Tonsillectomy is performed under general anesthesia and the surgery usually takes 30-45 minutes. It is frequently performed with an Adenoidectomy in younger children. The patient stays in the hospital overnight with close observation and a gradual introduction of oral intake.
The technique of Tonsillectomy involves “cold dissection”. The mouth is opened, and various surgical instruments are used to dissect the tonsil away from the underlying throat muscles.
Bleeding is controlled through the use of surgical ties and the application of heat (bipolar cautery) to seal blood vessels. The use of cautery is kept to a minimum as there is some evidence that the more that cautery is used, the greater the risk there is of having a bleed after the operation.
Once the operation has been completed, the patient is transferred to the Recovery Room, and then to their room on the ward. Children are often quite upset initially, not just because of the pain but also because of the foreign environment that they find themselves in. This soon settles. It’s not uncommon for children to be sleepy for a few hours after the operation.
The child is closely monitored, particularly when they first arrive back on the ward. If the operation has been done to relieve Sleep Disordered Breathing or Obstructive Sleep Apnoea, then the child will be closely observed for the first night including an ongoing measure of their oxygen levels using a probe placed on a finger or toe.
All patients have an intravenous drip to maintain adequate hydration. Oral intake is gradually introduced, starting with the first drink about 2 hours after returning to the ward.
Although the fluid line may be disconnected after the child is drinking, the plastic line providing access to the vein stays and is only removed just before discharge. This line also provides access to giving medication such as anti-vomiting medication.
If the line is removed early, and then a child refuses to drink it can be difficult to reinsert the line – not only is it unpleasant for the child, but also any dehydration makes finding a suitable vein more difficult.
It is not uncommon to have nausea and vomiting, and this may be due to the anesthetic, the pain medications being given, or blood swallowed during the operation upsetting the stomach.
Anti-vomiting medication can be given through the intravenous drip if required, although it often settles of its own accord within 24 hours.
The overall stay is usually one night in the hospital, but this may be delayed if the patient has not established an adequate oral intake.
After the Operation
It takes most children 7 to 10 days to recover. However, there is wide variability in this. Some children feel better after a few days (especially younger children) whereas others will take 14 days to recover.
It is best to keep your child home away from child care, kindergarten, school, or other large groups of children for 7-10 days to decrease the chance of picking up an infection during the recovery phase. Keep them home longer if they are still requiring pain medication and/or are not eating and drinking normally.
General activities can be resumed when your child feels up to it, but they should not exert themselves for the first two weeks when there is a risk of bleeding. Playing sport, swimming, heavy lifting, or rough play should all be avoided during this time.
Most children experience a fair amount of throat pain during this time. There can also be ear pain, jaw pain, and neck pain. Ear pain occurs because a nerve that supplies the throat also supplies the ears, and this nerve can get confused as to where the pain is coming from. It is unlikely that this pain is due to an ear infection.
The patient will need regular pain medication and it is important that this is given regularly, particularly during the first few days. Indeed, it is best to give regular Paracetamol (usually in syrup form – Dymadon, Panadol, or Panamax) every 4 to 6 hours for the first two to three days.
In older children, teenagers, and adults, the pain may worsen around day 5 to 7 after the operation. This is a normal occurrence and does not mean that there is an infection.
If your child refuses oral pain relief medication, then Panadol can be given as a suppository. If all strategies for providing pain relief fail and a child refuses to drink, then they will need to be readmitted for rehydration with intravenous fluids. This occurs in 3% of children having their tonsils out.
Non-Steroidal Anti-Inflammatory Drugs or NSAIDs such as Ibuprofen (Nurofen) can be used in conjunction with Paracetamol in older children. They are to be avoided in younger children – although there is no convincing evidence that NSAIDs cause bleeding after Tonsillectomy, they can make bleeding worse when it does occur.
What risks are associated with Tonsillectomy?
Even though all due care is taken, there can be an injury to lips, gums, tongue, and/or the skin of the face. This usually resolves without any problems. Very rarely there can be burns to the palate, tongue, or lips due to the use of diathermy (electrical energy producing heat) to seal blood vessels.
There is a very small chance that teeth may be chipped or knocked out. This is more likely if teeth are decayed or loose or have been capped or crowned.
The mouth is opened during the procedure and the corners of the mouth can dry out. At times, this can result in some cracking of the corners of the mouth. Lip balm should be applied whilst this heals.
A change in the sensation of the tongueor an altered taste can occur, but this settles with time.
Bleeding occurs in 1 out of every 50 patients, and this can occur during the initial hospital stay at the time of surgery or during the first 2 weeks after the operation. It is best that your child stays home with a parent and does not have any overnight stays away from home.
If there is any delayed bleeding, patients will need to be re-admitted to the hospital for observation and treatment with intravenous fluids and antibiotics at the very least. Up to half of the patients who have a bleed may need to go back to the operating theatre to have the bleeding blood vessel sealed, and this is more common if the bleed occurs within the first 24 hours after surgery.
Despite this, anytime that there is bleeding after having the tonsils removed, the patient must seek medical attention. Don’t delay in getting the patient to the nearest emergency department, and don’t delay in calling an ambulance if this is required.
You will know if the child is bleeding as there will be profuse bleeding from the nose, coughing out of fresh red blood, or if blood is swallowed it irritates the stomach and the child will start vomiting up blood.
Change in Vocal Resonance
If the tonsils are very large, then their removal can alter the sound of the voice. In this situation, the child’s voice changes from being abnormal because of large tonsils to be more what they should have always sounded like.
Sometimes children will have a small amount of fluid coming out of their nose when they drink. This should settle.
Small nubbins of tonsil can occasionally remain, particularly where the tonsils extend down towards the back of the tongue. If this occurs, these nubbins can grow over time and can then cause problems again although this is rare. A Revision Tonsillectomy may then be required.