative indications for adenotonsillectomy. Simple the 7th postoperative day and another after the 8th
adenoidectomy is a relative indication for otitis and the 15 th postoperative day. According to the
media with effusion, recurrent or chronic rhinosi- DRGs, a postoperative stay in the hospital for more
nusitis or adenoiditis. When it comes to peritonsil- than 6 days is difficult to be achieved5.
lar abscess, chronic or recurrent pharyngotonsillitis At the same time, there are arguments that sus-
and streptococcal carriage, tonsillectomy alone tain the outpatient procedure. Most trials that argue
might be performed2. for a same-day discharge take the low percentage of
During the years, many discussions appeared re- postoperative haemorrhage into account. Age, gen-
garding the hospitalization duration. While in the eral risk of postoperative haemorrhage and distance
USA and in Western Europe it is thought that pa- to the hospital are not enough criteria to indicate
tients’ quality of life is improved by a shorter stay inpatient observation. Also, the costs for each pa-
in the hospital, in Romania the optimal medium tient rise directly proportionally to the staying dura-
hospitalization duration is considered to be 5 days. tion; this is why each hospital has its own policy
In what adenotonsillectomy is concerned, hospi- regarding the number of hospitalization days for
talization for more than 24 hours after the surgical adenotonsillectomy. We should not forget that the
intervention is still controversial. government policy also has an involvement in tak-
In the USA, outpatient tonsillectomy and/or ad- ing the decision about the hospitalization length.
enoidectomy is the procedure of choice, especially
in patients with minimum complication risk.
In Europe, the transition between the tradi- PATIENTS VERSUS HOSPITAL MANAGERS
tional duration of hospital stay and same-day dis- VERSUS PHYSICIANS POINTS OF VIEW
charge slowly increases. A prospective 8-year study
performed 18 years ago by Rivas Lacarte, in Spain, Depending on who analyzes this problem, there
made the comparison between tonsillectomy in seem to be different opinions about the subject
outpatients and inpatients. The study concluded and each category judgement is influenced by
that patients can be discharged 4 hours after the very different types of reasoning more or less
surgical intervention, because there is a slow rate moral or ethical.
of complications after tonsillectomy 3. The authors In 2004, Wahlers 6 was interested in patients’
also studied the influence of age (children under point of view regarding hospitalization after ton-
4 years), sleep apnea syndrome and the complica- sillectomy, so he developed a questionnaire for
tion risk and they did not find any relationship 3. them. The conclusion was that most of the pa-
In Romania, most hospitals’ policy considers ton- tients (79.6%) wanted to be kept under observa-
sillectomy alone or in combination with adenoidec- tion in hospital for about 4 days postoperatively,
tomy to be an inpatient procedure, with a firstly for an optimal analgesic treatment and sec-
hospitalization duration from 24 to 48 hours. There ondarily in order to diminish the postoperative
are a few arguments that sustain this policy, such as bleeding risk. None of the patients who filled in
immediate and short-term complications that can the questionnaire checked the option of a 24-
arise after surgery, like haemorrhage, apnea and in- hour or less hospitalization.
fections, poor oral intake (with need for consecu- Another article based on patients’ preferences
tive i.v. fluid supply), fever and protracted vomiting4. regarding the length of hospital accommodation
Patients that undergo surgery because of severe ob- and published in Norway by Soreide and Olofsson
structive symptoms should be kept under observa- emphasized that 92% of the interviewed partici-
tion by both the otorhinolaryngologist and pants considered tonsillectomy eligible for a day
anaesthesiologist because they have significantly case procedure7.
more sequelae risk than those indicated for chronic After patients’ point of view, we bring into dis-
or recurrent infections. Also, patients with underly- cussion the hospital managers’ idea concerning
ing general diseases, post­o ­­perative bleeding and the hospitalization after adenotonsillectomy. Led
poor compliance should be maintained in hospital by managing principles such as costs and different
for at least 24 hours. Not least, there are patients or statistics regarding postoperative complications, a
Sarafoleanu et al The ethical and moral responsibility of the surgeon, hospital and government for the hospitalization... 37

