Wilson-Boyd ENT Brisbane: Tonsillectomy

Some people suffer acute peritonsillar abscess or Quinsy, which is usually managed with acute drainage of pus.

Previously one acute episode led to Tonsillectomy. However the current evidence is that 80% of people will have no further attacks of acute peritonsillar abscess hence it is generally now performed after the second episode has occurs leading to Tonsillectomy in only the 20% of people suffering a peritonsillar abscess.

Obstructive sleep apnoea is an increasingly identified condition both in children and in adults. In children this is most commonly due to enlargement of the adenoids and tonsils and remove of these tissues almost always results in cure of the obstructive sleep apnoea.

Snoring children fall into one of three groups. There can be pure snorers with no other secondary health problems, suffers of obstructive sleep apnoea where their breathing stops completely or a group in between were they snore and have shallow breathing or hypopnoea. These two subsequent groups have secondary health problems. The shallow breathing or cessation of breathing leads to elevation of carbon dioxide and a reduction in oxygen within the blood.

This most commonly occurs when the brain is in the best part of sleep, called REM sleep, when the muscles are most relaxed and the brain is doing its most dreaming. In order to improve the oxygen level in the blood, the brain needs to pass into the earlier phases of sleep and contract the muscles often leading to a gasp for breath. The child is usually not completely awakened.

The physiological changes that occur with breath holding during sleep can lead to secondary longer-term health problems. In the short term the child does not have enough REM sleep, each night leading to tiredness first thing in the morning and later in the day, often associated with irritability, poor concentration and behaviour.

Because they are so tired they commonly suffer from bed-wetting. More severe untreated cases can lead to failure to thrive or grow and even right heart failure.

While the diagnosis is reliably produced by a paediatric sleep study, in Brisbane these are only available at the Mater Hospital. In most cases the diagnosis is made clinically by observation from the child’s parents.

They are commonly seen to snore, snore, snore followed by sucking in of the soft tissues of the neck. They will then often gasp followed by further snoring. The children with pathological shallow breathing usually do not have the apnoeic episodes but have the same secondary tiredness during the day.

If the diagnosis is correct and Adenotonsillectomy performed, almost all children breathe better on the first night and begin behaving better with a greater ability to learn.

Tonsilloliths or tonsillar stones are a less common cause for Tonsillectomy. The crypts within the tonsil fill with food particles and debris.

This usually becomes contaminated with bacteria causing bad breath and bad smelling tonsillar discharge, which can be white or yellow concretions. If the tonsilloliths are the cause of bad breath the condition will be completely resolved following Tonsillectomy.

Tonsils can be affected by squamous cell carcinoma or lymphoma. Tonsillectomy is frequently required to either treat these conditions or exclude the diagnosis.

Hence, Tonsillectomy is occasionally indicated when one tonsil is larger than the other, when the tonsils are ulcerated or when there are suspicious lymph nodes in the neck.

1. Indications for Tonsillectomy and Adenotonsillectomy in Children – a joint Position paper of the Paediatrics & Child Health Division of The Royal Australasian College of Physicians and The Australian Society of Otolaryngology Head and Neck Surgery.
http://www.racp.edu.au/page/policy-and-advocacy/paediatrics-and-child-health

2. Paradise JL, Bluestone CD, Bachman RZ, Colborn DK, Bernard BS, Taylor FH, Rogers KD, Schwarzbach RH, Stool SE, Friday GA, et al. Efficacy of tonsillectomy for recurrent throat infection in severely affected children. Results of parallel randomized and nonradonmized clinical trails. N Engl J Med. 1984; 310(11): 674-83

Pain Relief

Pain is the main problems following Tonsillectomy. The wound at the Tonsillectomy site is usually left open and this wound fills with bacteria and slough, which causes pain and inflammation.

It takes several days for the bacteria to multiply and the inflammation to occur hence the pain following Tonsillectomy is usually the worse on the 4th and 5th day following the surgery. It is important to have good pain relief prior to this peak and this is achieved with a combination of Paracetamol or Codeine/Oxycodone or the two drugs in combination.

These medications should be prescribed on discharge and usually required every four hours except when sleeping. Children can use Painstop, available over the counter at your chemist, but this drug should not be used with Paracetamol or Codeine/Oxycodone as it contains both of these medications and there is a risk of over dosage.

I avoid Aspirin and anti-inflammatory medicines during the post-operative period, as this can be the cause of nuisance, anxiety-provoking bleeding.

Severe pain not controlled with Paracetamol and Codeine/Oxycodone may require further measures. Your general practitioner or myself should be contacted in this case for a combination of Penicillin, oral steroid, hydrogen peroxide gargles or a local anaesthetic gel (Xylocaine viscus). These measures should improve tolerance of normal diet.

Activity

Although the operative site is small, Tonsillectomy can make you feel lethargic and generally unwell. Any significant physical activity is usually poorly tolerated. I usually recommend ten days off work or school to allow enough time to recover. Excessive physical activity with an increase in blood pressure and pulse rate may lead to bleeding from the tonsillar fossae.

Diet

The open wound at the site of Tonsillectomy fills with bacteria and slough leading to pain and inflammation. It is important to eat a normal diet with rough type foods to debride or remove the slough from the healing wound site.

Although it is more painful to eat bread, toast and cereal consistency foods, this results in fewer bacteria in the wound and less pain between meals. Traditional ice cream and jelly feels better to eat but results in more bacteria lining the pharynx and subsequently more pain between meals.

Generally those presenting with post-operative bleeding have not been eating adequately. It is essential to have adequate fluid intake especially in younger children where dehydration can occur.

Complications

You should be well informed of the potential complications following Tonsillectomy by reading The Royal Australasian College of Surgeons pamphlet provided. The main concern is bleeding from the mouth and if this occurs you should contact myself or present to your nearest hospital via ambulance if required.

You may need to return to the operating theatre to have the bleeding stopped. Ear pain is not uncommon after Tonsillectomy and is the result of referred pain from the tonsillar fossae and usually does not indicate an abnormality in the ear. Bad breath is common and is due to the build up of bacteria and slough in the tonsillar fossae. This will be less with a normal diet, which debrides theslough.

Follow-up

You should have received an appointment card following your surgery for your post-operative appointment with Dr. Brian Wilson-Boyd.

If your only surgery is Tonsillectomy follow-up is usually at four weeks following the operation unless there are problems in the interim. It may be necessary to be seen earlier if another procedure has occurred in conjunction with your Tonsillectomy.

Dr Wilson-Boyd recommends these audiology clinics.

Some companies have several practices throughout Brisbane. Please phone, or visit their websites for more information on locations or to make a booking.

Downloadable Literature

• Indications for Tonsillectomy
• Post operative Instructions – Tonsillectomy
• Pre – operative Medication Guidelines