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Tonsillectomy and Adenoidectomy

Background

The tonsils are a pair of lymphoid tissue structures located in the back of throat. As they are a part of lymphatic system, they are involved in the body's immune defense against bacteria, viruses, and other pathogens. Tonsils come in a variety of sizes- large tonsils by themselves do not necessarily indicate a pathological problem. Tonsils generally are at their largest size in early childhood and then gradually recede in size over time. Tonsils often become inflamed during viral or bacterial throat infections. Viral infections typically resolve on their own, whereas bacterial infections, which are usually characterized by sore throat, fevers, and tonsils covered with white or yellow film, usually require antibiotic treatment. There are several processes that can occur that may require surgical removal of the tonsils, known as a tonsillectomy. The first is chronic bacterial tonsillitis. Tonsils can sometimes become chronic carries of bacteria, and as a result, they may be a source of recurrent bacterial infections despite repeated courses of antibiotics. If multiple infections are occurring yearly requiring antibiotics, and if these infections are causing significant interruptions in school or work attendance, then tonsillectomy may be indicated.

Another indication for tonsillectomy is obstructive sleep apnea. Sleep apnea is a serious health issue that can contribute to many future health problems, particularly related to the heart and lungs. Enlarged tonsils may cause an anatomical blockage in the back of the throat, causing breathing obstruction when sleeping. Warning signs indicating that sleep apnea may be present include heavy snoring, witnessed pauses in breathing, frequent waking up at night, and daytime tiredness or napping. Other signs that may be exhibited by children include frequent moving around in bed, daytime hyperactivity, and bed-wetting. A history of peritonsillar abscess is another indication for removal of tonsils. Bacterial tonsil infections can sometimes become so severe that a pus pocket, or abscess, can form around the tonsil itself. When this occurs, the abscess requires drainage along with antibiotic treatment. Untreated abscess can lead to potentially serious complications. Once a patient has had a peritonsillar abscess, they are at a higher risk for recurrence of the abscess, which is why tonsillectomy is often recommended. A significant asymmetry in tonsil size, particularly asymmetries that are relatively new in onset, can be a sign of a potentially more serious problem and may require a tonsillectomy to get tissue for pathological analysis. Another indication for tonsillectomy is chronic bad breath or tonsil stone (tonsillith) formation. The surface of the tonsils can sometimes have deep pits or crypts. These crypts are difficult to clean and may harbor food particles intermixed with calcium deposits known as tonsilliths. These tonsilliths may irritate the throat, causing patients to cough or spit them out of their mouth. They are also often a source of chronic halitosis, or bad breath.

The adenoids are a pad of lymphatic tissue located in the back part of the nasal cavity. Like the tonsils, they are involved in the body's immune defense against bacteria, viruses, and other pathogens, and can often become inflamed during viral or bacterial infections. Adenoids are at their largest in early childhood and gradually shrink over time. The primary reason for removing adenoid tissue is sleep apnea. Enlarged adenoids block the nasal airway, and since children primarily breathe through their nose at night, this effect is often more pronounced. Patients with sleep apnea secondary to enlarged adenoids can present with the same symptoms listed for tonsils along with chronic mouth breathing. Another indication for adenoid removal is chronic nasal obstruction and recurrent rhinitis/sinusitis in children. Most young children have underdeveloped nasal sinuses, so when they have recurrent sinonasal infections the culprit is often enlarged adenoids. A third indication for adenoidectomy is recurrent ear infections in children. The adenoids are located next to the openings to the eustachian tubes, which ventilate the middle ear. The adenoids can harbor bacteria that travel up the eustachian tube and cause repeated infection, or they can physically block the eustachian tube opening, which can cause chronic under ventilation of the middle ear which also leads to ear infection.

The Procedure

The surgery to remove the tonsils and adenoids is done in an ambulatory setting under general anesthesia and typically takes less than an hour. For children with sleep apnea, tonsillectomy is typically done in conjunction with adenoidectomy. The tonsil tissue is carefully dissected away from the surrounding throat muscles, and bleeding is controlled with electrocautery. Adenoids are removed in a similar manner. Both procedures are done through the mouth with no external cuts or scars.

After Surgery

Patients spend several hours in our recovery room before being discharged home. Pain after tonsillectomy can be quite severe- this pain is worse for older children and adults compared to younger children. Ear pain may occur during the first week after surgery. This is referred pain from the throat. Giving the prescription medication, as directed, plus a cold pack to the side of the neck and ear will give relief. One complication after surgery is dehydration secondary to pain, so it is important to encourage patients to continually drink fluids and to take pain medication as needed. Bed rest may be needed for 24 hours after surgery. Patients may be out of bed on the second day if their temperature is under 101 and may go out of doors on the third day if the weather is warm. Patients are encouraged to eat a regular diet as soon as they can tolerate it; however, most patients will be on a liquid/soft diet for several days Sharp-edged foods should be avoided as they can increase the risk of post-operative bleeding. Heavy lifting/straining/exercise/Aspirin use/NSAID use should be avoided for two weeks as well because all increase the risk of post-operative bleeding. An objectionable odor from the mouth and/or nose may be noticed for several days. The tonsil area (back of the throat) will appear white and foamy. Brush teeth and use mouthwash, but do not gargle. Do not use Listerine or Chloroseptic, but a milder mouthwash such as Cepacol (liquid or lozenges). Try to prevent coughing and clearing of the throat.

Risks of Surgery

There are several risks to tonsillectomy and adenoidectomy. The primary risk is post-operative bleeding. The risk for bleeding is highest at 7-10 days after surgery, and is primarily associated with tonsillectomy only. This is the time period when the scabs in the back of the throat slough off. If bleeding occurs, it typically is very light (less than 1/4 cup) and resolves almost immediately. Any bleeding heavier than that requires reevaluation in the ER or by your surgeon and may require cauterization of the bleeding site. This risk can be minimized by avoiding strenuous activity for two weeks after surgery, avoiding foods with sharp edges like chips for two weeks, and avoiding aspirin or NSAID for the same period of time. The overall risk of bleeding is approximately 2 percent. Another risk for both procedures is infection. This risk is very minimal and is lessened with post-operative antibiotics. A risk of tonsillectomy is change in voice. This risk may occur when particularly large tonsils are removed. This risk is very rare in occurrence, occurring less than 1% of the time. A risk of adenoidectomy is velopharyngeal insufficiency. This occurs when the palate does not for a complete seal with the back of the throat when speaking or swallowing. This can lead to hypernasal voice or food regurgitation through the nose. The main risk factor is cleft palate or submucosal cleft palate. Patients with these conditions should not have their adenoids removed. Another risk of adenoidectomy is eustachian tube scarring, which can lead to repeated ear infections. This is minimized by avoiding cauterization around the eustachian tube orifices when removing the adenoids.