http://ije.oxfordjournals.org/content/37/1/23.

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International Journal of Epidemiology

Commentary: Tonsillectomythen and now

1. Martin J Burton
+ Author Affiliations

1. Department of OtolaryngologyHead & Neck Surgery, University of Oxford, Level LG1, West Wing, John Radcliffe Hospital, Headley Way, Oxford, OX3 9DU, UK. 1. E-mail: mburton@cochrane-ent.org Accepted November 13, 2007.

Dr Alison Glover's article reminds usif we need remindingthat tonsillectomy has long been a controversial operation.1 It remains so today and recently, when calls were made in the UK to stop doing unnecessary operations, tonsillectomy was quickly cited as one of these. In 1936, Alison Glover clearly thought that many tonsillectomies being undertaken were unnecessary. Both then and now, this lack of necessity presumably refers to the belief that patients are no better off after tonsillectomy than they would have been had they not had the surgery. The wide variation in rates of tonsillectomy between and within countries seen 70 years ago, continues to the present day.2 It is difficult to work out from Dr Alison Glover's article what the contemporary indications for tonsillectomy were. Mention is made several times of enlargement and of sore throats and colds. When I rescued the 1937 edition of St Clair Thomson's classic ENT text book Diseases of the Throat and Nose from a library's discard pile I felt sure it would be useful one day; it has proved so now.3 Contemporary indications included: 1. Any interference with respiration, night or day. 2. Threatened alteration of voice or articulation. 3. Eustachian catarrh, or the presence of inflammatory middle-ear disease. 4. Chronic enlargement of the cervical glands 5. Chronic lacunar tonsillitis with recurrent exacerbations. 6. If adenoids [are going to be removed] the opportunity should be utilized for removing tonsils if also the cause of symptoms.

7. Attacks due to septic absorption through the tonsils, or a chronic condition of ill-health which can be attributed to infection through the tonsillar area. 8. Frequent attacks of tonsillar inflammation, or of peri-tonsillar abscess. The authors also comment (perhaps hinting at the increased frequency of tonsillectomy noted by Dr Alison Glover):Recently sepsis of the tonsils has been claimed as the cause of a large variety of disorders, and tonsil enucleation, at all ages, has become more frequent.It is axiomatic that removing the tonsils (more specifically the palatine tonsilsthose ovoid lumps of lymphoid tissue located between the faucial pillars in the oropharynx) will prevent an individual developing palatine tonsillitis. This is as true as the inevitability of a patient who has undergone appendicectomy being unable thereafter to develop appendicitis. But just as appendicectomy is not a panacea for all gastrointestinal disease, removing the tonsils is not a measure that will permanently rid the patient of sore throats or pharyngitis. And herein lies the key issue relating to tonsillectomy today. By its nature, tonsillectomy is a prophylactic procedure, undertaken to prevent future episodes of infection. In which case, how certain can one be that without surgery a patient will continue to have infected episodes? If a patient keeps their tonsils and does continue to have troublesome infections, will they be due to the continued presence of the palatine tonsils? I have been careful in my choice of words here, using the term infections in a purposefully rather vague way. It is sometimes said that tonsillectomy is only performed in patients with tonsillitis, to prevent tonsillitis. But clinical situations are rarely this simple. It is difficult to be sure that all of the episodes comprising malaise, fever and sore throat, accompanied by redness and swelling of the palatine tonsils are due primarily (let alone solely) to infection of those tonsils. Conversely, when the palatine tonsils are removed, the other lymphoid aggregates that comprise Waldeyer's ring of lymphoid tissue remain, as do all the soft tissues of the pharynx. All these are susceptible to infection and inflammation and the associated clinical features of sore throat, dysphagia, with malaise and fever. There is some information available from randomized controlled trials (RCTs) to suggest thatrather like in the financial marketsthe past does not always predict the future. Just because an individual has been suffering from repeated severe episodes of tonsillitis in the past, this pattern may

