Tonsils & Adenoids Surgery

Dr Jason Roth (MED0001185485) — Specialist Otolaryngologist & Head and Neck Surgeon, specialist registration in Otorhinolaryngology, Head & Neck Surgery.

Tonsillectomy and adenotonsillectomy are among the most frequently performed surgical procedures in ENT. They address a range of conditions — from recurrent tonsillitis and peritonsillar abscess, to tonsillar hypertrophy causing obstructive sleep apnoea, to chronic tonsillitis with tonsil stones and persistent halitosis. Understanding the anatomy, the range of indications, the surgical technique, and the recovery process in detail allows patients to make well-informed decisions about proceeding with surgery.

Anatomy — The Tonsils and Adenoids

The Waldeyer Ring

The tonsils and adenoids are components of Waldeyer’s ring — a circular band of lymphoid tissue surrounding the entrance to the pharynx that constitutes part of the mucosal immune system. Waldeyer’s ring includes the palatine tonsils (one on each side of the oropharynx), the pharyngeal tonsil or adenoid (at the roof of the nasopharynx), the lingual tonsils (at the base of the tongue), and smaller collections of lymphoid tissue on the posterior pharyngeal wall and around the Eustachian tube openings (tubal tonsils).

This lymphoid tissue functions as a front-line immune defence, sampling antigens from inhaled and swallowed material, generating immune responses through B and T lymphocyte activation, and producing secretory immunoglobulin A (sIgA). The tonsils and adenoids are most active immunologically in early childhood — their relative size peaks between the ages of three and seven, coinciding with the period of maximum exposure to new pathogens as children enter group care and school. After this peak, physiological involution gradually reduces their size through childhood and adolescence.

The Palatine Tonsils

The palatine tonsils are paired ovoid structures situated in the tonsillar fossae at the sides of the oropharynx, between the anterior (palatoglossal) and posterior (palatopharyngeal) pillars. Each tonsil is covered on its medial surface by squamous epithelium invaginated into multiple deep crypts, which increase the surface area available for antigen sampling. These crypts also collect desquamated epithelial cells, dead white blood cells, food debris, and bacteria — forming the tonsil stones (tonsilliths) that cause halitosis in some patients.

The tonsil’s lateral surface is separated from the superior constrictor muscle of the pharynx by a thin fibrous capsule and a potential space — the peritonsillar space. This space fills with pus during a peritonsillar abscess (quinsy). The proximity of the external carotid artery and its branches to the tonsil bed explains the risk of significant haemorrhage in tonsil surgery.

The Adenoid

The pharyngeal tonsil (adenoid) is an unpaired collection of lymphoid tissue on the posterior and superior wall of the nasopharynx. It sits immediately behind the posterior choanae — the opening from the nose into the nasopharynx — and adjacent to the Eustachian tube openings on the lateral walls. Enlarged adenoids therefore simultaneously obstruct nasal breathing (causing mouth breathing and contributing to snoring) and can mechanically obstruct the Eustachian tube opening or serve as a reservoir of bacteria perpetuating middle ear disease.

Unlike the palatine tonsils, the adenoid is not directly visible through the mouth — it is visualised by passing a small mirror behind the soft palate (indirect nasopharyngoscopy) or with a flexible or rigid nasendoscope through the nose.

Indications for Surgery

Recurrent Acute Tonsillitis

The most common indication for tonsillectomy in adults and older children. The standard UK and Australian threshold (Paradise criteria, modified) is seven or more episodes in one year, five or more per year for two consecutive years, or three or more per year for three consecutive years — provided the episodes are of sufficient severity to impair daily function, require antibiotic treatment, or include documented throat culture or rapid antigen test positive for Group A Streptococcus (GAS). The evidence strongly supports tonsillectomy in patients who meet these criteria: the number of sore throat episodes is substantially reduced, quality of life improves, and antibiotic use decreases.

Peritonsillar Abscess (Quinsy)

A peritonsillar abscess is a collection of pus in the peritonsillar space, almost always following bacterial tonsillitis. It presents with severe unilateral sore throat, trismus (difficulty opening the mouth from spasm of the pterygoid muscles), uvular deviation, and a “hot potato” (muffled) voice. Management involves drainage — either by needle aspiration or incision and drainage under local anaesthesia — and intravenous antibiotics. Tonsillectomy is generally recommended in patients who have had two or more quinsy episodes, or electively six to eight weeks after a first episode in patients with a significant background of recurrent tonsillitis. Interval tonsillectomy (at six to eight weeks, when the inflammatory changes have resolved) is preferred over immediate “quinsy tonsillectomy” because the acute anatomy is less favourable and bleeding risk is higher.

