eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Pediatric Otolaryngology

Tonsillectomy: Treatment

Author: Amelia F Drake, MD, Chief, Division of Pediatric Otolaryngology, Newton D Fischer Distinguished Professor of Surgery, Department of Otolaryngology-Head and Neck Surgery, University of North Carolina School of Medicine
Coauthor(s): Michele M Carr, DDS, MD, MEd, Associate Professor, Department of Otolaryngology, Hershey Medical Center
Contributor Information and Disclosures

Updated: Aug 6, 2009

Treatment

Medical Therapy

Adjunctive intraoperative medical therapy may include the following:

  • Rectal acetaminophen in children
  • Intravenous antiemetics
  • Intravenous narcotics (except if a history of airway obstruction is present)
  • Intravenous steroids (controversial, probably a small benefit)4
  • Local anesthetic
  • Sucralfate (debatable effect)5

Preoperative Details

  • Careful history taking is needed to evaluate for the following:
    • Bleeding disorders or wish to avoid transfusion
    • Anesthesia intolerance
    • Obstructive sleep apnea
  • In patients with Down syndrome, order cervical spine images to evaluate for C1-C2 subluxation. Also, be aware of possible underlying cardiac disease.
  • Sleep studies are recommended if the severity of the patient's symptoms is uncertain.
  • Regarding admission planning, insurance plans are increasingly disallowing inpatient admission for tonsillectomy or adenoidectomy. Children who should be admitted are those with obstructive sleep apnea, those with significant comorbid disease such as hypotonia or neuromotor delays, and those younger than 3 years.

Intraoperative Details

  • Place the patient in the Rose position with a shoulder roll.
  • Carefully, insert a mouth prop, and open and suspend it.
  • Apply an Alyss clamp to the tonsil to allow for traction during dissection.
  • Variations in dissection methods include the following:6,7 8,9
    • Use of cold steel (eg, scissors, curettes)
    • Monopolar cautery
    • Bipolar cautery with or without a microscope
    • Radiofrequency ablation, or coblation (can be used to shrink tonsils)
    • Harmonic scalpel with vibrating titanium blades
    • Powered instruments (eg, microdebrider) for an intracapsular technique
  • Variations in hemostasis methods include the following:
    • Pressure with sponge for several minutes
    • Use of bismuth subgallate
    • Use of ties
    • Suction cautery
    • Bipolar cautery
  • Leave the lingual tonsil in situ.
  • Be cautious when suctioning the patient's airway.

Postoperative Details

  • Use liquid acetaminophen (Tylenol) with or without codeine for pain control. (The unwillingness of parents to give analgesics is associated with children's refusal to eat, which results in dehydration, weight loss, and local infection.)
  • Maintain good hydration.
  • The patient should eat an adequate diet. No evidence suggests that a special diet is required; however, soft foods are more easily swallowed than hard foods.
  • Administer antibiotics. Oral antibiotic use for the week after tonsillectomy is associated with improved outcomes in children.10,11
  • Instruct the patient to avoid smoking.
  • Instruct the patient to avoid heavy lifting and exertion for 10 days.
  • Warn patients that pain will abate during the first 3-5 days then increase for 1-2 days before completely disappearing.
  • Most often, tonsillectomy is safely performed on an outpatient basis. Individuals who should not receive tonsillectomy as outpatients are those younger than 3 years, those with obstructive sleep apnea, those who live far away from the outpatient facility, those with Down syndrome, or those who have difficulty in complying with instructions.

Follow-up

Ideal times for follow-up care are (1) when the pain has its second peak (at 5-8 days) to reassure patients and (2) at 4-6 weeks after surgery to monitor for the resolution of symptoms. A phone call by a registered nurse may be adequate for postoperative follow-up, though the decision about the method of follow-up is up to the patient and surgeon.

Complications

Hemorrhage is the most common complication. An estimated 2-3% of patients have hemorrhage, and 1 of 40,000 patients die from bleeding.12 13

Pressure can be applied to a bleeding tonsil fossa by using a sponge and a long clamp. Dipping the sponge in epinephrine or thrombin powder may be helpful. If this fails, the patient should be taken to the operating room. Options to stop the bleeding are electrocautery of the tonsil bed, use of further topical hemostatics, or ligation of the ipsilateral carotid artery as the last resort. Diathermy is thought to be superior to ligation because of the risk of perforating large vessels with the needle. In severe situations, a sponge may be fixed in place by using sutures. Another last resort is ligation of other large vessels, such as the external carotid artery.