not continue.46 In the bad old days of long waiting lists in the British National Health Service, patients could be put on the waiting list for tonsillectomy with severe problems, only to remark when called for surgery 1218 months later that they no longer had any trouble at all, some not even having a single episode since they were put on the waiting list. There have been a number of RCTs looking at tonsillectomy and adenotonsillectomy in children46 and one at tonsillectomy in adults.7 Data on follow-up beyond the first year after randomization/surgery are so limited that no conclusions can be drawn about the effect of surgery beyond that first year. Within that year, surgery results in a very modest reduction in the number of days with a throat infection or sore throat; 17 days in the surgical group rather than 21 in the un-operated controls. Of the 17 days of pain however between 7 and 14 of those days comprised the immediate post-operative period and are entirely predictable. This issue of predictability is likely to be important to patients and their families and contrasts with the unpredictable nature of the other days with sore throats. The vast majority of patients who respond to questionnaires about their or their child's tonsillectomy (about half of all patients), profess to be very pleased that it was done.8 I have observed that most patients arriving for a consultation about their tonsils have made up their mind what they want to have done beforehand. Many are determined to have them out and are rarely dissuaded by explanations about the natural history of sore throats and tonsillitis as described above, combined with a detailed description of the operation, the convalescence required and the risks of primary and secondary haemorrhage. These individuals often have a family member or friend who has had their tonsils out or have been referred by their GP fortonsillectomy and are keen to follow their advice. A second, smaller group desperately don't want surgery unless absolutely necessary. Once the same explanation has been given, and the elective nature of the procedure emphasized, they seem to relax in the knowledge that they may legitimately decline surgery; the doctor said I didn't have to have them out. Is their consensus amongst otolaryngologists on those patients in whom it is appropriate to consider tonsillectomy? Criteria based on those proposed by Dr Paradise and his team from Pittsburgh and used in their RCT are widely used for children.4 The Paradise criteria require a standard to be met in terms of frequency of infection, a child needing to have had seven or more episodes in the preceding year, five or more in each of the preceding 2 years, or three or more in each of the preceding 3 years. The

original criteria for the RCT required specific clinical features, including at least one of the following: temperature of 38.3C, cervical lymphadenopathy, tonsillar or pharyngeal exudates or positive culture for group A beta-haemolytic streptococcus. In contemporary practice in the UK, accurate information about these clinical features are not always available to otolaryngologists, and a judgement is often made about the severity of the episodes of sore throat/tonsillitis based solely on the history. In adults, one or two episodes a year necessitating time off work, or two quinsies (peri-tonsillar abscesses) are usually deemed sufficient to consider surgery. As I have noted above, armed with a full explanation of the pertinent facts about natural history (that the past does not necessarily predict the future and that tonsillectomy does not prevent all sore throats) and a clear description of the nature and risks of surgery, a significant number of individuals still choose to have a tonsillectomy. The discussion which followed Dr Alison Glover's presentation is as illuminating as the paper itself, particularly because the speakers in 1938 mentioned a number of things with resonate with current practice. Sir Arthur MacNalty, President of the Section of Epidemiology and State Medicine at the Royal Society of Medicine, before whom the paper was read, noted that the need for children to have their tonsils removed was the honest belief of many practitioners and that this belief had spread to the laity and the influence of parental pressure could not be ignored. One Dr Layton commented that the decision about whether or not to recommend tonsillectomy was a very hard one and he felt that at least as much time should be given to deciding whether any operation should be done, as to the doing of it. Mr E D D David spoke in similar vein, emphasising the need for careful selection of patients. In more recent times, the patient presenting for tonsillectomy has often been seen by the most junior member of the surgical team. I agree with Dr Layton that the process of assessment and counselling of patients is less straightforward than might first appear and demands the attention of a senior surgeon. It is still the honest belief of many otolaryngologists, including myself, that tonsillectomy is a useful procedure in some patients, reducing the number and severity of episodes of throat infection in individuals who, without surgery, would have continued to have problems. The difficulty comes in identifying those patients in whom this is most likely to be the case. Until such time as we identify specific biomarkers for, or develop better predictive models of, recurrent throat infections, there will always be uncertainty about the necessity or effectiveness of tonsillectomy in an individual patient.

Iain Chalmers has written extensively about uncertainty and comments that:A prerequisite for constructive debate about uncertainties about the effects of treatments is a greater willingness among professionals and the public to admit and discuss them, combined with the humility to acknowledge that good intentions alone have not protected patients from the unintended harmful effects of treatments.9Nearly 70 years after Dr Alison Glover's presentation, my colleagues in the thriving Section of Laryngology & Rhinology at the Royal Society of Medicine are more aware than ever of the uncertainty surrounding the effectiveness of tonsillectomy and the importance of sharing that uncertainty with patients. But, like their forebears they have witnessed dramatic evidence of improvements in health following tonsillectomy in some patients and see any proposal to ban tonsillectomy as depriving patients of that potential benefit. They recognize the absence of evidence for the long-term effects of surgery, but rightly do not accept this as evidence of the absence of a positive, beneficial effect in some. When the uncertainty is openly and transparently shared with patients, the possible benefits being weighed with the risks and potential harms of surgery, all patients will exercise their right to choose and some will elect to undergo surgery. Others will not. Whether or not those who fund healthcare will continue to give this choice to patients is a different question; how much uncertainty are commissioners of healthcare provision prepared to pay for?

