Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Tonsillectomy Treatment & Management

  • Author: Amelia F Drake, MD; Chief Editor: Arlen D Meyers, MD, MBA  more...
 
Updated: Oct 23, 2015
 

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) [3]
  • Local anesthetic
  • Sucralfate (debatable effect) [4]
Next

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.

Previous
Next

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:[5, 6, 7, 8]

  • 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

Tonsillectomy with cautery and suction are shown in the videos below.

Tonsillectomy performed with the cautery technique. A Colorado needle-tip bovie is used to dissect the tonsil from its underlying muscular bed.
A suction bovie is used to achieve hemostasis. Ideally, the least amount of cautery necessary for hemostasis is used. Staying in the proper dissection plane limits the amount of bleeding, and possibly postoperative pain.

Leave the lingual tonsil in situ.

Be cautious when suctioning the patient's airway.

Previous
Next

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.)

Sutters et al conducted a study comparing scheduled postoperative opioid analgesia (acetaminophen and hydrocodone 167 mg/2.5 mg per 5 mL PO q4h for 3 d) with as needed (PRN) opioid analgesia in children aged 6-15 years undergoing outpatient tonsillectomy. Children in the scheduled-dose group received more analgesia compared with the PRN group (p < 0.0001). Children in the PRN group had higher pain intensity scores (p=0.017). Pain intensity scores were higher in the morning compared with the evening (p < 0.0001).[9]

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.

Previous
Next

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.

Previous
Next

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]  However, a literature review by De Luca Canto et al indicated that respiratory compromise is the most frequent complication occurring in children (9.4%) following adenotonsillectomy, with secondary hemorrhage being the second most frequent (2.6%). The investigators also found that in children who undergo adenotonsillectomy, the risk of respiratory complications is 4.9 times higher in those who have obstructive sleep apnea than in children who do not, but the risk of postoperative bleeding is lower.[14, 15]

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)

A single intravenous dose of the corticosteroid drug dexamethasone, administered intraoperatively, reduces likelihood of vomiting and postoperative pain and morbidity in children.[16]

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.

Previous
Next

Outcome and Prognosis

Compared with watchful waiting, tonsillectomy or adenotonsillectomy provided an additional, but small, reduction in the episodes of sore throat, days of school absence associated with sore throat, and upper respiratory infections.[17] Results of other studies have suggested an overall patient satisfaction and improved quality of life.

Paradise and colleagues monitored patients who had recurrent throat infections. Those who had tonsillectomy had fewer throat infections in the first 2 years after treatment than those who did not have tonsillectomy.[18]

Levels of alpha-streptococci (inhibitory protective bacteria) have been shown to increase after tonsillectomy.[19] This further explains why tonsillectomy decreases the rate of streptococcal infection (including pharyngitis).

Recent literature that looks at the persistence of obstructive sleep apnea syndrome in children after surgery shows that adenotonsillectomy yields improvements in respiratory abnormalities in children with obstructive sleep apnea, but complete normalization occurs in only 25% of the patients.[20] The main determinants for surgical outcome include obesity, which is an increasing occurrence in children, and apnea hypopnea index (AHI) at diagnosis.[21] Authors noted that, in cases of ADHD, it is helpful to treat not just the disorder of attentional issues, but also underlying sleep problems, which have adverse effects on daytime behavior and attention.[22] Lastly, studies are now recognizing the high incidence of obstructive sleep issues in certain populations such as the cleft palate population.[23]

Previous
Next

Future and Controversies

Research on tonsillectomy is still popular. Whether an optimal method of tonsillectomy exists, whether perioperative steroids are useful, and whether outpatient tonsillectomy is safe are still unclear.

To treat airway obstruction from large tonsils, tonsillotomy with lasers may be less painful than tonsillectomy and just as successful. Radiofrequency reduction of the volume of submucosal tissue may also be used to achieve this end in adults. Well-designed studies are necessary to prove the effectiveness of these methods.

