kid2

Tonsils

  • What to expect when your child is having a tonsillectomy

    During your office visit, we will discuss the different facilities in the area where we can do your surgery.  Once you decide on a facility and a date, our office will schedule the procedure.  Prior to the day of surgery, you will get a call from the facility.  They will ask some of your child’s health history and will give you specific instructions on when to not let your child have anything to eat or drink prior to surgery.  The day before your surgery, you will get another call from the facility telling you the specific time that you need to arrive.  We arrange the schedule by age so that younger children go first.

    The day of surgery

    • The most important thing parents can do is help keep their child calm.  It is normal to be nervous when your child is having surgery but the more calm you are, the more your child will be at ease.
    • Once registered at the facility, your child will change into a hospital gown.
    • The anesthesiologist and anesthetist will meet with you and answer any questions you have regarding anesthesia and sedation.
    • Parents can stay with their child right up to the time that they are taken to the operating room.
    • Your child can bring along a comfort item, such as a stuffed animal, if they like.
    • Most children go home immediately after the surgery.  If there is concern that your child may need to stay overnight, we will choose an appropriate hospital for the surgery.

    What to expect after surgery

    • It takes 1-2 weeks to fully recover from tonsillectomy.  Younger children recover quicker.  For the first week, children should avoid strenuous activity.  They will be more comfortable with softer foods but can advance their diet as they wish.  It is not uncommon to have some intermittent fever immediately after the surgery.  This should be controlled with Tylenol or ibuprofen.
    • Our office will call and check on your child.
    • It is not uncommon for your child to experience ear or jaw pain after tonsillectomy.  This phenomenon is know as referred pain and is normal.
    • As the area where the tonsils were removed heals, you will notice a white covering.  This is normal and should not cause concern.
  • How do I choose the right ENT surgeon?

    You should pick someone with appropriate experience.  Since tonsillectomy is so common, most ENT physicians will have adequate experience.  It is also important that you and your child are comfortable with your physician and their office staff.

    Why do tonsils need removing?

    The most common reason we remove them is to help relieve sleep disordered breathing, or sleep apnea, in children.  Chronic or recurrent infection, although less common, is another potential reason.

    Below is a link to the most recent clinical practice guidelines from the American Academy of Otolaryngology-Head and Neck Surgery.

    Why do adenoids need removing?

    Adenoids, just like tonsils, can cause obstruction and can be a source of infection.  They are removed for the same reasons as, and often in conjunction with, the tonsils.  Adenoidectomy is associated with only mild discomfort afterward so most of the discussion centers on the tonsils.  Be aware, though, that adenoidectomy does cause foul-smelling breath for about a week afterward.

    How will my child be put to sleep?

    Older children and young adults get an IV while in the pre-op area.  We can then administer anesthetic medication through the IV as they drift off to sleep.  Younger child will breathe an anesthetic gas through a mask once they are in the operating room.  It only takes about three full breaths for children to be asleep so the process is very quick.  Some children benefit from sedation prior to the procedure.  If this is needed, your child will likely wake up slower and have to spend additional time in the recovery area afterward.  For that reason, we like to avoid pre-op sedation if possible as children tend to be much happier if we can get them back home and in a familiar environment quicker.  The most important thing you can do is to help your child remain calm.  It is normal to have some anxiety if your child is having surgery but the less anxiety they see in you, the easier it will be for them.

    Once your child is asleep, they will get an IV unless it was placed previously.  I prefer an anesthetic technique that uses a laryngeal mask airway LMA).  This prevents us from having to place a breathing tube into the airway.  We are able to use less anesthetic medication allowing the child to wake up quicker and with less sedation and nausea afterward.  This technique is particularly beneficial for children with sleep disordered breathing (sleep apnea) or asthma.

    Not all surgeons have experience with this anesthetic technique but, with appropriate experience, it offers some significant advantages as described in the article linked below.

    How do you remove the tonsils?

    There are numerous techniques that have been tried and I have experience with several of them including electrocautery, harmonic scalpel, microdebrider, and coblation.  My preference is to use low-powered electrocautery.  I also like to leave a little tonsil tissue behind, similar to what has been described as intracapsular tonsillectomy.  Doing the procedure with electrocautery, at least in my hands, creates less blood loss during the surgery and allows for use of the LMA as described above.  Leaving a little tonsil tissue allow for some of the benefits of intracapsular tonsillectomy.  The goal is to control and prevent bleeding but with minimal trauma to the surrounding tissue.  Below are two articles.  One describes the benefit of leaving a small amount of tonsil tissue behind and the other affirms the increased bleeding seen during surgery when using the microdebrider.