Obstructive Sleep Apnoea and Sleep-Disordered Breathing

Adenotonsillectomy is the standard first-line surgical treatment for paediatric obstructive sleep apnoea where tonsillar and adenoid hypertrophy are the primary contributors. In adults, tonsillectomy with UPPP (uvulopalatopharyngoplasty) addresses oropharyngeal obstruction in patients with OSA who are not suitable for or tolerant of CPAP, particularly when tonsil size is grade 3–4 and the palate is the dominant collapse site. Patient selection for adult surgical OSA treatment is guided by drug-induced sleep endoscopy.

Chronic Tonsillitis and Tonsil Stones

Chronic cryptic tonsillitis — persistent low-grade infection within the tonsil crypts — causes continuous or recurrent sore throat, chronic bad breath (halitosis), tonsil stones (caseous concretions of keratin, dead cells, and bacteria that lodge in the crypts and produce a fetid odour), and generalised fatigue. These symptoms are often underestimated as an indication for tonsillectomy because they do not meet the frequency criteria for recurrent acute tonsillitis. However, in patients with significant quality of life impact from these symptoms, tonsillectomy is effective and appropriate.

Tonsillar Asymmetry or Suspected Malignancy

Marked asymmetry in tonsil size in an adult — particularly with firmness, surface irregularity, or associated cervical lymphadenopathy — raises concern for tonsillar lymphoma or squamous cell carcinoma, and requires urgent assessment. Tonsillectomy for histological diagnosis is indicated where biopsy alone is insufficient. Human papillomavirus (HPV)-associated oropharyngeal squamous cell carcinoma is an increasing cause of unilateral tonsillar malignancy in adults, even in non-smokers — any adult with a persistent, unilateral tonsillar mass should be assessed promptly.

Adenoid-Only Indications

Adenoidectomy without tonsillectomy is appropriate for: adenoid-related nasal obstruction and mouth breathing; recurrent or persistent glue ear where the adenoid is a contributing factor (adenoidectomy at the time of grommet insertion reduces recurrence rates); recurrent sinusitis in children where the adenoid serves as a bacterial reservoir; and nasopharyngeal obstruction in children who do not have tonsil hypertrophy.

The Surgery — Technique in Detail

Tonsillectomy

Tonsillectomy is performed under general anaesthesia with the patient supine and the neck slightly extended. A Boyle-Davis mouth gag holds the mouth open and depresses the tongue, providing access to the oropharynx. The tonsil is grasped with forceps and retracted medially. A dissection is performed in the peritonsillar plane — the layer between the tonsil capsule and the superior constrictor muscle — using a combination of sharp dissection (scalpel or scissors), diathermy (monopolar or bipolar), or the harmonic scalpel. The tonsil’s blood supply (derived primarily from the dorsal lingual artery, the ascending palatine artery, and the tonsillar branch of the facial artery) is controlled as the dissection proceeds. Local anaesthetic is infiltrated into the tonsillar bed at the conclusion to reduce early post-operative pain. A thorough check for haemostasis is performed before the patient is woken.

Adenoidectomy

The adenoid is visualised with a small mirror passed behind the soft palate, or with a 0-degree or 30-degree rigid nasal endoscope. The standard technique uses a suction diathermy or a powered microdebrider (shaver) to remove the adenoid tissue under direct vision through the nose. Bleeding is controlled with suction diathermy applied to the adenoid bed. The Eustachian tube openings are identified and protected to avoid injury. The procedure adds approximately 10–15 minutes to the operation.

Recovery — A Detailed Guide

Recovery from tonsillectomy is typically more demanding than patients anticipate, particularly in adults. Managing expectations accurately reduces anxiety and improves adherence to pain management protocols.

Days 1–2 — immediate post-operative period

Most patients are discharged the same day or after one overnight stay. Nausea is common in the first 24 hours from the anaesthetic; anti-nausea medication is given on the ward. The throat is sore but often not at its worst on day 1 due to residual local anaesthetic. Regular paracetamol and oxycodone (as prescribed) should be commenced and maintained around the clock for the first five days — do not wait for pain to become severe before taking analgesia.

