Tonsillectomy and adenoidectomy introduction

Your doctor has recommended a tonsillectomy and/or adenoidectomy for you, a loved one, or your child. The following information is provided to help individuals prepare for surgery, and to help those involved understand more clearly the associated benefits, risks, and complications. Patients or caregivers are encouraged to ask the doctor any questions they feel necessary to help better understand the above procedure.

The tonsils and adenoids are masses of immune cells commonly found in lymph glands (lymphoid tissue). These tissues are located in the mouth and behind the nasal passages, respectively. Infected or enlarged tonsils may cause chronic or recurrent sore throat, bad breath, dental malocclusion, abscess, upper airway obstruction causing difficulty with swallowing, snoring, or sleep apnea. Infected adenoids may become enlarged, obstruct breathing, cause ear infections or other problems. Tonsillectomy and adenoidectomy are surgical procedures performed to remove the tonsils and adenoids.

These instructions are designed to help you, a loved one, or your child recover from surgery as easily as possible. Taking care of yourself the individual having surgery can prevent complications. The doctor will be happy to answer any questions that you or the person having surgery has regarding this material. If you or your loved one, or child is having ear tube surgery (myringotomies and tympanostomy tubes placed) in conjunction with his/her tonsillectomy and adenoidectomy, please read information on these procedures as well.

What are the risks and complications of tonsillectomy and adenoidectomy?

The patient's surgery will be performed safely and with care in order to obtain the best possible results. The surgery may involve risks of unsuccessful results, complications, or injury from both known and unforeseen causes. Because individuals differ in their response to surgery, their anesthetic reactions, and their healing outcomes, ultimately there can be no guarantee made as to the results or potential complications. Furthermore, surgical outcomes may be dependent on preexisting or concurrent medical conditions.

The following complications have been reported in the medical literature. This list is not meant to be inclusive of every possible complication. They are listed here for your information only, not to frighten you, but to make you aware and more knowledgeable concerning this surgical procedure. Although many of these complications are rare, all have occurred at one time or another in the hands of experienced surgeons practicing the standard of community care. Anyone who is contemplating surgery must weigh the potential risks and complications against the potential benefits of the surgery or any alternative to surgery.

1. Failure to alleviate every episode of sore throat, or resolve subsequent or concurrent ear or sinus infections/nasal drainage. Possible need for additional surgery.
   
   
2. Bleeding. In very rare situations there may be a need for blood products or a blood transfusion. The patient has the right, should he/she choose, to have autologous or designated donor directed blood prepared in advance in case an emergency transfusion was necessary. Patients are encouraged to consult with a doctor if they are interested in this option.
   
   
3. Infection, dehydration, prolonged pain, and/or impaired healing that could lead to the necessity for hospital admission for fluids and/or pain control.
   
   
4. A permanent change in voice or nasal regurgitation (rare).
   
   
5. Failure to improve the nasal airway or resolve snoring, sleep apnea, or mouth breathing.

What happens before surgery?

In most situations the surgery is performed as an outpatient at either a hospital or a surgery center. In both facilities, quality care is provided without the expense and inconvenience of an overnight stay. An anesthesiologist will monitor the patient throughout the procedure. Usually, the anesthesiologist (or surgery staff) will call the night before surgery to review the medical history. If they are unable to reach the patient the night before surgery, they will talk with the patient the morning of the surgery. If the doctor has ordered preoperative laboratory studies, the patient should arrange to have these done several days in advance. The patient should arrange for someone to take them to the surgical facility, back home, and to spend the first night after surgery with the patient.

The patient should not take aspirin, or any product containing aspirin, within 10 days of the date of the surgery. Nonsteroidal antiinflammatory medications (such as ibuprofen, Advil, and others) should not be taken within 7 days of the date of surgery. Many over-the-counter products contain aspirin or ibuprofen-related drugs so it is important to check all medications carefully. If there is any question please call the office or consult a pharmacist. Acetaminophen (Tylenol) is an acceptable pain reliever. Usually the doctor will give the patient several prescriptions at the preoperative visit. It is best to have these filled prior to the date of surgery so they are available when you return home.