Published by Oxford University Press on behalf of the International Epidemiological Association The Author 2008; all rights reserved.
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Paradise JL, Bluestone CD, Colborn DK, Bernard BS, Rockette HE, Kurs-Lasky M
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http://www.mayoclinic.com/health/tonsillectomy/MY00132

Tonsillectomy
Definition
By Mayo Clinic staff

Inflamed tonsils

Tonsillectomy (ton-sih-LEK-tuh-me) is the surgical removal of the tonsils, two oval-shaped pads of tissue at the back of the throat one tonsil on each side. A tonsillectomy was once a common procedure to treat infection and inflammation of the tonsils (tonsillitis). Today, a tonsillectomy is usually performed for sleep-disordered breathing but may still be a treatment when tonsillitis occurs frequently or doesn't respond to other treatments. A tonsillectomy may also be necessary to treat breathing and other problems related to enlarged tonsils and to treat rare diseases of the tonsils. Recovery time for a tonsillectomy is usually at least 10 days to two weeks.

Why it's done

By Mayo Clinic staff

Inflamed tonsils
A tonsillectomy is used to treat: Recurring, chronic or severe tonsillitis Complications of enlarged tonsils Other rare diseases of the tonsils

Tonsillitis Tonsils produce certain types of disease-fighting white blood cells. Therefore, the tonsils are believed to act as the immune system's first line of defense against bacteria and viruses that enter your mouth. This function may make them particularly vulnerable to infection and inflammation. The problem is more common in children because the immune system function of tonsils is most active before puberty. Also, unlike an adult's immune system, a child's system has had less exposure to bacteria and viruses and has yet to develop immunities to them. A tonsillectomy may be recommended to prevent frequent, recurring episodes of tonsillitis. Frequent is generally defined as: More than seven episodes a year More than five episodes a year in each of the preceding two years More than three episodes a year in each of the preceding three years The procedure may also be recommended if: A bacterial infection causing tonsillitis doesn't improve with antibiotic treatment An infection that results in a collection of pus behind a tonsil (tonsillar abscess) doesn't improve with drug treatment or a drainage procedure Complications of enlarged tonsils Tonsils may become enlarged after frequent or persistent infections, or they may be naturally large. A tonsillectomy may be used to treat the following problems caused or complicated by enlarged tonsils: Difficulty breathing Disrupted breathing during sleep Difficulty swallowing Other diseases of the tonsils A tonsillectomy may also be used to treat other rare diseases or conditions of the tonsils, such as: Cancerous tissue in one or both tonsils Recurrent bleeding from blood vessels near the surface of the tonsils

Risks
By Mayo Clinic staff

Tonsillectomy, like other surgeries, has certain risks: Reactions to anesthetics. Medication to make you sleep during surgery often causes minor, shortterm problems, such as headache, nausea, vomiting or muscle soreness. Serious, long-term problems are rare, though general anesthesia is not without the risk of death. Swelling. Swelling of the tongue and soft roof of the mouth (soft palate) can cause breathing problems, particularly during the first few hours after the procedure. Bleeding during surgery. In rare cases, severe bleeding occurs during surgery and requires additional treatment and a longer hospital stay. Bleeding during healing. Bleeding can occur during the healing process, particularly if the scab from the wound is dislodged too soon. Emergency surgery to stop the bleeding is riskier than scheduled surgeries that allow for appropriate pre-surgical safeguards, such as fasting. Infection. Rarely, surgery can lead to an infection that requires further treatment.

How you prepare

By Mayo Clinic staff You'll receive instructions from the hospital on how to prepare yourself or your child for a tonsillectomy. Information you'll likely be asked to provide includes: All medications, including over-the-counter drugs and dietary supplements, taken regularly Personal or family history of adverse reactions to anesthetics Personal or family history of bleeding disorders Known allergy or other negative reactions to medications, such as antibiotics Instructions for preparing will include the following: Don't take aspirin or other medications containing aspirin for at least two weeks prior to surgery. Don't eat anything after midnight before the scheduled surgery. Your surgeon should provide you instructions about drinking liquids prior to reporting to the hospital. Make arrangements for a ride home. Plan for 10 days to two weeks or more of recovery time. Adults may need more time than children. Questions to ask your doctor or the hospital staff for yourself or on behalf of your child include:

What are my dietary restrictions before surgery? When should I arrive at the hospital? Where do I need to check in? Can I take other prescription medications in the days before surgery? When can I take the last dose? What is the expected recovery time? What restrictions to activities or diet should I expect during recovery?

