Chadwick N. Ahn, M.D.
Ronald Shashy, M.D.
TONSILLECTOMY AND ADENOIDECTOMY
What exactly are tonsils and adenoids?
Tonsils and adenoids are both composed of the same type of tissue known as “lymphoid”
tissue. Lymphoid tissue provides a place for the development and maturation of white blood
cells. There are hundreds of such collections of lymphoid tissue throughout the body. As such,
these other areas can readily take over the job of the tonsils and adenoids whenever they are
removed. The tonsils are located in the very back and side of the throat between the soft palate
and tongue. The adenoids are hidden in the very back of the nose in an area we call the
“nasopharynx”. This area is above the roof of the mouth and is difficult to examine without
special instruments or x-rays.
Why are tonsils and adenoids removed?
There was a time, which some parents might remember, when tonsils were routinely
removed. A tonsillectomy was as much a part of growing up as was losing your baby teeth.
Fortunately, those days are over. There are now specific indications for removing the adenoids
or tonsils of any patient.
1) Airway obstruction
Some people’s tonsils and adenoids are so large that they interfere with breathing.
Symptoms include loud snoring, nasal obstruction and congestion, runny nose,
and mouth breathing. The most severe form of obstruction is apnea. Patients
with apnea actually stop breathing while they sleep. Long term, the consequences
of apnea can be extremely detrimental to a patient’s health.
2) Recurrent tonsillitis
Some patients experience repeated episodes of tonsillar infections that cause them
to miss work or school and require them to take antibiotics and occasionally
steroids. We are particularly concerned about repeated “strep” infections.
“Strep” is short for Streptococcus, a particular type of bacteria that has a
propensity to cause infections in the tonsil.
3) “Strep carrier”
Some people are thought to harbor the Strep bacteria in their tonsils all of the
time, serving as a source of infection for themselves and others.
4) Asymmetry
Rarely, the tonsil can be a source of cancer, especially in older individuals who
smoke and drink alcohol heavily. On examination, both tonsils should be about
the same size – when one is significantly larger than the other, the surgeon may
recommend removal for biopsy purposes.
5) Peritonsillar abscess
This is a specific infection that develops around the capsule of the tonsil, and can
be quite serious. Treatment for this infection is surgical drainage and antibiotics.
Once the abscess has resolved, tonsillectomy is often recommended to prevent
this infection from returning.
6) Tonsil stones/tonsilliths
Some people develop hard “tonsil stones” that can be a source of pain and bad
breath. If these stones significantly alter the quality of life for a patient, then
tonsillectomy is routinely offered to eradicate the source.
The adenoids are often removed with the tonsils, especially in cases of airway
obstruction. When the tonsils are big enough to obstruct breathing, the adenoids are frequently
enlarged as well. In isolated cases, sometimes the adenoids are the primary culprit and will be
removed without the tonsils.
How is the procedure performed?
Tonsillectomy and Adenoidectomy (T&A) is performed in the hospital operating room
with the patient under general anesthesia. This is almost always an outpatient procedure – i.e.
overnight hospitalization is rarely required. With the patient asleep, an instrument is placed in
the mouth to hold it open and expose the back of the throat. This gives the surgeon easy
visualization of the tonsils, and the adenoids are viewed using a mirror. I typically use a cautery
device to remove the tonsils. There are many techniques utilized for tonsil removal – lasers,
coblator, radiofrequency, etc. The method I use has been tried the most and is safe, effective,
and cost-efficient.
After removal, electrocautery is used to control any bleeding. The tonsil area is then
injected with a long acting form of Marcaine and the patient is awakened and taken to the
recovery room.
Common Calls to the Doctor/Complications
1) Bleeding – the most common, serious complication following tonsillectomy. This
occurs in 1-2% of patients regardless of age, sex, etc. Most episodes are minor and
stop with simple measures such as gargling ice water. Some bleeding may be severe
enough to necessitate a visit to the emergency room and rarely a return to the
operating room to control the source of bleeding. You will get my cell phone number
after surgery to call in case of a bleeding emergency. If bleeding occurs, it typically
happens within the first 24 hours after surgery or at the 7-10 day post-op time period.
