Tonsillectomy and adenotonsillectomy
Tonsillectomy and adenotonsillectomy
Key points to remember
- a tonsillectomy is an operation to remove the tonsils
- an adenotonsillectomy is an operation to remove both the adenoids and tonsils
- the reasons for an adenotonsillectomy are usually snoring/obstructed breathing/pauses between breathing at night (see snoring or noisy breathing), or frequent and severe bouts of tonsillitis or chronic tonsillitis
- it takes 10 to 14 days for children to recover from the operation
- you can care for your child at home by giving regular pain relief (as advised by your doctor) and encouraging plenty of fluids
- don't give your child any aspirin or aspirin-containing medicines (such as Aspro, AsproClear or Codis). If you are unsure, check the label and see if the words aspirin or salicylic acids are mentioned. Aspirin may increase the risk of bleeding during or after surgery and may increase the risk of a serious and rare disease named Reye syndrome
- bleeding from the operation site can be a complication - if this happens give your child some ice to suck. If it does not stop after 5 minutes or if there is a large amount of blood (more than 1 to 2 teaspoonfuls), dial 111 within New Zealand and ask for emergency medical help (use the appropriate emergency number in other countries)
What are tonsils and adenoids?
Tonsils and adenoids are lumps of tissue (similar to the 'glands' that are in the neck and other parts of the body).
The tonsils sit on either side of the back of the throat (pharynx).
Adenoids sit where the back of the nose meets the throat. They can't be seen through the mouth without the use of special instruments.
Tonsils and adenoids are usually larger in children but tend to shrink to adult proportions by the age of 8 to 12 years.
Although tonsils and adenoids are part of the immune system (the body's defence against potentially harmful germs), they are not essential and there is no harm to the immune system if they are removed. Other parts of the immune system in the upper throat continue to function.
What is a tonsillectomy/adenotonsillectomy?
A tonsillectomy is an operation to remove the tonsils.
An adenotonsillectomy is an operation to remove both the adenoids and tonsils.
How do I know if tonsils and adenoids are causing problems for my child?
Big tonsils in child with obstructive sleep apnoea.
Tonsillitis - tonsils have yellow, cheesy material on them.
If tonsils and/or adenoids get too big they can:
- cause narrowing of the airway during sleep which makes it difficult for your child to breathe
- cause blockage of the nose resulting in mouth breathing and a nasal sounding voice
- cause snoring, which can be a sign of obstructive sleep apnoea
- contribute to repeated throat infections or tonsillitis (swelling and inflammation of the tonsils)
- cause difficulty eating
- cause continuing nasal discharge
- cause an infection of the sinuses (sinusitis). The sinuses are air-filled hollow spaces in the bone of the cheeks and forehead
- change the growth of the upper jaw and cause changes in the position of the teeth
Long lasting (chronic) adenoid infection (not necessarily with enlargement) may contribute to glue ear and/or repeated ear infections due to swelling and redness of the tube between the throat and middle ear (eustachian tube).
When might my child need a tonsillectomy/adenotonsillectomy?
Your doctor may recommend a tonsillectomy/adenotonsillectomy if your child has:
- obstructed breathing at night, accompanied by snoring and restlessness; short pauses in breathing (apnoeas) may occur (see snoring or noisy breathing)
- frequent and severe bouts of tonsillitis; as a general guideline:
- 7 or more infections in 1 year (and each infection is severe enough to affect normal life such as needing time off school)
- 5 each year over 2 consecutive years or
- 3 to 4 each year over 3 or more years
- long lasting (chronic) tonsillitis – when there is so much damage to the tonsils that they remain infected and do not respond well to antibiotic treatment. The throat is sore much of the time, often with bad breath and sometimes yellow, cheesy, bad smelling and tasting material in the small cracks in the tonsils
Often, a combination of factors are considered when deciding whether or not a tonsillectomy/adenotonsillectomy is necessary.
How successful is the operation?
For sleep disordered breathing
Studies show that an adenotonsillectomy will cure or improve symptoms of sleep disordered breathing in 80 to 97 percent of cases. The operation is more successful if there are no other conditions that may be contributing to sleep disordered breathing (such as obesity). On rare occasions, the adenoids may regrow.
For repeated acute tonsillitis
Once the tonsils have been removed, tonsillitis should never happen again. Throat infections due to colds and influenza will still happen (see sore throat fact sheet).
Who will perform the operation?
Your family doctor will refer you to a specialist ENT (ear nose and throat) surgeon (also known as an otolaryngologist or ORL surgeon). After talking to you and examining your child they may recommend removal of the tonsils and/or adenoids.
What happens to my child during the operation?
- a tonsillectomy/adenotonsillectomy is usually a 40 minute operation. A child may have a partial tonsillectomy only on rare occasions for night time obstructive breathing, but usually a complete tonsillectomy is done to minimise the risks of needing a repeat tonsillectomy later
- your child will have a general anaesthetic
- the operation is performed through the mouth
- there are usually no stitches in the throat
- there will be a small raw patch, like a graze, on each side of the throat where the tonsils are removed which will take 10 to 14 days to heal
How long will my child need to be in hospital after the operation?