managing director of a hospital said: “There is no tween the use of the harmonic scalpel and other
need for hospitalization and patients can return home a tonsillectomy techniques regarding postoperative
few hours after surgery; nine out of ten patients do well haemorrhage12.
enough to go home”. LASER-assisted tonsillectomy has shown less in-
Analyzing this reaction, the questions one should traoperative bleeding and shorter operative time.
ask have to be the following: According to Wan Ishlah, in the hospital where a
Is this attitude compatible with moral and ethical re- laser machine and expertise are available, it is jus-
sponsibility? tifiable to use this technique as an effective method
Is it enough to experience a potential fatal complica- of performing tonsillectomy13.
tion once to change this opinion or the only leading prin- From an otorhinolaryngologist’s point of view,
ciple is the cost? the determinant factors for establishing the dura-
Last but not least, the physicians’ point of view tion of hospitalization should be represented by:
is different depending on various factors. Accord- the type of surgical procedure, local anatomic con-
ing to Wright et al. 8, the indications for inpatient ditions, general associated diseases, the surgeon’s
monitoring should include the following: option and experience, intraoperatory complica-
1. Age younger than 3. tions, patients’ requirement. Most of all, adenoton-
2. Obstructive sleep apnea or craniofacial syn- sillectomy should be performed only when it is
dromes involving the airway. believed to provide enough benefit to justify doing
3. S ystemic disorders which would put the pa- the surgery.
tient at increased perioperative risk. In our opinion, ethics should break any admin-
4. P oor socioeconomic status or other situa- istrative barrier and no restrictions should be re-
tion which would limit the patient’s ability lated to the hospital or government policy if there
to return quickly to the hospital. are medical arguments for a longer hospitaliza-
5. W hen the procedure is done for a periton- tion. Different opinions can be found worldwide
sillar abscess. regarding hospitalization after adenotonsillectomy
6. Those who experience vomiting or haemor- and medico-legal aspects should be taken into ac-
rhage. count when deciding patient discharge.
Talking from the physician’s point of view, ton-
sillectomy and adenoidectomy can be performed
using various types of procedures and the hospital- CONCLUSIONS
ization duration should be established also de-
pending on the surgical procedure type used by Adenotonsillectomy with hospitalization remains
the ENT doctor. one of the most performed procedures in otorhino-
Traditional methods of tonsillectomy include laryngology, but its frequency trends to decrease
the use of a scalpel and scissors, which can cause due to the new available surgical techniques with
considerable bleeding during and after the surgi- less intra- and post-operative complications.
cal intervention. The duration of hospitalization is still debatable
Electrosurgery has provided improvements in sur- and different worldwide, but the physician should
gical technique by decreasing operating time and be the one who decides for how long the patients
improving haemostasis. Compared to cold dissection, remain under observation, taking into consider-
there is no difference in postoperative haemorrhage ations all the risk factors, because he is the first one
rates, but electrosurgery increases pain9. who has ethical and moral responsibility not only in
In case of coblation tonsillectomy, compared to front of the patient, but also in front of the law.
the traditional procedures, patients report less Various factors influence the duration of hospi-
pain, less necessity of narcotic pain medication talization and the most important seems to be the
and much quicker return to a regular diet and nor- type of procedure, special conditions related to the
mal daily activities 10. case and costs. Also, the medical insurance of the
Intracapsular power-assisted partial tonsillec- patient plays an important role.
tomy produces less postoperative pain and fewer Unfortunately, both ethical and moral aspects are
episodes of delayed haemorrhage and dehydra- sometimes neglected or underestimated, the doctor
tion, but the effectiveness is the same as standard – patient relationship being seriously affected.
tonsillectomy in relieving obstructive sleep-disor- Surgeons should be sufficiently cautious to avoid
dered breathing11. fatal events and complications, self-related ethical
The harmonic scalpel uses ultrasonic technology and moral problems, medico-legal issues, indepen-
to cut and coagulate tissues at lower temperatures. dent of hospital and government policy. Patients’
There is no evidence of important differences be- life is above all administrative policies.
38 Romanian Journal of Rhinology, Volume 9, No. 33, January-March 2019

point of view. HNO. 2004;52(2):153-5.

Conflict of interest: The authors have no con- 7. Søreide AK, Olofsson J. Tonsillectomy--day surgery or hospitaliza-
flict of interest. tion? Tidsskr Nor Laegeforen. 1999;119(10):1423-7.
Contribution of authors: All authors have 8. Wright S, Deskin R. Tonsillitis, Tonsillectomy, and Adenoidectomy.
equally contributed to this work. In: Quinn FB Jr., Ryan MW. Grand Rounds Presentation, UTMB,
Dept. of Otolaryngology, University of Texas Medical Branch; 2003.
Available from: http://www.utmb.edu/otoref/grnds/Tons-2003-
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