Days 3–6 — the peak pain window

Pain typically worsens progressively in the first three to five days as the local anaesthetic resolves, the wound inflammatory response develops, and the tonsillar bed muscles undergo reactive oedema. Referred otalgia (ear pain) from the glossopharyngeal nerve is common and expected — it does not indicate an ear infection. Maintaining adequate analgesia and keeping up fluid intake are the two most important tasks. Adults consistently experience more pain than children after tonsillectomy.

Days 5–10 — healing membrane and gradual improvement

A white or greyish-yellow membrane forms over the healing tonsillar fossae — this is fibrin and granulation tissue, not infection, and does not require antibiotics. Pain should gradually improve after day five or six but may plateau or transiently worsen as the membrane begins to detach around days eight to twelve. This phase is the highest-risk period for secondary haemorrhage.

Days 10–14 — membrane detachment and haemorrhage risk

The period of highest secondary haemorrhage risk is between days 5 and 14 post-operatively, peaking around day 10 when the healing membrane detaches from the underlying granulation tissue, exposing vessels. Blood-streaked saliva is common and not concerning. Frank bleeding from the mouth requires urgent emergency department attendance — do not wait to see whether it stops. Most secondary bleeds settle with observation or antibiotics, but approximately 1–2% require a return to theatre for vessel ligation under general anaesthesia.

Weeks 2–3 — return to normal activity

Most patients feel substantially better by the end of the second week. Return to non-physical work is appropriate for most after 10–14 days. Strenuous exercise, heavy lifting, contact sports, and alcohol should be avoided for three weeks from the date of surgery — these activities increase blood pressure and the risk of haemorrhage while the wound is still healing.

Risks and Complications

Seek immediate emergency assessment for any of the following:

Bleeding from the mouth or nose — particularly between days 5–14 — that does not stop within one to two minutes
Signs of severe dehydration: very dry mouth, minimal urination, inability to drink for more than 24 hours
Severe breathing difficulty

Secondary haemorrhage: The most clinically significant risk. Occurs in approximately 2–5% of patients (higher in adults than children). The majority settle conservatively; a minority require return to theatre. Rare fatalities from post-tonsillectomy haemorrhage do occur — emergency attention for any significant bleeding is non-negotiable.
Dehydration and hospital readmission: Inadequate oral intake due to pain is a common reason for hospital readmission, particularly in children. Maintaining adequate hydration with regular analgesia is the primary preventive strategy.
Nausea and vomiting: Common in the first 24 hours post-anaesthetic.
Voice changes: Temporary changes in voice resonance occur in approximately 10–15% of patients due to altered oropharyngeal geometry. Persistent velopharyngeal insufficiency (nasal regurgitation or a hypernasal voice) is rare but more likely in patients with an undiagnosed submucous cleft palate.
Dental injury: The Boyle-Davis gag may occasionally cause chipping of loose or crowned teeth — inform the surgical team of any dental concerns pre-operatively.
Anaesthetic risks: Discussed with the anaesthetist at pre-operative assessment.

Dr Roth’s Clinical Perspective

The tonsillectomy threshold question is the one I spend the most time on at these consultations. The Paradise criteria exist for a reason — a small number of throat infections managed conservatively is a very different clinical situation from genuinely recurrent bacterial tonsillitis that has required multiple antibiotic courses and significant time off work or school each year. I take a detailed history of the episodes at consultation — what required antibiotics, what the culture showed, how long each episode lasted — because the number alone is less informative than the pattern and severity. An accurate history determines whether the threshold is met, and that determination should happen before any surgical commitment is made.

— Dr Jason Roth, MBBS, FRACS (ORL-HNS), IBCFPRS

Dr Jason Roth — Specialist Otolaryngologist Sydney

Arrange a Consultation

Speak with Dr Jason Roth

Dr Roth consults from Dee Why on Sydney’s Northern Beaches. A GP referral is recommended.

Request an Appointment
(02) 9982 3439

Dr Jason Roth (MED0001185485) — Specialist Otolaryngologist & Head and Neck Surgeon.

Dr Jason Roth | MBBS, FRACS (ORL-HNS) | MED0001185485
Specialist Otolaryngologist & Head and Neck Surgeon
Specialist registration — Otorhinolaryngology, Head & Neck Surgery
View full profile