Tonsillectomy

Indications

1. Obstructive tonsils: associated with sleep apnea, dysphagia, speech defects, failure to thrive

2. Recurrent sore throats

American Academy of Otolaryngology Guidelines:

• 7 sore throats in 1 year
• 5 in each of 2 years
• 3 in each of 3 years

Associated with:

• Fever > 38oC
• Swollen anterior cervical nodes
• Tonsillar exudate
• or Positive Strep culture
• Key feature: recurrent sore throats which have significant impact on patient's life: lots of missed time from work or school, association with febrile seizures, development of multiple antibiotic allergies, development of Strep complications etc.

3. Suspicion of tonsillar cancer

There are lots of other indications that are popular in specific regions or with specific surgeons...

Otitis media is not an indication for tonsillectomy!!

How they do a Tonsillectomy

Patient is laid supine and operator sits at head of bed

Inserts mouth prop

Grasps tonsil with a tenaculum, retracts it medially, and dissects it from tonsil bed (constrictor muscles)

Hemostasis in tonsil bed (various methods: cautery, pressure, ligatures, bismuth subgallate etc.)

Suctions clear oropharynx

Complications

1. Hemorrhage (most common complication; estimated at 2-3%)

• Intra-op
• Primary (within first 24 hrs)
• Secondary (between 24 hrs and usually at most 10 days)
• Treatment of bleeds:

1. Local pressure with towel holder and gauze (can use epinenephrine on gauze)

-Hold for 10-20 minutes

2. Silver nitrate cautery

3. Cold water rinses

4. Start IV and call the surgeon

2. Dehydration (common in kids who won't eat due to pain)

3. Weight loss (also common in kids who won't eat due to pain)

4. Fever (not common: usually related to local infection)

5. Post-op airway obstruction (due to edema, hematoma, aspirated material)

6. Local trauma to oral tissues

7. Tonsillar remnants

8. Death (uncommon; usually related to bleeding or anesthetic complications)

Post-op Care

1. Pain control

• Use liquid tylenol +/- codeine
• Parents' unwillingness to give analgesics is associated with children's refusal to eat which results in dehydration, weight loss, and local infection

2. Hydration (push fluids)

3. Adequate diet

• There's no evidence that a special diet is required; obviously soft foods will go down easier

4. No smoking (delays healing)

5. No heavy lifting/ exertion for 10 days (think it's associated with late hemorrhage)

6. Warn patients that pain will first abate over 5 days or so, then will increase for a day or 2 before completely disappearing (think this is related to eschar separation)