What you can expect

By Mayo Clinic staff Tonsillectomy is usually done as an outpatient procedure. That means you'll be able to go home the day of the surgery. An overnight stay is possible if complications arise of if the surgery is done on a young child or on someone who has a complex medical condition. During the surgery Because a tonsillectomy is performed under general anesthesia, you or your child won't be aware of the procedure or experience pain during the surgery. The surgeon may cut out the tonsils using a blade (scalpel) or a specialized surgical tool that uses heat or high-energy heat or sound waves to remove or destroy tissues and stop bleeding. During recovery Nearly everyone experiences pain after a tonsillectomy. Pain is most often in the throat, but it may also be located in the ears, jaw or neck. Steps that you can take to reduce pain, promote recovery and prevent complications include the following: Medications. Take pain medications as directed by your surgeon or the hospital staff. Fluids. It's important to get plenty of fluids after surgery. Water and ice pops are good choices. Food. Bland foods that are easy to swallow, such as applesauce or broth, are the best choices immediately after surgery. Foods such as ice cream and pudding can be added to the diet if they're tolerated. Foods that are easy to chew and swallow should be added to the diet as soon as possible. Avoid spicy, hard or crunchy foods. Rest. Bed rest is important for several days after surgery, and strenuous activities such as running and bike riding should be avoided for two weeks after surgery. You or your child should be able to

return to work or school after resuming a normal diet, sleeping normally through the night and not needing pain medication. Talk to your doctor about any activities that should be avoided. When to see the doctor or get emergency care Watch for the following complications that require prompt medical care: Bleeding. Any bleeding requires a trip to the emergency room for a prompt evaluation and treatment. Surgery to stop bleeding may be necessary. Fever. Call your doctor if you or your child has a fever of 102 F (38.9 C) or higher. Dehydration. Call your doctor if you observe signs of dehydration, such as reduced urination, thirst, weakness, headache, dizziness or lightheadedness. Common signs of dehydration in children include urinating fewer than two or three times a day or crying with no tears. Breathing problems. Snoring or noisy breathing is common during the first week or so of recovery. However, if you or your child is having difficulty breathing, get emergency care. References
1. 2. 3. 4. 5. Fact sheet: Tonsils and adenoids. American Academy of Otolaryngology Head and Neck Surgery. http://www.entnet.org/HealthInformation/tonsilsAdenoids.cfm. Accessed April 23, 2012. Fact sheet: Tonsils and adenoids: Postop. American Academy of Otolaryngology Head and Neck Surgery. http://www.entnet.org/HealthInformation/tonsilsAdenoidsPostop.cfm. Accessed April 23, 2012. Kliegman RM, et al. Nelson Textbook of Pediatrics. 19th ed. Philadelphia, Pa.: Saunders Elsevier; 2011. http://www.mdconsult.com/das/book/body/208746819-6/0/1608/0.html. Accessed April 23, 2012. Tagliareni JM, et al. Tonsillitis, peritonsillar and lateral pharyngeal abscesses. Oral and Maxillofacial Surgery Clinics of North America. 2012;24:197. Tonsillopharyngitis. The Merck Manuals: The Merck Manual for Healthcare Professionals. http://www.merckmanuals.com/professional/ear_nose_and_throat_disorders/oral_and_pharyngeal_disorders/tonsilloph aryngitis.html. Accessed April 23, 2012. Fact sheet: Tonsillitis. American Academy of Otolaryngology Head and Neck Surgery. http://www.entnet.org/HealthInformation/tonsillitis.cfm. Accessed April 23, 2012. Q & A: What you should know before surgery. American Society of Anesthesiologists. http://www.asahq.org/Lifeline/What-To-Expect/QA-What-You-Should-Know-Before-Surgery.aspx. Accessed April 28, 2012. McPhee SJ, et al. Current Medical Diagnosis & Treatment 2012. 51st ed. New York, N.Y.: The McGraw-Hill Companies; 2012. http://www.accessmedicine.com/content.aspx?aID=2356. Accessed April 30, 2012. Fact sheet: Tonsillectomy procedures. American Academy of Otolaryngology Head and Neck Surgery. http://www.entnet.org/HealthInformation/tonsillectomyProcedures.cfm. Accessed April 23, 2012.

6. 7.

8. 9.

10. Combating antibiotic resistance. U.S. Food and Drug Administration. http://www.fda.gov/forconsumers/consumerupdates/ucm092810.htm. Accessed April 27, 2012. 11. Hoecker JL (expert opinion). Mayo Clinic, Rochester, Minn. May 15, 2012. 12. Baugh RF, et al. Clinical Practice Guideline: Tonsillectomy in children. Otolaryngology Head and Neck Surgery. 2011;144:S1. 13. Orvidas LJ (expert opinion). Mayo Clinic, Rochester, Minn. May 15, 2012. MY00132Aug. 4, 2012 1998-2013 Mayo Foundation for Medical Education and Research (MFMER). All rights reserved. A single copy of these materials may be reprinted for noncommercial personal use only. "Mayo," "Mayo Clinic," "MayoClinic.com," "EmbodyHealth," "Enhance your life," and the triple-shield Mayo Clinic logo are trademarks of Mayo Foundation for Medical Education and Research.

http://www.nlm.nih.gov/medlineplus/ency/article/003013.htm

Tonsillectomy
Tonsillectomy is surgery to remove the tonsils. The tonsils are glands at the back of your throat. The tonsils are usually removed along with your adenoid glands. That sugery is called adenoidectomy. Description The surgery is done while the child is under general anesthesia. Your child will be asleep and pain free. The surgeon will place a small tool into your childs mouth to hold it open. The surgeon then cuts or burns away the tonsils. The doctor will control bleeding. The wounds heal naturally without stitches.

