Tonsillectomy Treatment & Management
- Author: Amelia F Drake, MD; Chief Editor: Arlen D Meyers, MD, MBA more...
Adjunctive intraoperative medical therapy may include the following:
Careful history taking is needed to evaluate for the following:
Bleeding disorders or wish to avoid transfusion
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.
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)
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
Tonsillectomy with cautery and suction are shown in the videos below.
Leave the lingual tonsil in situ.
Be cautious when suctioning the patient's airway.
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).
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.
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.
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.
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.
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. 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.
Levels of alpha-streptococci (inhibitory protective bacteria) have been shown to increase after tonsillectomy. 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. The main determinants for surgical outcome include obesity, which is an increasing occurrence in children, and apnea hypopnea index (AHI) at diagnosis. 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. Lastly, studies are now recognizing the high incidence of obstructive sleep issues in certain populations such as the cleft palate population.
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.
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.
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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.