Pediatric Ear, Nose & Throat
Tonsils and Tonsillectomy
The tonsils are two clumps of tissue, on either side of the throat, embedded in a pocket at the side of the palate (roof of the mouth). The lower edge of each tonsil is beside the tongue...way in the back of the throat. The adenoids are a single clump of tissue in the back of the nose (nasopharynx). They are located (in the adult) on the back wall of the throat (pharynx)...about one inch above the uvula (the little teardrop shaped piece of tissue that hangs down in the middle of the soft palate).
The tonsils and the adenoids are mostly composed of lymphoid tissue, which is found throughout the gastrointestinal tract and on the base of the tongue. Lymphoid tissue is composed of lymphocytes...which are mostly involved in antibody production. Since we generally consider antibody production to be a good thing, many studies have been performed to try to clarify the importance of the tonsils. There seems to be no adverse effect on the immune status or health of patients who have had them removed. Any noticeable effect has generally been positive. It appears that the tonsils and adenoids were not "designed" to effectively handle the multitude of viral infections that occur in children in an urban population. Rather, the immune system, including the tonsils and adenoids, developed during a era where the child was rarely exposed to a large number of other people and the germs they carried. It may also be that these organs are relatively more important in dealing with certain types of infections, such as worms or other parasites, that are relatively uncommon in today's society. It is clear that in many cases, the tonsils and/or the adenoids become "dysfunctional" and are more of a liability than an asset.
There are a number of well-established valid reasons for removal. Some patients will have more the one reason. The most common are listed below.
In general, yes. We rarely see patients over 40 years old with significant enlargement or infections of the tonsils. However, we have also seen 35 year old patients in severe heart failure due to sleep apnea and severely enlarged tonsils...about to undergo a heart transplant...and their doctor had said they did not need the tonsils out because they would outgrow the problem. (A tonsillectomy would have prevented the heart failure and years of sleep deprivation.) In short, the potential gain of a tonsillectomy (or any other procedure) has to be weighed against the likelihood of resolution, the risks of the procedure, the discomfort, and the expense. For many patients, tonsillectomy is still an appropriate decision.
At least in young children, enlargement or infection frequently affects the adenoids as well as the tonsils...so they are often removed together. Compared to a tonsillectomy, an adenoidectomy is less traumatic and painful.
There are many techniques used for tonsillectomy. General anesthesia is usually employed; but it is possible to perform tonsillectomy with sedation and local anesthesia. In the United States, some degree of electrocautery assisted dissection is most commonly employed, because of the ability to rapidly stop bleeding. Some surgeons use very little cautery...with more bleeding, but with less burned tissue. Use of lasers has been studied and considered by most surgeons. We feel that laser use is primarily a marketing gimmick at this point, since it offers no apparent advantage over certain cautery techniques, and has some very real hazards and extra costs.
Most surgical procedures share the general risks of anesthesia, bleeding, and infection. The anesthetic risk is, in general, proportional to the health of the patient; and serious problems should be very rare. Bleeding is most commonly encountered in a delayed fashion...five to ten days after surgery...when an eschar (scab) comes off. Post-operative bleeding is more likely in teenagers and adults, as opposed to younger children (who have smaller vessels). The area where the tonsils were removed (the tonsillar fossae) always become colonized with high numbers of bacteria, and often cause a low-grade fever. Serious infections are very rare. If tonsils are very large, speech may be different post-operatively (often temporarily high-pitched and "whiney"). Most often the post-op speech is actually more normal. Remember...very rarely, someone can die from complications of tonsillectomy (or any other surgery); so no surgical procedure should be undertaken lightly.
Not usually. Nine out of ten patients do well enough to go home. We will admit anyone who doesn't meet standard discharge criteria...significant breathing problems, no oral intake, severe nausea/vomiting, or serious co-existing illnesses. An occasional patient goes home, but comes back to the hospital, because of poor liquid consumption or bleeding.
After removal of the tonsils and adenoids, your child may lack energy and tire easily for several days, and be restless at night and not sleep well. These problems gradually get better in three to 14 days. Your child may be constipated for several days because of the codeine in the pain medication and because he or she will not feel like eating much.
The most important thing for your child to have in the first three days after surgery is liquids. This will help lessen problems with fever and constipation and promote healing. Make an effort to give your child a drink (2 or 3 ounces) every hour during waking hours for the first two days after surgery. Soft drinks, fruit juice nectars, jello, custard, popsicles or Gatorade® are good choices. Frequent small feedings of soft foods and cool liquids are usually the most comfortable. As your child’s appetite gets better, encourage him or her to eat solid foods. There are no limits to the foods you may give your child. Let your child have his or her favorite foods; it can’t hurt the throat. Your child should not drink through a straw after surgery until the throat is completely healed because it may increase the risk of bleeding.
Your child may feel sick to the stomach, throw up or feel tired and cranky after surgery. This should get better within a few hours. Occasionally, nausea and vomiting can be caused by the codeine in pain medication. A very sore throat or ear pain is normal after the tonsils are removed. Expect pain in the ears between the third and seventh days because the same nerve that goes to the tonsils also goes to the ears. Give recommended doses of pain medicine (any acetaminophen medicines, such as Tylenol®) four to five times a day for one week. If your child has severe pain, use the prescription pain medicine as labeled. DO NOT USE ASPIRIN OR IBUPROFEN because these medicines increase the chance of bleeding. You can use cool compresses or ice packs on your child’s neck to help your child feel more comfortable. You can also have your child suck on ice chips or chew gum. Prescriptions and instructions for taking the pain medication will be given to you in the recovery room prior to discharge as applicable.
It is normal for children to run a fever between 99°F (37°C) and 101°F (38°C) for the first few days after surgery. The fever will be worse if your child doesn’t drink enough liquids and becomes dehydrated. Give acetaminophen for the fever.
Bad breath is normal and is caused by a white to yellowish scab that forms over the tonsil surgery site. The scab breaks off during healing within five to 10 days and the bad breath will go away.
There should be no bleeding from the nose or mouth after your child returns home. Get up to check on your child once or twice during the first night after surgery. If there is any bleeding, take the child to the Emergency Center immediately. The ear, nose and throat (ENT) doctor on call will check your child. Between the fifth and 10th days after surgery, the scab breaks off the surgery site and your child may spit up some bloody mucus. If the bleeding does not stop in 20 to 30 minutes, bring your child to the Emergency Center.
It is best for your child to rest at home for the first 48 hours after surgery. Activity may be slowly increased as your child’s strength increases. There is no rule for the right time to go back to school, but a guideline is seven to 10 days after the tonsils are taken out. Rough play and contact sports should not be allowed until 14 days after tonsil or adenoid surgery. A school note will be provided after surgery.
Children' s Memorial Hermann Hospital6411 FanninHouston, Texas 77030
Phone: (713) 222-2273
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