After surgery, your child will stay in the recovery room until he or she is awake and can breathe easily, cough, and swallow. Most children go home several hours after this surgery. Why the Procedure is Performed The tonsils help protect against infections. But children with large tonsils may have many sore throats and ear infections. You and your childs doctor may consider a tonsillectomy if: Risks The risks for any anesthesia are: Reactions to medications Breathing problems Your child has infections often (seven or more times in 1 year, or five or more times over 2 years). Your child misses a lot of school. Your child has trouble breathing. Your child has abscess or growth on their tonsils.

The risks for any surgery are: Bleeding Infection

Rarely, bleeding after surgery can go unnoticed and cause very bad problems. Swallowing a lot may be a sign of bleeding from the tonsils. Another risk includes injury to the uvula (soft palate). Before the Procedure

Your childs doctor may ask your child to have: Blood tests (complete blood count, electrolytes, clotting factors) A physical exam and medical history

Always tell your childs doctor or nurse: What drugs your child is taking Include any drugs, herbs, or vitamins you bought without a prescription

During the days before the surgery: Ten days before the surgery, your child may be asked to stop taking aspirin, ibuprofen (Advil, Motrin), naproxen (Aleve, Naprosyn), warfarin (Coumadin), and other drugs like these. Ask your childs doctor which drugs your child should still take on the day of the surgery.

On the day of the surgery: Your child will usually be asked not to drink or eat anything for several hours before the surgery. Give your child any drugs your doctor told you to give your child with a small sip of water. Your childs doctor or nurse will tell you when to arrive at the hospital.

After the Procedure A tonsillectomy is usually done in a hospital or surgery center. Your child will go home the same day as the surgery. Children rarely need to stay overnight in the hospital for observation. Complete recovery takes about 1 to 2 weeks. During the first week, your child should avoid people who are sick. It will be easier for your child to become infected during this time. Outlook (Prognosis) After surgery, the number of throat infections is usually lower, but your child will still get some. Alternative Names Tonsils removal References Wetmore RF. Tonsils and adenoids. In: Kliegman RM, Behrman RE, Jenson HB, Stanton BF, eds. Nelson Textbook of Pediatrics. 19th ed. Philadelphia, Pa: Saunders Elsevier; 2011:chap 375. Update Date: 11/12/2012 Updated by: Neil K. Kaneshiro, MD, MHA, Clinical Assistant Professor of Pediatrics, University of Washington School of Medicine. Also reviewed by A.D.A.M. Health Solutions, Ebix, Inc., Editorial Team: David Zieve, MD, MHA, David R. Eltz, Stephanie Slon, and Nissi Wang. Browse the Encyclopedia MedlinePlus Topics

Tonsils and Adenoids Images Throat anatomy Tonsillectomy Tonsillectomy - series Read More

Adenoid removal Otitis Tonsillitis Patient Instructions

Tonsil and adenoid removal - discharge Tonsil removal - what to ask your doctor

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http://www.medicinenet.com/tonsillectomy/article.htm

Tonsillectomy and Adenoidectomy Surgical Instructions

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Medical Author: John Mersch, MD, FAAP Medical Editor: William C. Shiel Jr., MD, FACP, FACR

Tonsillectomy and adenoidectomy introduction

Comment on thisRead 27 CommentsShare Your Story Your doctor has recommended a tonsillectomy and/or adenoidectomy for you, a loved one, or your child. The following information is provided to help individuals prepare for surgery, and to help those involved understand more clearly the associated benefits, risks, and complications. Patients or caregivers are encouraged to ask the doctor any questions they feel necessary to help better understand the above procedure. The tonsils and adenoids are masses of immune cells commonly found in lymph glands (lymphoid tissue). These tissues are located in the mouth and behind the nasal passages, respectively. Infected or enlarged tonsils may cause chronic or recurrent sore throat, bad breath, dental malocclusion, abscess, upper airway obstruction causing difficulty with swallowing, snoring, or sleep apnea. Infected adenoids may become enlarged, obstruct breathing, cause ear infections or other problems. Tonsillectomy and adenoidectomy are surgical procedures performed to remove the tonsils and adenoids. These instructions are designed to help you, a loved one, or your child recover from surgery as easily as possible. Taking care of yourself the individual having surgery can prevent complications. The doctor will be happy to answer any questions that you or the person having surgery has regarding this material. If you or your loved one, or child is having ear tube surgery (myringotomies and tympanostomy tubes placed) in conjunction with his/her tonsillectomy and adenoidectomy, please read information on these procedures as well.