Further research on the efficacy of tonsillectomy to treat recurrent sore throats is still needed. We know of no definitive studies since the original study by Paradise et al, which showed that tonsillectomy is beneficial in patients with recurrent sore throats.[18]

A study of malpractice claims filed after tonsillectomy provided by 16 medical liability insurance companies identified 154 claims between 1985 and 2006. Bleeding complications led to 17.5% of the claims, while miscellaneous claims such as uvular injuries and postoperative scarring led to 45.5% of claims. Burn injuries accounted for 18.2% of claims. These figures suggest that the majority of malpractice claims following tonsillectomy stem from complications other than hemorrhage, which is typically considered the most common complication of the procedure.[24]

Previous
 
Contributor Information and Disclosures
Author

Amelia F Drake, MD Newton D Fischer Distinguished Professor of Otolaryngology, Department of Otolaryngology-Head and Neck Surgery, University of North Carolina at Chapel Hill 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, North Carolina Medical Society, American Society of Pediatric Otolaryngology

Disclosure: Nothing to disclose.

Coauthor(s)

Michele M Carr, DDS, MD, MEd, PhD Associate Professor, Department of Otolaryngology, Milton S Hershey Medical Center, Pennsylvania State University College of Medicine

Michele M Carr, DDS, MD, MEd, PhD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, 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, American Head and Neck Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan;RxRevu;SymbiaAllergySolutions<br/>Received income in an amount equal to or greater than $250 from: Symbia<br/>Received from Allergy Solutions, Inc for board membership; Received honoraria from RxRevu for chief medical editor; Received salary from Medvoy for founder and president; Received consulting fee from Corvectra for senior medical advisor; Received ownership interest from Cerescan for consulting; Received consulting fee from Essiahealth for advisor; Received consulting fee from Carespan for advisor; Received consulting fee from Covidien for consulting.

Acknowledgements

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.

Acknowledgments

Medscape Reference thanks Vijay R Ramakrishnan, MD, Assistant Professor, Department of Otolaryngology, University of Colorado School of Medicine, for the videos in this article.

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

  2. 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].

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

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

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

  6. 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. 2000 May 30. 52(3):239-46. [Medline].

  7. 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. 2004 Aug. 83(8 Suppl 3):4-13; quiz 14-5. [Medline].

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

  9. Sutters KA, Miaskowski C, Holdridge-Zeuner D, Waite S, Paul SM, Savedra MC, et al. A randomized clinical trial of the efficacy of scheduled dosing of acetaminophen and hydrocodone for the management of postoperative pain in children after tonsillectomy. Clin J Pain. 2010 Feb. 26(2):95-103. [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. 1986 Jun. 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. 1999 Oct 15. 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. 1997 Jul 18. 41(1):29-36. [Medline].

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

  14. De Luca Canto G, Pacheco-Pereira C, Aydinoz S, et al. Adenotonsillectomy Complications: A Meta-analysis. Pediatrics. 2015 Oct. 136 (4):702-18. [Medline].

  15. Henderson D. One fifth of kids have complication after tonsillectomy. Medscape Medical News. Sep 23, 2015. [Full Text].

  16. Steward DL, Grisel J, Meinzen-Derr J. Steroids for improving recovery following tonsillectomy in children. Cochrane Database Syst Rev. 2011 Aug 10. CD003997. [Medline].

  17. 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. 2005 Jan. 90(1):19-25. [Medline].

  18. 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. 1984 Mar 15. 310(11):674-83. [Medline].

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

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

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

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

  23. 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. 2009 Mar. 46(2):117-23. [Medline].

  24. Simonsen AR, Duncavage JA, Becker SS. A review of malpractice cases after tonsillectomy and adenoidectomy. Int J Pediatr Otorhinolaryngol. 2010 Sep. 74(9):977-9. [Medline].

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

  26. US Food and Drug Administration. FDA Drug Safety Communication: Codeine use in certain children after tonsillectomy and/or adenoidectomy may lead to rare, but life threatening adverse events or death. Available at http://www.fda.gov/Drugs/DrugSafety/ucm313631.htm. Accessed: March 27, 2013.

 
Previous
Next
 
Typical appearance on the morning after tonsillectomy, which was performed by using a blunt dissection method.
Tonsillectomy performed with the cautery technique. A Colorado needle-tip bovie is used to dissect the tonsil from its underlying muscular bed.
A suction bovie is used to achieve hemostasis. Ideally, the least amount of cautery necessary for hemostasis is used. Staying in the proper dissection plane limits the amount of bleeding, and possibly postoperative pain.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.