Tonsillectomy & Adenoidectomy

The surgery is done under general anesthesia, and this is usually the most frightening part of the procedure for parents. Modern pediatric anesthesia is extremely safe. It is given in a well monitored setting by a trained professional, in pediatric patients usually an anesthesiologist specializing in the care of children. There will be time before the surgery for patients and parents to speak with the anesthesiologist and ask specific questions. Lesser degrees of anesthesia (such as sedation) may actually be more dangerous than general anesthesia in this procedure and are inappropriate for surgery in the throat. While anxiety during the administration of anesthesia is common it is infrequently remembered by patients as anesthesia has an amnestic effect for the events surrounding surgery.

The most common risk of tonsillectomy is bleeding after surgery. It usually takes approximately two weeks for the throat to heal completely, and bleeding can be seen at any time before then. However, when bleeding does happen, it is most common between five to ten days after the operation when the scab over the healing area of the throat, where the tonsils were removed, separates. Bleeding that is enough to be noticed happens in about 2-4% of patients, and will be seen as blood in the mouth or vomiting of bright red blood. Significant bleeding after adenoidectomy alone is extremely rare.

Bleeding after tonsillectomy that requires intervention is rare. Any significant bleeding after tonsillectomy or adenoidectomy should be evaluated in a controlled setting such as an emergency room. If significant bleeding does occur in the post-operative period please contact your doctor and proceed to the emergency room as directed by your physician or to the nearest ER in a significant emergency. This type of bleeding occurs in less than 1% of patients but is slightly more common in adolescents and adults.

You may see a change in the quality of your child’s voice after surgery. Usually this results in a high pitched quality to the voice which is at its worst at three weeks and usually resolves by 12-14 weeks after surgery. This occurs because the muscles in the back of the throat become weakened from being stretched by large tonsils and take time to strengthen up after surgery. In very rare causes speech therapy may be required to improve the vocal quality after surgery.

Occasionally, a child will have pain after surgery that is so severe that he or she will not be able to drink enough liquid and will become dehydrated. If this happens, the child may need to be readmitted to the hospital overnight for stronger pain medication and intravenous fluids. Other risks such as excessive bleeding during surgery, scarring of the throat and severe infection are extremely rare.

Most commonly tonsillectomy and adenoidectomy are done for recurrent infections. By removing the place where infections had lodge and grow (the tonsils and adenoids) there is a much higher chance of eradicating the infection. There is still a small chance of your child still getting strep throats after surgery but the possibility of continued infections is rare.

Another indication for tonsillectomy and adenoidectomy is Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) syndrome. These children are affected with the rapid onset of neuropsychiatric illnesses such as severe anxiety, obsessive compulsive disorders and tics which are thought to be associated with streptococcal infections. One of the treatments for PANDA’s syndrome if medical therapy fails is tonsillectomy and adenoidectomy.

I work closely with your PANDA’s specialist and we have found success in treating PANDA’s syndrome with this approach. Please do not hesitate to have either you or your PANDA’s specialist contact me to obtain a consultation for your child.

Everything in our body is put there for a reason and in their healthy state the tonsils and adenoids are filters. However like any filter when they become unhealthy or “dirty”, like an air conditioning filter might, they need to be removed. In their healthy state the tonsils and adenoids trap bacteria, viruses and other contaminants which enter the body on their surface and then transport them to the center of the tonsil or adenoids and kill them. When the tonsils and adenoids become too large they act like sponges not filters and can be reservoirs of infection rather than filters. Since adenoids disappear naturally by 10-15 years of age and tonsils shrink down significantly during adolescence they have only a small part in our immune function as adults. The other areas of lymph tissue in the head and neck pick up the filter function that the tonsils and adenoids previously performed.