What are the risks and complications of tonsillectomy and adenoidectomy?

Comment on thisRead 25 CommentsShare Your Story The patient's surgery will be performed safely and with care in order to obtain the best possible results. The surgery may involve risks of unsuccessful results, complications, or injury from both known and unforeseen causes. Because individuals differ in their response to surgery, their anesthetic reactions, and their healing outcomes, ultimately there can be no guarantee made as to the results or potential complications. Furthermore, surgical outcomes may be dependent on preexisting or concurrent medical conditions. The following complications have been reported in the medical literature. This list is not meant to be inclusive of every possible complication. They are listed here for your information only, not to frighten you, but to make you aware and more knowledgeable concerning this surgical procedure. Although many of these complications are rare, all have occurred at one time or another in the hands of experienced surgeons practicing the standard of community care. Anyone who is contemplating surgery must weigh the potential risks and complications against the potential benefits of the surgery or any alternative to surgery. 1. Failure to alleviate every episode of sore throat, or resolve subsequent or concurrent ear or sinus infections/nasal drainage. Possible need for additional surgery. 2. Bleeding. In very rare situations there may be a need for blood products or a blood transfusion. The patient has the right, should he/she choose, to have autologous or designated donor directed blood prepared in advance in case an emergency transfusion was necessary. Patients are encouraged to consult with a doctor if they are interested in this option. 3. Infection, dehydration, prolonged pain, and/or impaired healing that could lead to the necessity for hospital admission for fluids and/or pain control. 4. A permanent change in voice or nasal regurgitation (rare). 5. Failure to improve the nasal airway or resolve snoring, sleep apnea, or mouth breathing.

What happens before surgery?

In most situations the surgery is performed as an outpatient at either a hospital or a surgery center. In both facilities, quality care is provided without the expense and inconvenience of an overnight stay. An anesthesiologist will monitor the patient throughout the procedure. Usually, the anesthesiologist (or surgery staff) will call the night before surgery to review the medical history. If they are unable to reach the patient the night before surgery, they will talk with the patient the morning of the surgery. If the doctor has ordered preoperative laboratory studies, the patient should arrange to have these done several days in advance. The patient should arrange for

someone to take them to the surgical facility, back home, and to spend the first night after surgery with the patient. The patient should not take aspirin, or any product containing aspirin, within 10 days of the date of the surgery. Nonsteroidal antiinflammatory medications (such asibuprofen, Advil, and others) should not be taken within 7 days of the date of surgery. Many over-the-counter products contain aspirin or ibuprofen-related drugs so it is important to check all medications carefully. If there is any question please call the office or consult a pharmacist. Acetaminophen (Tylenol) is an acceptable pain reliever. Usually the doctor will give the patient several prescriptions at the preoperative visit. It is best to have these filled prior to the date of surgery so they are available when you return home. If it is a child who is having the surgery, it is advised that you be honest and up front with them as you explain their upcoming surgery. Encourage the child to think of this as something the doctor will do to make them healthier. Let them know that they will be safe and that you will be close by. A calming and reassuring attitude will greatly ease the child's anxiety. Let them know that if they have pain it will only be for a short time period, and that they can take medicines which will greatly reduce it. You may want to consider a visit to the surgical facility or hospital several days in advance to that the child can become familiar with the setting. Contact the surgical facility or hospital to arrange for a tour. The patient must not eat or drink anything 6 hours prior to the time of surgery. This includes even water, candy, or chewing gum. Anything in the stomach increases the chances of an anesthetic complication. If the patient is ill or has a fever the day before surgery, call the surgeon's office. If the patient wakes up sick the day of surgery, still proceed to the surgical facility as planned. The doctor will decide if it's safe to proceed with surgery. However, if your child has chickenpox, do not bring your child to the office or to the surgical facility.

What takes place the day of surgery?

It is important that the patient (or caregiver) knows precisely what time they are to check in with the surgical facility, and that they allow sufficient preparation time. Bring all papers, forms, and insurance information including the preoperative orders and history sheets. The patient should wear comfortable loose fitting clothes, (pajamas are OK). Leave all jewelry and valuables at home. Children may bring a favorite toy, stuffed animal, or blanket. The patient should not take any medication unless instructed by the doctor or anesthesiologist. Usually in the pre-operative holding room, a nurse will start an intravenous infusion line (IV) and the patient may be given a medication to help them relax.

What happens during surgery?