    How do you control pain afterward?

    One of the most important things to do is to encourage your child to drink plenty of fluids.  Doing so will help reduce pain and speed recovery.  I use Tylenol and Ibuprofen as first line pain medications.  Recent studies (linked below) have shown that these medications can be safely used after tonsillectomy.  In addition, I use an every other day dose of a steroid anti-inflammatory medication with the first dose given during surgery.  This medication helps significantly with pain and allows for a quicker return to normal diet.  Most children do not need additional medication for pain but, if they do, I use hydrocodone.  If used as directed, this medication is safe for children.

    Some children metabolize narcotic medications differently and most children with sleep disordered breathing, or sleep apnea, are more sensitive to the sedating effects of narcotics.  As a result, we like to minimize the use of these medications in children.  Codeine, in particular, should be avoided in children.  We have a specific pain management protocol that we use after tonsillectomy.

    Does my child need antibiotics after surgery?

    No.  In fact, the most recent clinical practice guideline recommends against the routine use of antibiotics after tonsillectomy.

    What about diet and activity after surgery?

    We ask that children refrain from strenuous activity until they are eating and drinking normally.  We do not, however, restrict their diet.  Recent studies have shown that restricting diet does not improve outcomes.  Children will want to stick to softer foods while the throat heals but they can advance their diet as their pain level allows.

    What about bleeding after surgery?

    Between 2% and 5% of patients will have some bleeding afterward, usually between days 5 and 10 after surgery.  Most bleeding resolves without treatment.  Rinsing and gargling with cold water will take care of the problem most of the time.  Nationally, about 1% of patients will have bleeding that requires a return to the hospital or emergency room.  Over the course of my career, between 0.3% and 0.5% of my patients experience this kind of bleeding.  When this happens, we cauterize the bleeding area.  I have never had a patient with blood loss that required a transfusion.

  • Post-Operative Instructions for Tonsillectomy With or Without Adenoidectomy

    • Our office will call you to arrange for follow-up.
    • It is important that you drink plenty of fluids.  This makes recovery quicker and helps control the pain.
    • For the first week, it will be more comfortable to eat soft foods.  You can advance your diet as the pain allows.
    • Avoid heavy lifting and strenuous activity until able to eat and drink normally.
    • You may have some intermittent fever for a couple of days after surgery.  Call our office if you are unable to control it with Tylenol and/or Ibuprofen.
    • If you experience any bleeding, rinse and gargle with cold water.  If the bleeding persists, call our office.
    • It is normal to have referred ear or jaw pain after surgery.
    • As the throat heals, you will notice white patches where the tonsils were.  This is normal and is not a sign of infection.  It can last up to two weeks.
    • It is also common to have some bad breath while the throat heals.  This is normal and is not a sign of infection.
    • If you need to go to an Emergency Room, please use Crestwood Medical Center so Dr. Lockette can see you.
  • Post-Operative Tonsillectomy Pain Management Protocol

    Acetaminophine

    • 10 mg/kg by mouth every 4 hours
    • Max: 1g per dose, 4g per day, 75 mg/kg/day

    Ibuprofen

    • 10 mg/kg by mouth every 8 hours
    • Max: 2400 mg per day, 40 mg/kg/day

    Dexamethasone

    • 0.5 mg/kg by mouth once a day on post-operative days 2, 4 and 6
    • Max: 20 mg dose

    Ondansetron ODT

    • 4 mg by mouth every 4 hours as needed for nausea/vomiting

    Hydrocodone/Acetaminophine Elixir

    0.1-0.15 mg/kg by mouth every 4 hours as needed for pain

    DO NOT TAKE ADDITIONAL TYLENOL WITH THIS MEDICATION

    Use acetaminophine and ibuprofen as first choice for pain control.  For the first week, make sure that your child gets these medications scheduled throughout the day.  It is not necessary to awaken your child but, if they are sleeping, resume scheduled dosing once they awaken.

    Give the dexamethasone on days 2, 4 and 6 following surgery.  Day 1 is the day that the tonsils were removed.  Although it can be given anytime, it is best to give the dexamethasone in the morning.

    If additional pain relief is needed, use hydrocodone as prescribed.  Start with the lowest dose and escalate only as needed being careful not to exceed the maximum dose prescribed for your child.  Since this medication contains Tylenol, it is important that you NOT take any additional Tylenol.