Bleeding may be classified as intraoperative, primary (occurring within the first 24 hours), or secondary (occurring between 24 hours and 10 days).

Other complications include the following:

  • Pain (eg, sore throat, otalgia)
  • Dehydration (common in children who do not eat because of pain)
  • Weight loss (common in children who do not eat because of pain)
  • Fever (not common, usually related to local infection)
  • Postoperative airway obstruction (because of uvular edema, hematoma, aspirated material)
  • Pulmonary edema (occurs in people with true airway obstruction caused by tonsils)
  • Local trauma to oral tissues
  • Tonsillar remnants or subsequent regrowth
  • Vocal changes (If the tonsils are large, the patient's voice may be muffled, as the resonance has changed)
  • Temporomandibular joint dysfunction, pain or clicking, which can be associated with any procedure in which the mouth is opened widely
  • Psychological trauma, night terrors, or depression
  • Death (uncommon, usually related to bleeding or anesthetic complications)

Late complications are nasopharyngeal stenosis and velopharyngeal incompetence. These complications are most likely to occur if adenoidectomy or uvulopalatopharyngoplasty is undertaken at the same time as tonsillectomy.

More on Tonsillectomy

Overview: Tonsillectomy
Workup: Tonsillectomy
Treatment: Tonsillectomy
Follow-up: Tonsillectomy
Multimedia: Tonsillectomy
References
Further Reading
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References

  1. Gabriel P, Mazoit X, Ecoffey C. Relationship between clinical history, coagulation tests, and perioperative bleeding during tonsillectomies in pediatrics. J Clin Anesth. Jun 2000;12(4):288-91. [Medline].

  2. Howells RC 2nd, Wax MK, Ramadan HH. Value of preoperative prothrombin time/partial thromboplastin time as a predictor of postoperative hemorrhage in pediatric patients undergoing tonsillectomy. Otolaryngol Head Neck Surg. Dec 1997;117(6):628-32. [Medline].

  3. Fujikawa S, Hanawa Y, Ito H, Ohkuni M, Todome Y, Ohkuni H. Streptococcal antibody: as an indicator of tonsillectomy. Acta Otolaryngol Suppl. 1988;454:286-91. [Medline].

  4. Carr MM, Williams JG, Carmichael L, Nasser JG. Effect of steroids on posttonsillectomy pain in adults. Arch Otolaryngol Head Neck Surg. Dec 1999;125(12):1361-4. [Medline].

  5. Ozcan M, Altuntas A, Unal A, Nalca Y, Aslan A. Sucralfate for posttonsillectomy analgesia. Otolaryngol Head Neck Surg. Dec 1998;119(6):700-4. [Medline].

  6. Carr MM, Muecke CJ, Sohmer B, Nasser JG, Finley GA. Comparison of postoperative pain: tonsillectomy by blunt dissection or electrocautery dissection. J Otolaryngol. Feb 2001;30(1):10-4. [Medline].

  7. Pizzuto MP, Brodsky L, Duffy L, Gendler J, Nauenberg E. A comparison of microbipolar cautery dissection to hot knife and cold knife cautery tonsillectomy. Int J Pediatr Otorhinolaryngol. May 30 2000;52(3):239-46. [Medline].

  8. Lee KC, Bent JP 3rd, Dolitsky JN, Hinchcliffe AM, Mansfield EL, White AK. Surgical advances in tonsillectomy: report of a roundtable discussion. Ear Nose Throat J. Aug 2004;83(8 Suppl 3):4-13; quiz 14-5. [Medline].

  9. Nelson LM. Radiofrequency treatment for obstructive tonsillar hypertrophy. Arch Otolaryngol Head Neck Surg. Jun 2000;126(6):736-40. [Medline].

  10. Telian SA, Handler SD, Fleisher GR, Baranak CC, Wetmore RF, Potsic WP. The effect of antibiotic therapy on recovery after tonsillectomy in children. A controlled study. Arch Otolaryngol Head Neck Surg. Jun 1986;112(6):610-5. [Medline].

  11. Colreavy MP, Nanan D, Benamer M, et al. Antibiotic prophylaxis post-tonsillectomy: is it of benefit?. Int J Pediatr Otorhinolaryngol. Oct 15 1999;50(1):15-22. [Medline].

  12. Rakover Y, Almog R, Rosen G. The risk of postoperative haemorrhage in tonsillectomy as an outpatient procedure in children. Int J Pediatr Otorhinolaryngol. Jul 18 1997;41(1):29-36. [Medline].