If it is a child who is having the surgery, it is advised that you be honest and up front with them as you explain their upcoming surgery. Encourage the child to think of this as something the doctor will do to make them healthier. Let them know that they will be safe and that you will be close by. A calming and reassuring attitude will greatly ease the child's anxiety. Let them know that if they have pain it will only be for a short time period, and that they can take medicines which will greatly reduce it. You may want to consider a visit to the surgical facility or hospital several days in advance to that the child can become familiar with the setting. Contact the surgical facility or hospital to arrange for a tour.

The patient must not eat or drink anything 6 hours prior to the time of surgery. This includes even water, candy, or chewing gum. Anything in the stomach increases the chances of an anesthetic complication.

If the patient is ill or has a fever the day before surgery, call the surgeon's office. If the patient wakes up sick the day of surgery, still proceed to the surgical facility as planned. The doctor will decide if it's safe to proceed with surgery. However, if your child has chickenpox, do not bring your child to the office or to the surgical facility.

What takes place the day of surgery?

It is important that the patient (or caregiver) knows precisely what time they are to check in with the surgical facility, and that they allow sufficient preparation time. Bring all papers, forms, and insurance information including the preoperative orders and history sheets. The patient should wear comfortable loose fitting clothes, (pajamas are OK). Leave all jewelry and valuables at home. Children may bring a favorite toy, stuffed animal, or blanket.

The patient should not take any medication unless instructed by the doctor or anesthesiologist. Usually in the pre-operative holding room, a nurse will start an intravenous infusion line (IV) and the patient may be given a medication to help them relax.

What happens during surgery?

In the operating room, the anesthesiologist will usually use a mixture of gas and an intravenous medication for the general anesthetic. In most situations, an IV will have been started either in the preoperative holding room or after the patient has been given a mask anesthetic. During the procedure, the patient will be continuously monitored by a pulse oximeter (measuring oxygen saturation) and a continuous heart rate monitor. The surgical team is well trained and prepared for any emergency. In addition to the surgeon and anesthesiologist, there will be a nurse and a surgical technician in the room.

After the anesthetic takes effect, the doctor will remove the tonsils and/or adenoids through the mouth. There will be no external incisions. The base of the tonsils and/or adenoids will be burned (cauterized) with an electrical cauterizing unit. The whole procedure usually takes less than 60 minutes. The doctor will come to the waiting room to talk with any family or friends once the patient is safely transferred to the recovery room.

What happens after surgery?

After surgery, the patient will be taken to the recovery room where a nurse will monitor them. Relatives are generally invited into the recovery room as the patient becomes aware of their surroundings, and if the patient is a child, they will be looking for his or her parent(s) or caregiver. The patient, will be able to go home the same day as the surgery once they have fully recovered from the anesthetic. This usually takes several hours. The patient will need a friend or family member to pick them up from the surgical facility to take them home. A relative, caregiver, or friend should spend the first night after surgery with the patient.

When the patient arrives home from the surgical facility, they should go to bed and rest with the head elevated on 2-3 pillows. Keeping the head elevated above the heart minimizes edema and swelling. Applying an ice pack to the neck may help decrease swelling. The patient may get out of bed with assistance to use the bathroom. Visitors should be kept to a minimum since they may unknowingly expose the patient to infection, or cause over excitement. If the patient is constipated, avoid straining and take a stool softener or a gentle laxative.

Once the patient has recovered from the anesthetic, if tolerable, a light, soft, and cool diet is recommended. Avoid hot liquids for several days. Even though the patient may be hungry immediately after surgery, it is best to feed slowly to prevent postoperative nausea and vomiting. Occasionally, the patient may vomit one or two times immediately after surgery. However, if it persists, the doctor may prescribe medications to settle the stomach. It is important to remember that a good overall diet with ample rest promotes healing. Weight loss is very common following a tonsillectomy. The patient need not worry about nutritional requirements during the recovery so long as they are drinking adequate amounts of fluid.

The patient may be prescribed antibiotics after surgery. The patient should take all of the antibiotics prescribed by the doctor. Some form of a narcotic will also be prescribed (usually acetaminophen/Tylenol with codeine), and is to be taken as needed. If the patient requires narcotics he or she is cautioned not to drive. If the patient has nausea or vomiting postoperatively, the patient may be prescribed anti-emesis medications such as promethazine (Phenergan) or ondansetron (Zofran). If the patient or caregivers have any questions or feel the patient is developing a reaction to any of these medications, a doctor should be consulted. Patients should not take or give any other medications, either prescribed or over-the-counter, unless they have been discussed them the doctor.