To minimize risk of bleeding, I am adamant that all patients drink plenty of fluid and
restrain from physical activity for two weeks (14 days) after surgery.
2) Pain – although not really a complication, it is something I get called about routinely.
I expect all of my patients to experience some pain following surgery. Pain is unique
to the individual, but as a general rule I tell my patients to expect 7-10 days of
discomfort. In adults, this pain is typically more severe. I give everyone liquid
narcotics and antibiotics to assist with the pain. Additionally, I supply every patient
with tetracaine lollipops, which are suckers that dissolve in the mouth and instantly
numb the throat and tonsil areas. The more a patient drinks and swallows, the shorter
the recovery period.
3) Nausea and vomiting – this commonly occurs during the first day after surgery due
to the lingering effects of the anesthesia. It can also occur as a side effect of the pain
medication. If it occurs beyond the first day, give me a call and I may switch the pain
medication or call in Zofran/Phenergan for the nausea.
4) Allergic Reactions – this can be minimized by informing the surgeon and
anesthesiologist of any unusual reactions you or your child may have experienced in
the past.
5) Fever – this is a common response to the stress of surgery. Fever in the range of 99101.5 can be expected in the first several days following surgery. Very high fevers
(>102) that respond poorly to medication should be brought to my attention. Do not
give over the counter Motrin/Aleve/Ibuprofen/aspirin/etc. as this may increase
bleeding risk.
6) Voice Changes – sometimes after surgery, patients may experience a change in
voice. This is usually a temporary change that will disappear as the healing process is
completed.
7) Risk of anesthesia – T&A is performed under general anesthesia, and in otherwise
healthy individuals, the risk is generally extremely low. The anesthesiologist will
discuss these complications in more detail with you, and if you have any questions
regarding anesthesia technique, please bring this to their attention on the morning of
surgery.
8) Color changes in the throat – it is normal for the tonsil area to form a gray-white
membrane after the tonsils are removed. This will go away and be replaced by the
normal pink lining of the throat when healing is complete. This does not represent
thrush.
9) Nasal congestion – most patients experience nasal congestion and drainage after the
adenoids are removed. This may lead to coughing during the post-op period, and this
is normal. Blowing the nose is ok as long as it is done gently. Afrin nasal spray can
be used in limited applications – two sprays in each nostril twice a day for only two
days. It is very important to not use Afrin for longer periods as it can lead to a
rebound effect and subsequent addiction to the product. Cold nasal saline (keep it in
the refrigerator) can also be used instead of the Afrin and it can be used as often as
you like.
10) School excuse – if the patient is a child in school, I generally ask the parent to call us
when he/she is ready to return. We will mail the excuse to the school to cover the
dates missed. This allows us to excuse the patient for as long as necessary.
11) Taste disturbance – this is typically a temporary change that resolves in 3-4 weeks
following surgery. It may be a side effect of medications, the healing process, or the
tongue depressor that is used during surgery.
12) Bad breath – I caution patients to expect this for 2-3 weeks following surgery. This
is a self-limiting process that will resolve without any intervention.
13) Ear pain – one of the most common calls I get is regarding post-op ear pain. This is
extremely common and expected. The same nerves that control sensation in the
throat also supply the ears – when the tonsil area hurts, the ears often do as well. We
call this effect “referred pain”. Unfortunately, there are no medications I can give to
help outside of the narcotics that I prescribe for the pain.
14) The “Post-tonsillectomy” Wall – it is common for the patient to regress 3-5 days
after surgery. Parents get especially worried when they see general progress in terms
of pain control and suddenly encounter a morning of increased pain. Almost every
patient goes through this rough transition. I recommend routine use of the pain
medication during and through this time to minimize the intensity of the discomfort.