The tonsils and adenoids are removed through the mouth. There are no external incisions on the skin. My technique utilizes a device that removes the tissue and seals the tissue at the same time. This is called an electrocautery and is the most common method for removal of tonsils in the United States. It has a minimal risk of bleeding post-operatively and the vast majority of patients less than 14 years of age may return to school within one week. Older children and adults, due to the higher incidence of scarring of the tonsils, may require a much longer recovery. The adenoids are also removed through the mouth using a mirror and a special device that removes the majority of the adenoid tissue. A small amount of adenoid tissue is left to help decrease the chance of speech problems post-operatively. This small amount of adenoid tissue does not interfere with breathing or predispose to infections. A newer procedure is the partial tonsillectomy. In this procedure a shaver is used to remove 80-90% of the tonsils. A small amount of tonsil tissue is left behind to help with healing. The advantage of this procedure is that it decreases post-operative pain. Studies have shown that children return to a normal diet 1-2 days earlier and require less pain medication. The disadvantages to this procedure are that there is an approximately 3% risk of regrowth of the tonsils and an approximately 3% risk of future recurrent infections in the pieces of tonsil which are left behind. As tonsil tissue is left behind this is not the primary procedure recommended for children or adults with multiple episodes of strep tonsillitis. I will discuss with you or your family which procedure is right for you or your child.

The vast majority of children and almost all adults can be discharged home after surgery. If there are underlying medical problems or severe OSA and obesity than an overnight admission will be recommended. In very young children, i.e. two years of age or less, please plan to stay overnight and your child will be reassessed as the day progresses for the need for admission.

A soft diet is recommended for the first 7-10 days after surgery. Foods such as pasta, rice, scrambled eggs, soggy french toast or pancakes are perfect. Drinks such as fruit punch, herbal ice teas, Kool Aid, and white grape juice are also well tolerated. Stay away from rough foods such as cookies, apples, potato chips, apples or popcorn for two weeks as they may promote bleeding. Please avoid citrus containing products such as real orange juice, grapefruit juice, cranberry juice and tomato sauce for the first 10-14 days . Foods and drinks with a high salt level such as Gatorade and French fries should be avoided. Our grandmothers were right, milk does thicken the mucous. Please limit the amount of milk consumed and avoid lots of ice cream for the first 10 days after surgery. Ice pops and sorbet are better tolerated.

Each person heals differently. Overall, there is pain associated with a tonsillectomy and adenoidectomy. The vast majority of patients require narcotic pain medication in the post-operative period. Narcotics should be used to control pain but have side effects such as upset stomach, constipation and, in rare cases, suppression of breathing (particularly of concern in patients with severe obstructive sleep apnea). Most other non-prescription pain medicines (such as aspirin, or Ibuprofen containing drugs like Motrin™ and Advil™) can interfere with the body’s clotting ability. This can make bleeding more likely, and therefore they can not be used for two weeks before or after T&A. Vitamins can also affect blood clotting and should be avoided for two weeks before and for two weeks after surgery.

Patients may swallow some blood during surgery, and it is not unusual to see a small amount of old, dark red blood mixed with vomitus for the first one to two days after surgery. However, any active bleeding (with bright red blood) is abnormal and the patient should be immediately taken to the emergency room for evaluation. Even if the bleeding has stopped by the time the child is in the hospital, there may be a reason to admit the patient for overnight observation. For this reason it is very important not to travel more than one and one half hour from home for the first 10 days after surgery. No flying for two weeks. Limit physical activity for the first 10 days after surgery, ie no gym classes, after school activities or trips to the playground, park or swimming pool for 10 days after surgery. Children may usually return to school one week after surgery. Adults and older children may require a longer recovery time and this should be discussed with your surgeon.

If you or your child are not drinking enough after surgery, dehydration may occur. As long as they are taking in enough fluids, eating is less of a concern in the first week after surgery. Calories can be supplemented by giving drinks which are high in sugar. A dehydrated adult or child may feel excessively tired or dizzy, have a dry mouth, and urinate less often. If this is the case, they should be seen by their pediatrician or surgeon, who may recommend evaluation in the emergency room for intravenous fluid therapy and pain management.