In some surgical centres, tonsillectomies/adenotonsillectomies are performed as a day procedure; in other centres, an overnight stay in hospital is required. Usually there is a minimum recovery period of 4 hours in hospital after the surgery. Some children with severe obstructive sleep apnoea before the operation may need to have their breathing monitored more closely in hospital after the operation. These children may need to stay in hospital longer.
What can my child expect after the operation?
- a tonsillectomy with or without an adenoidectomy is a painful and uncomfortable procedure. Your child's throat can be sore for 10 to 14 days after the operation
- 5 to 6 days after the operation the pain may get worse as the white membrane over the healing area contracts
- there is much less discomfort after an adenoidectomy alone
- your child may have referred pain to the ear for 7 to 10 days following an adenotonsillectomy
- you will notice white areas over the throat where the tonsils were removed; this does not mean infection and will resolve within the first 2 to 3 weeks after surgery
- bad breath is common during healing
- there can be some blood stained saliva, nasal discharge or bleeding after the operation. Sucking ice can help this, but if there is a larger amount of fresh blood (more than 1 to 2 teaspoonfuls) or if the bleeding continues for more than 5 minutes, dial 111 within New Zealand and ask for emergency medical help (use the appropriate emergency number in other countries)
- some children's voices can be slightly different after the operation but soon return to normal after 3 or 4 weeks
- some children experience a change in their sense of taste after the operation but this usually only lasts for a few weeks
How can I care for my child at home?
- pain relief is important after the operation. Your doctor or nurse can advise you about what pain relief to use. Giving pain relieving medication (such as paracetamol) regularly is important for as long as your child needs it
- make sure you don’t give your child any aspirin or aspirin-containing medicines (such as Aspro, AsproClear or Codis). If you are unsure, check the label and see if the words aspirin or salicylic acids are mentioned. Aspirin may increase the risk of bleeding during or after surgery and may increase the risk of a serious and rare disease named Reye syndrome
- please discuss the use of any other medicines or remedies with your doctor during this period
- encourage your child to eat and drink as normally as possible. They may feel more comfortable having softer foods initially. Avoid giving your child hot liquids, acidic or highly spiced foods for several days. Cool fluids and ice blocks are a good option. Fluids are especially important to help your child recover, to prevent dehydration and the build up of debris and blood clots at the operation site
- giving pain relief 30 minutes before eating can help. Regular pain relief (as advised by your doctor) can help your child drink adequate amounts
- vomiting once or twice after leaving hospital is common. If your child feels sick, stop giving food and fluid for a few hours then try small amounts when they are feeling better. If your child continues to vomit contact your doctor
- children should rest for 5 to 7 days after their operation; they should avoid sports and swimming for 14 days. They can usually return to more normal activity after 14 days. Children will usually need 2 weeks off school
- many doctors give antibiotics following a tonsillectomy as there is evidence that this speeds the healing process, reduces postoperative pain and may lessen the chance of bleeding
What are the complications?
Bleeding after the operation
- bleeding from the area where the tonsils have been removed (the tonsillar bed) is the most frequent complication; it occurs in 2 to 5 percent of children
- dehydration and excessive activity following the operation increase the chances of bleeding
- in most cases the bleeding is relatively mild. Only a small number of children have to return to the operating theatre to stop the bleeding or even more rarely for a blood transfusion
- bleeding may occur more commonly 7 to 14 days after the operation but can occur up to 21 days after the operation. It is best to avoid going away in the 3 weeks following the operation in case of bleeding. It is strongly recommended that you not travel overseas or to a remote area during this period
- if bleeding occurs get your child to suck on ice or drink cold water and rest with their head raised on a high pillow
- if there is a large amount of blood (more than 1 to 2 teaspoonfuls) or if the bleeding continues for more than 5 minutes, dial 111 within New Zealand and ask for urgent medical help (use the appropriate emergency number in other countries)
- infection following an adenotonsillectomy is not common. Increasing pain or fever can be a sign of infection
When should I seek help?
Dial 111 within New Zealand and ask for urgent medical help (use the appropriate emergency number in other countries) if:
- bleeding does not stop after 5 minutes of rest, elevation and sucking on ice
- there is a large amount of blood (more than 1 to 2 teaspoonfuls)
Return to the hospital where your child had the operation, or the nearest hospital emergency department if:
- your child continues to vomit and cannot take any fluids
- your child is experiencing pain that is not controlled by the pain relief that was prescribed
- your child has a fever greater than 38 degrees for longer than 4 hours
Paediatrics and Child Health Division of The Royal Australasian College of Physicians and The Australian Society of Otolaryngology, Head and Neck Surgery. 2008. Indications for tonsillectomy and adenotonsillectomy in children: A joint position paper.
The diagram of the tonsils has been reproduced with kind permission from Great Ormond Street Hospital for Children NHS Trust. © GOSH Trust 2001.
Thank you to Dr Murali Mahadevan for providing the photos of enlarged tonsils and tonsillitis from his personal collection.