Tonsillectomy and Adenoidectomy

Introduction

The tonsils are bumps of tissue at the back of the throat. There is one on each side. Tonsils are usually removed because they are a focus of repeated infections, but they may also be removed if they are causing a blockage at the back of the throat that is interfering with eating or breathing. In this situation the adenoids are often removed at the same time. The adenoids are very similar to the tonsils and are found at the back of the nose. Tonsillectomy for tonsil stones is not available on the NHS but may be performed privately.

What problems do children have when their tonsils and adenoids are causing a blockage?

When the tonsils and adenoids cause a blockage at the back of the throat, it is usually because they are very large. Children often have large adenoids and tonsils, but they usually shrink as they get older. They only need removal if they are causing problems with breathing and eating.

Children with this problem will often snore quite loudly. In addition, they may stop breathing for short periods throughout the night (obstructive sleep apnoea/OSA). Because they don’t sleep well, they may be irritable and badly behaved during the day. They will often be poor eaters, eating little food and taking a long time to do it, becoming thin and pale as a result.

Why may an operation help?

Removing the adenoids and tonsils will remove the source of the blockage in a child’s throat. They will then sleep and eat better, and this usually means they put on weight and are not so tired and irritable during the day. It is effective in around 9 out of 10 children with these symptoms.

What will happen if I decide that I don’t want my child to have an operation?

As a child grows older it is normal for the tonsils and adenoids to shrink. The blockage at the back of the throat will then subside. This means that children with this problem will usually get better without any treatment.

Are there any alternatives to surgery?

There are no other known effective treatments for throat blockage due to large adenoids and tonsils.

THE OPERATION

What does the operation involve?

Anaesthetic: Tonsils and adenoids are always removed under general anaesthetic. This means you/your child will be asleep throughout the procedure and will not feel anything.

Approach: The tonsils and adenoids are removed through the mouth, so there are no external scars

Procedure:

1. Traditional adenotonsillectomy: The tonsils sit in the side of the throat like boiled eggs in egg cups. In traditional tonsillectomy the whole egg is removed from the cup. The holes where the tonsils were are not stitched shut, so if you look into your child’s mouth after the operation you will see a grey/white area where the tonsils used to be.

2. Coblation intracapsular tonsillectomy/adenoidectomy: In many cases, your surgeon may recommend partially removing the tonsils to reduce the size, rather than complete removal. To use the example above: instead of removing the whole egg from the egg cup, a bit of egg shell and a thin rim of egg white are left behind. This method is less painful, has a shorter recovery and a lower risk of bleeding, but balanced against this is a small chance that the tonsil tissue left behind can regrow and cause symptoms again. If this happens, a further operation might be necessary to remove the remaining tonsil.

With either method, the adenoids are stripped from the back of the nose with a special instrument.

Dressings: No dressings or bandages are required.

Aftercare: You/your child will normally be able to go home late on the day of surgery, or the following morning (depending on their age and weight). You will need to buy Calpol and Ibuprofen syrup to give to your child, and you will usually also be given stronger painkillers (oramorph) to take home after the surgery. It is very important that you give these to your child on a regular basis for the first week.

You must also make sure you/your child keeps eating and drinking properly after discharge, even though it can be painful to swallow at first.

Follow up: You/your child will have a follow up appointment around 4 weeks post op with Mr Rainsbury to check everything has healed up properly. 

WHAT WILL I NEED TO DO AFTERWARDS?

Do I need to keep my child home from school/stay off work?

We normally recommend that children be kept home from school for 2 weeks to recover fully from the effects of the surgery. Children who have coblation adenotonsillectomy can usually return to school after a week. These times also apply to adults and return to work. A sick note will be provided if necessary.

Are there any things my child must not do afterwards?

We recommend that patients avoid other people with coughs and colds during the recovery period.

COMPLICATIONS

 Are there any complications?

Most operations are successful, and there are generally very few problems.

However, every operation has risks and these need to be understood before you agree to go ahead with treatment. These risks fall into 3 categories: 

Complications of the anaesthetic: The anaesthetist will discuss the anaesthetic with you before the operation. Anaesthetics in otherwise healthy children are very safe. Further information can be found on the Royal College of Anaesthetists website.

Complications of the surgery:

• It is not fully understood what our tonsils or adenoids actually do – and people who have had their tonsils and adenoids removed do not seem to suffer any ill effects as a result. However, there is recent evidence from a very large study in the USA that suggests that people who have their tonsils completely removed as a child may suffer more coughs, colds and upper respiratory tract infections as an adult (JAMA Otolaryngol Head Neck Surg. 2018 Jul 1;144(7):594-603. doi: 10.1001/jamaoto.2018.0614), so many surgeons are choosing to leave behind a small amount of tonsil tissue to reduce this risk (coblation intracapsular tonsillectomy)·       

• Pain: This occurs with every operation. Having your tonsils removed is always painful; the level of pain is similar to that experienced during an attack of tonsillitis. Coblation adenotonsillectomy is less painful than traditional tonsillectomy. The pain is usually well-controlled with painkillers, although some children with obstructive sleep apnoea may not tolerate some stronger, morphine-based painkillers, so may have to just use Calpol & Ibuprofen. Adenoidectomy by itself is not usually very painful.

• Bleeding: this can occur during or after any operation, and about 1 in 10 patients having their tonsils out will bleed after the operation. Most bleeding tends to occur 5 or 6 days after the operation, and if there is any bleeding at all you need to consult a doctor.  Usually bleeding settles quickly by itself, but occasionally a second operation is necessary to stop it (around 1 in 100). The risk of bleeding from the adenoids is very small (around 1 in 1000). The risk of bleeding is much lower after coblation adenotonsillectomy, around 1 in 300.

• Regrowth: The risk of symptoms coming back after coblation is 1 in 50 children; this is due to the adenoids or tonsils growing back.

WHAT NOW?  

What happens on the day of the operation?

On the day of your surgery, your child will be required to attend Freedom Day Case Unit at Derriford Hospital. Adults will have their surgery at the Nuffield Hospital, Plymouth. The anaesthetist and a member of the surgical team will also see you to answer any questions and to confirm you still wish to go ahead.