In the operating room, the anesthesiologist will usually use a mixture of gas and an intravenous medication for the general anesthetic. In most situations, an IV will have been started either in the preoperative holding room or after the patient has been given a mask anesthetic. During the procedure, the patient will be continuously monitored by a pulse oximeter (measuring oxygen saturation) and a continuous heart rate monitor. The surgical team is well trained and prepared for any emergency. In addition to the surgeon and anesthesiologist, there will be a nurse and a surgical technician in the room. After the anesthetic takes effect, the doctor will remove the tonsils and/or adenoids through the mouth. There will be no external incisions. The base of the tonsils and/or adenoids will be burned (cauterized) with an electrical cauterizing unit. The whole procedure usually takes less than 60 minutes. The doctor will come to the waiting room to talk with any family or friends once the patient is safely transferred to the recovery room.

What happens after surgery?

After surgery, the patient will be taken to the recovery room where a nurse will monitor them. Relatives are generally invited into the recovery room as the patient becomes aware of their surroundings, and if the patient is a child, they will be looking for his or her parent(s) or caregiver. The patient, will be able to go home the same day as the surgery once they have fully recovered from the anesthetic. This usually takes several hours. The patient will need a friend or family member to pick them up from the surgical facility to take them home. A relative, caregiver, or friend should spend the first night after surgery with the patient. When the patient arrives home from the surgical facility, they should go to bed and rest with the head elevated on 2-3 pillows. Keeping the head elevated above the heart minimizes edema and swelling. Applying an ice pack to the neck may help decrease swelling. The patient may get out of bed with assistance to use the bathroom. Visitors should be kept to a minimum since they may unknowingly expose the patient to infection, or cause over excitement. If the patient is constipated, avoid straining and take a stool softener or a gentle laxative. Once the patient has recovered from the anesthetic, if tolerable, a light, soft, and cool diet is recommended. Avoid hot liquids for several days. Even though the patient may be hungry immediately after surgery, it is best to feed slowly to prevent postoperative nausea and vomiting. Occasionally, the patient may vomit one or two times immediately after surgery. However, if it persists, the doctor may prescribe medications to settle the stomach. It is important to remember that a good overall diet with ample rest promotes healing. Weight loss is very common following a tonsillectomy. The patient need not worry about nutritional requirements during the recovery so long as they are drinking adequate amounts of fluid. The patient may be prescribed antibiotics after surgery. The patient should take all of the antibiotics prescribed by the doctor. Some form of a narcotic will also be prescribed (usually acetaminophen/Tylenol with codeine), and is to be taken as needed. If the patient requires narcotics he or she is cautioned not to drive. If the patient has nausea or vomiting postoperatively, the patient may be prescribed anti-emesis medications such

aspromethazine (Phenergan) or ondansetron (Zofran). If the patient or caregivers have any questions or feel the patient is developing a reaction to any of these medications, a doctor should be consulted. Patients should not take or give any other medications, either prescribed or overthe-counter, unless they have been discussed them the doctor.

General instructions and follow-up care

An appointment for a checkup should be made 10 to 14 days after the procedure. Call the office to schedule this appointment. The most important thing one can do after a tonsillectomy to prevent bleeding and dehydration is to drink plenty of fluids. At times it may be very difficult to swallow. If the patient drinks, they will have less pain overall. Try to drink thin dilute, non-acidic drinks or frozen popsicles. Soft foods such as gelatin, ice cream, custards, puddings, and mashed foods are helpful to maintain adequate nutrition. Hot, spicy, coarse, and scratchy foods such as fresh fruits, toast, crackers, and potato chips should be avoided because they may scratch the throat and cause bleeding. If dehydration occurs and attempts at home cannot correct the problem, then admission to the hospital for intravenous fluids will be necessary. Pain is common after a tonsillectomy. It is often hard to predict who will recover quickly or who will have prolonged pain. Immediately after surgery, many patients report only minimal pain. The next day the pain may increase and remain significant for several days. At one week following surgery, patient's will often appear to relapse when their pain becomes significant again. They usually report pain in the ears, especially when they swallow. The scabs are often falling off at this time. If bleeding is going to occur, this is the most common time. This pain is usually the last time pain will be experienced. Overall, most patients will have recovered fully by two weeks after surgery. However, the patient will occasionally have throat tenderness with hot or spicy foods for up to 6 weeks postoperatively. The patient will notice white patches in the back of the throat where the tonsils were formerly located. These are temporary scabs which occur during the healing process. They are not a sign of infection, and will fall off within the first two weeks following surgery and no attempt should be made to remove them. They will give the patient bad breath which will resolve once the area is fully healed. It will take up to 6 weeks for the throat to return to the normal pink color. It is not unusual to have nasal stuffiness following surgery. The nasal stuffiness may last for several months as swelling decreases. Saline nose drops (Ocean Spray) can be used to help dissolve any clots and decrease edema. The patient may notice persistent or even louder snoring for several weeks. A temporary change in voice is common following surgery, and will usually return to normal after several months. Bleeding occurs in 1%-3% of patients' after a tonsillectomy. Although it may occur at any time, it almost always occurs 5-10 days after the surgery. Dehydration and excessive activity increases the chances of postoperative bleeding. If bleeding occurs, the patient should try to remain calm and relaxed. Rinse the mouth out with cold water and rest with the head elevated. If the bleeding continues, call the doctor. Treatment of bleeding can be simple. Rarely it may require a trip back