General instructions and follow-up care

An appointment for a checkup should be made 10 to 14 days after the procedure. Call the office to schedule this appointment.

The most important thing one can do after a tonsillectomy to prevent bleeding and dehydration is to drink plenty of fluids. At times it may be very difficult to swallow. If the patient drinks, they will have less pain overall. Try to drink thin dilute, non-acidic drinks or frozen popsicles. Soft foods such as gelatin, ice cream, custards, puddings, and mashed foods are helpful to maintain adequate nutrition. Hot, spicy, coarse, and scratchy foods such as fresh fruits, toast, crackers, and potato chips should be avoided because they may scratch the throat and cause bleeding. If dehydration occurs and attempts at home cannot correct the problem, then admission to the hospital for intravenous fluids will be necessary.

Pain is common after a tonsillectomy. It is often hard to predict who will recover quickly or who will have prolonged pain. Immediately after surgery, many patients report only minimal pain. The next day the pain may increase and remain significant for several days. At one week following surgery, patient's will often appear to relapse when their pain becomes significant again. They usually report pain in the ears, especially when they swallow. The scabs are often falling off at this time. If bleeding is going to occur, this is the most common time. This pain is usually the last time pain will be experienced. Overall, most patients will have recovered fully by two weeks after surgery. However, the patient will occasionally have throat tenderness with hot or spicy foods for up to 6 weeks postoperatively.

The patient will notice white patches in the back of the throat where the tonsils were formerly located. These are temporary scabs which occur during the healing process. They are not a sign of infection, and will fall off within the first two weeks following surgery and no attempt should be made to remove them. They will give the patient bad breath which will resolve once the area is fully healed. It will take up to 6 weeks for the throat to return to the normal pink color. It is not unusual to have nasal stuffiness following surgery. The nasal stuffiness may last for several months as swelling decreases. Saline nose drops (Ocean Spray) can be used to help dissolve any clots and decrease edema. The patient may notice persistent or even louder snoring for several weeks. A temporary change in voice is common following surgery, and will usually return to normal after several months.

Bleeding occurs in 1%-3% of patients' after a tonsillectomy. Although it may occur at any time, it almost always occurs 5-10 days after the surgery. Dehydration and excessive activity increases the chances of postoperative bleeding. If bleeding occurs, the patient should try to remain calm and relaxed. Rinse the mouth out with cold water and rest with the head elevated. If the bleeding continues, call the doctor. Treatment of bleeding can be simple. Rarely it may require a trip back to the operating room for cauterization of the bleeding area under general anesthesia. In very rare situations, a blood transfusion may become necessary. Conversely, bleeding is rare following an adenoidectomy. There may be some bleeding from the nose following surgery. If it occurs, pediatric Neosynephrine nose drops can be used. If it is persistent and bright red in color, call the doctor.

Most patients require at least 7-10 days off from work or school. After 3 weeks exercise and swimming can usually be resumed, but no diving for 6 weeks. The patient should plan to stay in the local area for at least 2-3 weeks to allow for postoperative care and in case you have bleeding.

When to call the doctor

Notify the doctor if the patient has:

1. A sudden increase in the amount of bleeding from the mouth or nose that lasts more than a few minutes.
   
   
2. A fever greater than 101.5 F (38.6 C) that persists despite increasing the amount of fluid they drink and administration of acetaminophen (Tylenol and others). A child with a fever should try to drink approximately one-half cup of fluid each waking hour, and an adult should drink one cup per hour.
   
   
3. Persistent sharp pain or headache which is not relieved by pain medications prescribed.
   
   
4. Increased swelling or redness of the nose, neck, or eyes.

Tonsillectomy and Adenoidectomy At A Glance

• Tonsillectomy and adenoidectomy is a surgical procedure performed to remove the adenoids.
  
  
• The tonsils and adenoids are masses of lymphoid tissue located behind the nasal passages.
  
  
• All surgical procedures have risks and potential complications.
  
  
• Understanding what is involved before, during, and after surgery can help the patient recover from surgery as comfortably as possible.

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