Post-Tonsillectomy Pain

Red flags

 

Why is this important?

  • The recovery period after tonsillectomy is very painful.  A significant proportion (>50%) of readmissions following tonsillectomy are for pain, nausea and general malaise without any bleeding.

 

When to involve the ENT Registrar

  • If there is post-tonsillectomy bleeding

 

Who to admit

Admit anyone unable to cope at home i.e. vomiting, aphagia secondary to pain.  Some patients will have tried hard to resume a normal diet after their tonsillectomy. Others will have found it very difficult and a vicious cycle develops where analgesia cannot be swallowed, leading to more dysphagia.

Depending on fluid status and analgesia requirements, the patient may be able to go home if analgesia can be optimised in the emergency department.

NB At times, operations can act as a distracting injury.  Watch out for the signs and symptoms of an unrelated acute illnesses e.g. meningitis, and do not presume that all symptoms are due to the tonsillectomy.

 

Assessment and recognition

Assess the patient's general status and asssess for pain and hydration.

Patients who are in pain after a tonsillectomy do not typically have swinging high pyrexia, profuse vomiting, true photophobia or other worrying signs.

Referred otalgia and mild trismus are normal, especially if there is severe pain.

     Photo A. Normal appearance of the oropharynx three days after tonsillectomy. Yellow/white/green slough in the tonsillar fossae is entirely normal and does not  represent infection.    With thanks to James Heilman MD, via Wikimedia Commons. 

 

Photo A. Normal appearance of the oropharynx three days after tonsillectomy. Yellow/white/green slough in the tonsillar fossae is entirely normal and does not  represent infection.

With thanks to James Heilman MD, via Wikimedia Commons. 

 

Immediate and ovenight management

Treatment is symptomatic and supportive. Control pain and nausea and rehydrate the patient orally if possible - if not possible then obtain intravenous access. Blood tests are usually unnecessary.

Treatment includes:

  • Regular paracetamol, NSAID and weak opioid (if not contraindicated)
  • Topical benzydamine (Difflam) that the patient administers themselves
  • Antiemetics if required
  • Plenty of fluid orally or intravenously

Ensure that patients with chronic diseases (epilepsy, diabetes etc.) receive their medication parenterally if needed.

Counsel patients that the pain usually gets worse around five days after a tonsillectomy - before improving. Monitor the patient for signs of improvement. Discharge them as soon as they are managing a soft diet and can swallow oral medication.

 

Further management

None specific. 

 

 

 

Page last reviewed: 29 July 2018