Tonsillectomy

Indications

Frequent tonsillitis (see SIGN 117)

Obstructive sleep apnoea (combined with adenoidectomy for this indication)

Suspicion of malignancy

 

Procedure

The mouth is held open with a metal gag. The tonsils are removed by dissection around their capsule, using steel instruments, bipolar diathermy, or Coblation, or a combination thereof.

 

Operative time

Variable, but generally around 30 minutes.

 

Complications

Pain This occurs in all patients and is generally severe, lasting up to 2 weeks.  The patient will need regular analgesia, and will need to be encouraged to eat. Readmissions for pain are relatively uncommon and can be avoided by giving clear information about what to expect. Warn parents/patients that pain will increase over the first 48-72 hours – this is normal.

Bleeding This may be primary (during the procedure), reactionary (on the ward/in recovery), or secondary (usually around a week post-op). Primary bleeding is usually negligible. Reactionary bleeds are quite uncommon, but usually need returning to theatre immediately. Secondary bleeds are the most common serious complication, and occur in approximately 4% of cases. Around one quarter (1% of all patients) have persistent bleeding, requiring a return to theatre. Warn the parent/patient that they must return to their nearest A&E if they have any post-operative bleeding, even if it stops spontaneously (see Post-tonsillectomy bleeding). 

Infection This is over-diagnosed. Patients attending their GP due to ongoing pain will be prescribed antibiotics frequently due to the “pus” at the operative site. This is in fact yellow sloughy tissue which is present in all cases – reassure parents that this is normal. 

Dental/lip/jaw injury Rarely a tooth can be chipped or a lip cut inadvertently during the procedure. Ask the patient/parent if there are any loose teeth or caps/crowns. Rarely the jaw can be dislocated but this is checked at the end of surgery when the mandible can be relocated.

Altered taste A very rare complication but we mention it here because of its significance to the patient. 

 

Post-operative management

Patients almost always go home the same day.

No follow-up is needed unless histology has been taken.

 

TTO

Analgesia (for 2 weeks):

  • In children, paracetamol 15 mg/kg qds, ibuprofen 10 mg/kg tds (30 mg/kg in three divided doses), with Difflam (benzydamine) spray (check BNF for age-related doses). Do not prescribe codeine in the under-18s: see MHRA alert.
  • In adults, paracetamol 1g qds, ibuprofen 400mg tds, codeine 30-60 mg 6-hourly PRN, Difflam spray.
  • Some consultants prescribe antibiotics post-operatively – this is a matter of choice rather than evidence.

 

 

 Page last reviewed: 23 September 2016