Tonsils & Adenoids Surgery
The tonsils are collections of lymph tissue located at the back of the mouth. They are composed of special cells that help fight infection. Small pits are present on the surface, and these extend down into the tissue forming small tubes known as “crypts”.
The tonsils that typically cause tonsillitis are called the pharyngeal tonsils.
There are other groups of the same tissue nearby, including the lingual tonsils in the back of the tongue and the adenoids at the back of the nose.
The adenoids are a collection of tissue above the soft palate at the back of the nose.
Respiratory viruses are more likely to infect the adenoids first because they are located at the back of the nose.
Tonsils and adenoids can be safely removed, as they form only a very small part of the body’s total immune system. If they are diseased, after they are removed the immune system actually functions in a more healthy way.
You can read more about what is involved in removing the adenoids through surgery here.
Tonsillitis is inflammation of the tonsils in the mouth (the pharyngeal tonsils). It is usually caused by a viral infection, but can also be caused by bacteria. It is usually impossible to tell the difference between a viral or bacterial infection by looking at the tonsils. The adenoid tissue located at the back of the nose or the lingual tonsils at the back of the tongue may become infected at the same time.
The symptoms of tonsillitis include sore throat, difficulty swallowing, bad breath, fever, swollen neck glands, loss of appetite, change in voice and fatigue. The tonsils generally become red and swollen and may have pus visible on the surface of the small pits of the tonsil.
Most people suffer from tonsillitis at some point in their lives. Young children are most commonly affected, as their immune systems are still developing.
Types of tonsillitis
- Patients have a fever, sore throat, foul breath, painful swallowing and tender neck glands.
- Patients who have more than one attack of acute tonsillitis per year have recurrent tonsillitis.
- Patients who have had either repeated attacks or a very severe attack of tonsillitis can develop chronic tonsillitis. A low-grade bacterial infection continues to cause problems within the tonsil tissue. Excessive scarring often leads to the build-up of old food, dead cells and bacteria within the tonsil crypts. This can cause a range of symptoms including pain, bad breath, tonsil stones and fatigue.
Peritonsillar abscess (quinsy)
- Very severe tonsillitis can lead to a collection of pus forming between the capsule of the tonsil and the muscle of the throat. This usually needs to be drained. Significant scar tissue can be left behind, and a small cavity can form leading to repeated episodes of abscess formation.
Sleep disordered breathing in children (snoring, sleep apnoea)
Tonsillectomy or Adenotonsillectomy
What is a tonsillectomy (Adenotonsillectomy)?
A tonsillectomy is a procedure that can remove the tonsils. The tonsils are clumps of lymph tissue that sit at the back of the mouth. An adenotonsillectomy can remove the tonsils as well as the adenoids, which is a clump of lymph tissue sitting at the back of the nose.
Tonsils are adenoids are usually removed to treat the following conditions:
- Frequent episodes of tonsillitis
- A chronic tonsillitis infection that does not respond to antibiotics
- Recurrenct quinsies (an abscess around the tonsil)
- Snoring or sleep apnoea
- Drooling or eating problems in children
- Asymmetrical tonsils where there suspicion for a growth
- Recurrent formation of tonsil stones causing bad breath
Sometimes only the adenoids are removed and this may be for other conditions such as problems with Eustachian tube, recurrent ear infections or for breathing and snoring problems .The Eustachian tube (also known as the auditory tube) joins the nose to the middle ear. The adenoids are located very close to where the Eustachian tube opens into the nose and cause problems with it’s function.
The decision to have surgery needs to consider a number of factors. These include
- The frequency and severity of infections
- The history of antibiotic use and effectiveness
- The severity of symptoms
- Other complicating illnesses
- The effect on schooling or work
- The presence of sleep disordered breathing (snoring, sleep apnoea), swallowing difficulties, poor weight gain or growth and any associated middle ear infections.
How is the surgery performed?