  13. Randall DA, Hoffer ME. Complications of tonsillectomy and adenoidectomy. Otolaryngol Head Neck Surg. Jan 1998;118(1):61-8. [Medline].

  14. van Staaij BK, van den Akker EH, van der Heijden GJ, Schilder AG, Hoes AW. Adenotonsillectomy for upper respiratory infections: evidence based?. Arch Dis Child. Jan 2005;90(1):19-25. [Medline].

  15. Paradise JL, Bluestone CD, Bachman RZ, et al. Efficacy of tonsillectomy for recurrent throat infection in severely affected children. Results of parallel randomized and nonrandomized clinical trials. N Engl J Med. Mar 15 1984;310(11):674-83. [Medline].

  16. Richtsmeier WJ, Shikhani AH. The physiology and immunology of the pharyngeal lymphoid tissue. Otolaryngol Clin North Am. May 1987;20(2):219-28. [Medline].

  17. Tauman R, Gulliver TE, Krishna J, et al. Persistence of obstructive sleep apnea syndrome in children after adenotonsillectomy. J Pediatr. Dec 2006;149(6):803-8. [Medline].

  18. Lam YY, Chan EY, Ng DK, et al. The correlation among obesity, apnea-hypopnea index, and tonsil size in children. Chest. Dec 2006;130(6):1751-6. [Medline].

  19. Galland BC, Dawes PJ, Tripp EG, Taylor BJ. Changes in behavior and attentional capacity after adenotonsillectomy. Pediatr Res. May 2006;59(5):711-6. [Medline].

  20. Maclean JE, Waters K, Fitzsimons D, Hayward P, Fitzgerald DA. Screening for obstructive sleep apnea in preschool children with cleft palate. Cleft Palate Craniofac J. Mar 2009;46(2):117-23. [Medline].

  21. Fowler RH. The rise of the tonsil operation. In: Tonsil Surgery: Based on a Study of the Anatomy. Philadelphia: FA Davis Co; 1931:54-60.

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Further Reading

Clinical guidelines

Thomas M. Specific management of IgA nephropathy: role of tonsillectomy. Nephrology 2006 Apr;11(S1):S146-8.

Finnish Medical Society Duodecim. Sore throat and tonsillitis. In: EBM Guidelines. Evidence-Based Medicine [Internet]. Helsinki, Finland: Wiley Interscience. John Wiley & Sons; 2007 Feb 2

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Keywords

tonsils, tonsillectomy, tonsillectomy surgery, tonsillectomy procedure, sore throat, swollen tonsils, tonsil infection, tonsillitis, palatine tonsils, tonsillectomy adults

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Contributor Information and Disclosures

Author

Amelia F Drake, MD, Chief, Division of Pediatric Otolaryngology, Newton D Fischer Distinguished Professor of Surgery, Department of Otolaryngology-Head and Neck Surgery, University of North Carolina School of Medicine
Amelia F Drake, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Otolaryngology-Head and Neck Surgery, American Cleft Palate/Craniofacial Association, American Society of Pediatric Otolaryngology, and North Carolina Medical Society
Disclosure: Nothing to disclose.

Coauthor(s)

Michele M Carr, DDS, MD, MEd, Associate Professor, Department of Otolaryngology, Hershey Medical Center
Michele M Carr, DDS, MD, MEd is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery
Disclosure: Nothing to disclose.

Medical Editor

Ari J Goldsmith, MD, Chief of Pediatric Otolaryngology, Long Island College Hospital; Associate Professor, Department of Otolaryngology, Division of Pediatric Otolaryngology, State University of New York Downstate Medical Center
Ari J Goldsmith, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Medical Association, and Medical Society of the State of New York
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Gregory C Allen, MD, Assistant Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine
Gregory C Allen, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Academy of Pediatrics, American Cleft Palate/Craniofacial Association, American College of Surgeons, American Laryngological Rhinological and Otological Society, American Medical Association, Christian Medical & Dental Society, and Colorado Medical Society
Disclosure: Nothing to disclose.

CME Editor

Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders
Christopher L Slack, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine
Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Head and Neck Society
Disclosure: Covidien Corp Consulting fee Consulting; US Tobacco Corporation unstricted gift unknown; Axis Three Corporation Ownership interest Consulting; Omni Biosciences Ownership interest Consulting; Sentegra Ownership interest Board membership; Syndicom Ownership interest Consulting; Oxlo  Consulting; Medvoy Ownership interest Management position

 
 
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