15) Swollen lips and swollen uvula – The device I use to open the mouth during surgery
stretches the lips to a moderate degree. As a result, you will likely notice some lip
swelling for 24-48 hours. The uvula, which is the descending portion of the soft
palate near the tonsils, will also swell occasionally. Both of these events are
considered normal, and both will spontaneously resolve.
Alternatives to surgery
By the time most patients are referred to me for consideration of T&A surgery, the family
physician or pediatrician will have exhausted most, if not all, nonsurgical options. In patients
having T&A surgery for recurrent infections, continued treatment of these infections with
antibiotics remains an option. In cases of significant airway obstruction, medications designed to
improve nasal breathing (decongestants, nasal steroid sprays, etc.) are sometimes tried with
varying levels of success. While it is true that some children’s airway obstruction improves with
age, this improvement with observation alone may take several years to become evident.
Diet and activity after surgery
Patients are usually discharged from the hospital several hours after their procedure. The
remainder of the day is to be used for recovery from the anesthesia. Most patients spend the
majority of the day sleeping. After the first day, I encourage patients to spend time out of bed –
you will feel the need to take frequent naps, and this is ok. Short walks and quiet, non-contact
activity is allowed to help regain strength. I ask all patients to refrain from strenuous activity for
14 DAYS after the surgery. If patients are in school, physical education classes must be
withheld as well. Most children will miss approximately a week of school and adults usually
miss about the same amount of work. This timeframe is patient specific, as everyone’s recovery
schedule is unique.
The degree of discomfort following T&A requires dietary adjustments to ensure adequate
hydration and caloric intake. Hydration (fluid balance) is extremely important. This is
especially true the first several days after surgery. A patient can become significantly
dehydrated in only a few days if enough fluids are not consumed. Fluids can be administered in
several forms: juices, sodas, water, popsicles, ice cubes, broths, jello, and soups. Once liquids
are being tolerated well, soft solid foods may be introduced. The only true restriction I have for
my patients is that they avoid sharp foods such as pretzels, chips, Doritos, etc. As long as the
patient is drinking enough fluids, there is no great rush to start solid foods. Some patients will
lose 5-10 lbs during the post-op period, and almost always gain it back quickly once the
discomfort subsides.
How severe is the pain after surgery?
T&A is an operation like any other in which tissue is cut and removed. It is therefore
anticipated that patients will experience some degree of pain. During surgery, I inject a longacting form of an anesthetic into the areas where the tonsils were removed. This provides 4-8
hours of pain relief. I inject the tonsil area to give my patients immediate relief in the postoperative recovery period. Unfortunately, this medication wears off and additional pain
medications must be taken by mouth. Most patients experience moderately severe pain for the
first 3-5 days following surgery. The pain medications prescribed help to lessen this pain and
make it tolerable. Pain medications taken by mouth usually take 30-45 minutes to become fully
effective and last for 3-4 hours. During the first 3-5 days, it is recommended that these
medications be given on a regular schedule rather than “as needed”. All medications given
should be taken as directed, and any adverse reactions should be reported to the office.
Tetracaine lollipops are given after surgery and are to be used in conjunction with the
liquid oral medication. The lollipops topically “numb” the back of the throat and tonsil areas.
This effect usually lasts for 10-15 minutes. If the lollipops don’t work well, or if patients don’t
like the taste, I will also often recommend Chloraseptic throat spray.
What should be done is bleeding occurs?
In the unusual event that significant bleeding is noted from the mouth, the patient should
immediately gargle cold ice water. DO NOT SWALLOW THE WATER IF AT ALL
POSSIBLE. Gargling will stop the majority of bleeding episodes. If the bleeding persists, you
should call my cell phone and go to the emergency room.
I hope that this information has been helpful to you. It is not intended to replace the advice and
recommendations of the physician and I encourage you to ask any question or voice any
concerns that you might have. Thank you very much for the honor and privilege of taking care
of you and your healthcare needs.
Sincerely,
Chadwick N. Ahn, MD
Ronald Shashy, MD