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Correspondence to Benjamin John Miller, [email protected]
Background
Postoperative pain is a common complaint following routine ear, nose and throat (ENT) procedures such as adenotonsillectomy, and in most cases is successfully managed with simple analgesia and rest. While pain can limit an individual’s range of movement, any significant restriction in range of neck movement or fixed neck posture should raise suspicion of an underlying atlantoaxial injury, a rare but extremely important and often overlooked complication of adenotonsillectomy. The case we describe is of particular importance to those working in general practice, emergency medicine, paediatrics and ENT, who do not infrequently encounter patients complaining of pain following this common procedure.
Case presentation
An 11-year-old boy presented to the emergency department 8 days following an uneventful adenotonsillectomy with postoperative bleeding. The adenoidectomy had been performed with monopolar suction diathermy, and the tonsillectomy with bipolar diathermy. His mother reported that he had coughed up a small quantity of blood in the early hours of the morning. He had a medical history of autism spectrum disorder and was otherwise fit and well. On presentation, he was haemodynamically stable, and on examination of the oropharynx, there was a small quantity of blood staining in the right tonsillar fossa but no active bleeding. On detailed physical examination, markedly abnormal head posture was noted, including an inability to bring his head into midline, with no associated neurological deficits (video 1). His mother reported that from day 1 postoperatively, she had been concerned about a stiff neck, and had previously taken him to a walk-in centre where he was assessed and discharged with simple analgesia.
Treatment
The patient was initially managed with a soft collar, simple analgesia and muscle relaxants and an urgent neurosurgical review was sought. In addition, intravenous antibiotics and hydrogen peroxide gargles were prescribed in the context of a post tonsillectomy bleed. Difficulty was noted in administering oral medications including muscle relaxants due to the patient’s autism spectrum disorder, and on neurosurgical review, it was determined that conservative management was unlikely to bring about resolution. He underwent manipulation under anaesthesia of C1 and C2 the following day. The procedure used an established three step manual-reduction technique, comprising (1)...