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Tonsillectomy


Tonsils are pair of lymphoid tissue collections on the side of the oropharynx (back of the mouth/ throat). They are part of a ring of lymphoid tissue (Waldeyer’s ring), which also includes the adenoids. Their function is to combat inhaled particles or infection, but there is so much similar tissue in the throat that they are not essential.
When tonsils/ adenoids are abnormal or diseased, they not only fail in their function, but also make their owner more ill than if they were removed. 
Tonsillectomy is a surgical procedure performed to remove the tonsils in order to address the problem the tonsils causing. It is performed under general anaesthesia and takes approximately 20 minutes. Patients’ mouth is kept open by using an instrument called a gag. There are various techniques to remove tonsils such as using cold dissection, diathermy dissection and coblation technique. The surgeon will choose the procedure based on their experience, competence and suitability for the patient.



A case of tonsillitis


Indications for tonsillectomy


1) Recurrent acute tonsillitis- attacks occurring 4-6 times per year or more despite adequate medical therapy (i.e. antibiotics) and that is affecting quality and lifestyle (work/ school) of the patient.

2) Peritonsillar abscess (Quinsy)-when an abscess is formed in tissues adjacent to the tonsil following an attack of acute tonsillitis.

3) Obstructive sleep apnoea- when large tonsils physically block the passage of the airflow causing snoring, pauses in breathing during sleep, lethargy, sleepiness and lack of concentration during the day.

4) Suspicion of neoplasm “tumour”-Unilateral “one sided” tonsillar enlargement is occasionally caused by “tumour”. Therefore tonsillectomy is necessary to rule out malignancy.


Important information about tonsillitis and tonsillectomy

Tonsillectomy is indicated when the benefits of having the surgery outweighs its risks and complications.

We now know that if we stick to the criteria as above, we will only be taking out those that will be really beneficial to the patient. 

Tonsils do not grow back if removed completely.

Tonsillectomy stops attacks of tonsillitis but this does not stop completely the risk of getting viral throat infections (usually milder than tonsillitis).

It is important to know that most children who suffer with a few attacks of tonsillitis will improve as they get older and their tonsils get smaller “shrink” and cause less and less attacks of tonsillitis.

Many surgeons have a high threshold for operating on children under 6 years of age.

Complications of tonsillectomy


1) Bleeding - tonsils have a very rich blood supply and it is not surprising that this is potentially the most serious complication.
Bleeding from the operative site can occur anytime from time of surgery to 2 weeks post surgery.
The risk of bleeding is slim, 3-5% and although many cases are very mild cases (e.g. a little blood noted in the saliva), some cases may be very severe, requiring emergency re-admission to hospital, and sometimes return to the operating theatre to stop the bleeding. A blood transfusion is only required if there is severe haemorrhage.
Haemorrhage tends to occur in those who get a post-op infection.

2) Infection- as with any surgery when there is a “cut or wound”, there is a potential risk for infection. Infection occurs up to 2 weeks after surgery if at all. The patient may require antibiotic treatment and readmission to the hospital depending on severity.
Infection is more likely if eating and drinking are inadequate or if the patient “catches a cold” from someone he meets during the recovery.

3) Lip/ tooth damage- As part of the operation an instrument is used to keep the mouth open (gag). There is a small risk for this to cause damage to the lips/ tooth or even cause dislocation of TMJ (tempromandibular joint), the joints responsible for opening and closing your mouth.

4) Pain-tonsillectomy is a very painful and this can last 2 to 3 weeks. Children recover quicker than adults. Patient may even experience pain in ears. This is a referred pain from the throat. Painkillers will be provided to take home.

Expectations and Advice following  tonsillectomy surgery


·Pain can be severe and last about 2 weeks. Pain can get worse before it gets better (between day 4-7) and you may find you have severe earache.

·You must take the medications provided regularly. They not only reduce pain but may also have anti-inflammatory action, which helps in your recovery.

·You must drink plenty of fluids; ice-cool fluids are better tolerated, and larger swallows more comfortable than small sips. About 3-4 hours after the operation you will be offered some sips of water. 
·You must eat a normal diet as soon as possible. Try eating about 30-45 minutes after taking the pain medicine.
The chewing and swallowing action promotes healing of the tonsil bed and reduces the risk of infection and bleeding. Chewing gum is also helpful. Avoid using straw, and avoid alcohol for 2 weeks.

·Do rest indoors for at least the first week. Sick-note will be provided for two weeks off work/ school. This is because you are susceptible to any infection during this time. Some adults may require even three weeks off work.

·It is normal for your breath to smell and your throat to look white.

·Avoid very hot baths and showers. Take these quite cool. It may lead to tonsillar haemorrhage.

·Avoid smoking and dusty and dry atmospheres.

·Avoid crowded places and people with infections (e.g. cold) for two weeks.

·Do not drive for 48 hours (because of the effect of the general anaesthetic).

·Avoid taking aspirin as it increases risk of bleeding.

·A small amount of bleeding from the mouth is common up to 10 days after the surgery. Do not be alarmed or surprised. Simply wash the mouth out with cold water, and contact the department where the surgery took place for advice. Readmission to hospital may be advised but the huge majority of cases settle without any need for transfusion or repeat surgery.

·Follow up appointment is not always required. However one may be required if other surgical procedures were also performed at the sometime as tonsillectomy or if tonsils were sent for histology.


In case of Emergency...

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Whilst every effort has been made to ensure that the information contained on this website is accurate you should always discuss the risks, limitations and complications of your specific operation with the relevant surgeon.

Mr Behrad Elmiyeh MRCS DO-HNS