With the mouth held open with a special instrument the tonsils are gently grasped. This allows visualisation of the plane between the tonsil capsule and the underlying muscle fibres. The tonsils are then carefully separated from the fibres overlying the muscle. Any small blood vessels encountered are treated before bleeding can occur. Local anaesthesia is injected at the end of the procedure for patient comfort.
The adenoids are then removed via the mouth under direct visualisation with the help of a small mirror or endoscope. They are vapourised with heat (cautery) with very little bleeding. At the end of the case a thorough check is made for any bleeding. The patient is then woken and transferred to the recovery ward.
What is the recovery from tonsillectomy or adenotonsillectomy like?
Patients are often concerned about pain management following these operations. Most patients are not in pain when they wake from their tonsil surgery. This is due to the combination of local anaesthesia and pain relief that is given during the surgery by the anaesthetist through their intravenous drip. Children are often disorientated and confused from general anaesthesia when they awaken. They can be frightened and cry but usually settle down quickly. A parent is allowed to attend the recovery ward shortly after the child has woken up and this is always helpful.
Nausea and vomiting
Nausea and vomiting is also common over the first 24 hours. The vomit may contain traces of blood that were swallowed during surgery. Generally patients are able to eat any drink within hours.
Time off work
Most people take one or two weeks off school or work and are advised to refrain from exercise for 3 weeks.
Antibiotics are not required after surgery on the tonsils or adenoids. It is completely normal for the healing tonsil wound to develop a yellow membrane during the first week. This is not an infection but the normal healing tissue.
Most patients experience some pain for at least 7 days. Regular pain relief is important rather than letter pain build up before treating it. Adults often have more pain than children. You will be given a prescription for pain killers. Usually this will include both paracetamol and oxycodone (liquid for children, tablets for adults).
It is very important to continue drinking fluids even if eating becomes difficult. This is very important in children. If patients become dehydrated pain generally worsens. If dehydration becomes severe readmission to hospital may be necessary for rehydration. Signs of dehydration include dry mouth, dizziness, decreased urine output, increasing fatigue and looking increasingly unwell. You may be able to hide the oxycodone syrup (pain relief) in your child’s fruit juice if you are having difficulty having them take it.
There is not special diet after this surgery. All normal foods can be eaten however some patients find it difficult to acidic, hot or spicy food or food that is very rough (toast or potato chips). Traditionally the coldness of ice cream has been said to provide some pain relief.
While the palate is healing children often have a change in their voice. This usually returns to normal once all pain has subsided.
What are the risks of the surgery?
Tonsil and adenoid surgery is very safe. All complications are uncommon or rare. There is no detrimental effect on your immune system or general health from having the tonsils or adenoids removed.
Specific risks of tonsil and adenoid surgery
- Bleeding. There is a 3% of bleeding within the first 14 days following tonsil and adenoid surgery. This can sometimes (and classically does) occur all of a sudden on day 10-14 when a child is otherwise progressing well. If bleeding starts and does not stop almost immediately, you need to go to your closest emergency department. Most of the time the bleeding settles down quickly and requires either a brief period of observation or an overnight admission for antibiotics and some rehydration. Less commonly the bleeding does not stop and requires the patient to return to the operating theatre to stop the bleeding.
- Blood transfusion. If bleeding is excessive a blood transfusion may be necessary.
- Problems with breathing. Children who have severe sleep apnoea occasionally have problems with breathing in the 24 hours after surgery.
- Speech problems. Children who have very large adenoids and short palate are at risk of air or fluid escaping from the mouth into the nose. This is called velopharyngeal insufficiency (VPI). It generally settles down without treatment but occasionally speech therapy is necessary or very rarely further surgery.
- Very rare complications – burns to the lips or tongue from the diathermy, dislocation of the jaw joint or a chipped tooth.
General risks of any surgical procedure
- Wound infection
- Persistent pain and discomfort
- Nausea (usually from the anaesthetic)
- Slow healing (worse in smokers and people with Diabetes)
- Allergies to anaesthetic agents or other products used in the hospital