to the operating room for cauterization of the bleeding area under general anesthesia. In very rare situations, a blood transfusion may become necessary. Conversely, bleeding is rare following an adenoidectomy. There may be some bleeding from the nose following surgery. If it occurs, pediatric Neosynephrine nose drops can be used. If it is persistent and bright red in color, call the doctor. Most patients require at least 7-10 days off from work or school. After 3 weeks exercise and swimming can usually be resumed, but no diving for 6 weeks. The patient should plan to stay in the local area for at least 2-3 weeks to allow for postoperative care and in case you have bleeding.

Tonsillectomy and Adenoidectomy At A Glance

Tonsillectomy and adenoidectomy is a surgical procedure performed to remove the adenoids. The tonsils and adenoids are masses of lymphoid tissue located behind the nasal passages. All surgical procedures have risks and potential complications. Understanding what is involved before, during, and after surgery can help the patient recover from surgery as comfortably as possible.

Last Editorial Review: 2/25/2009

http://www.webmd.com/oral-health/tonsillectomy-for-strep-throat

Oral Care
Tonsillectomy
A tonsillectomy is the surgical removal of the tonsils. The adenoids may or may not be removed at the same time. Adenoidectomy is not discussed in this topic. For more information, see the topic Ear Infections. A general anesthetic is always used to sedate a child having a tonsillectomy. Adults may require only a local anesthetic to numb the throat.
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What To Expect After Surgery The surgery may be done as outpatient surgery or, sometimes, during an overnight hospital stay. A very sore throat usually follows a tonsillectomy and may last for several days. This may affect the sound and volume of the person's voice and his or her ability to eat and drink. The person may also have bad-smelling breath for a few days after surgery. There is a very small risk of bleeding after surgery. A child having a tonsillectomy may feel "out of sorts" for a period of a week to 10 days. But if the child is feeling well enough, there is no need to restrict his or her activity or to keep the child at home after the first few days. Why It Is Done A tonsillectomy may be done in the following cases: A person has ongoing or recurring episodes of tonsillitis. A person has recurring episodes of strep throat in a single year despite antibiotic treatment. Abscesses of the tonsils do not respond to drainage. Or an abscess is present in addition to other indications for a tonsillectomy. A persistent foul odor or taste in the mouth is caused by tonsillitis and does not respond to antibiotic treatment. A biopsy is needed to evaluate a suspected tumor of the tonsil. Especially in children, the tonsils are so large they affect nighttime breathing, called sleep apnea. Large tonsils are not a reason to have a tonsillectomy unless they are causing one of the above problems or they are blocking the upper airway, which may causesleep apnea or problems with eating.

How Well It Works Children whose tonsils are removed for recurrent throat infections may have fewer and less severe strep throat infections for at least 2 years. But over time many children who do not have surgery also have fewer throat infections.1 Adults who have their tonsils removed after repeated strep throat infections don't get as many new infections as adults who do not have the surgery. And adults who had the surgery also don't get sore throats as often.2 Risks Normal or expected risks of tonsillectomy include some bleeding after surgery. This is common, especially when the healed scab over the cut area falls off. Less common or rare risks include: More serious bleeding. Anesthetic complications. Death after surgery (very rare). What To Think About When you are trying to decide whether to have the tonsils removed, you might want to think about: How much time a child is missing from school because of throat infections. How much stress and inconvenience the illness has on the family. The risks of surgery must also be weighed against the risks of leaving the tonsils in. In some cases of persistent strep throat infections, especially if there are other complications, surgery may be the best choice. Some people think that removing the tonsils may hurt the body's immune system, but research does not support this. Complete the surgery information form (PDF) to help you prepare for this surgery. Citations 1. Paradise JL, et al. (2002). Tonsillectomy and adenotonsillectomy for recurrent throat infection in moderately affected children.Pediatrics, 110(1): 7-15. 2. Alho OP, et al. (2007). Tonsillectomy versus watchful waiting in recurrent streptococcal pharyngitis in adults: Randomised controlled trial. BMJ. Published online March 8, 2007 (doi: 10.1136/bmj.39140.632604.55).