TONSILLECTOMIES

A tonsillectomy is a surgical procedure to remove the tonsils. I recently had this procedure done, so I thought that I would provide some useful information regarding the surgery and the recovery.

Tonsils

Tonsils are the oval masses of lymphoid tissue at the back of the throat. They are part of the immune system and help the body fight off viral and bacterial infections.

Tonsillitis

Tonsillitis occurs when tonsils become infected and swell. The back of the throat may be red or have a white or yellow coating on them. Other indications of tonsillitis include: sore throat, painful swallowing, raspy voice, fever, and swollen glands.

When Should Surgery be Considered?

Because of success with antibiotics, surgery is no longer the standard treatment for tonsillitis that it was years ago. However, a physician may find surgery the best treatment when the patient has had:

• 7 or more episodes of tonsillitis in 1 year
• 5 or more episodes per year over a 2-year period
• Enlarged tonsils that interfere with breathing
• An abscess in the tonsils
• Grossly asymmetric tonsils
• Obstructive sleep apnea (a condition in which one may stop breating for a few seconds at a time during sleep because of enlarged tonsils)
• Infections that do not respond to treatment (e.g. antibiotics)
• Infections interfere with daily functioning

Preparation for Surgery

Patients should be warned that they will experience an extremely sore throat and that swallowing will be painful after the operation. It is important that patients do not eat or drink anything after midnight the night before surgery. Alcohol and tobacco may not be used 24 hour prior to surgery. No contact lenses, jewelry, or nail polish are to be worn on the day of surgery. In the pre-operative appointment, usually a week before the date of surgery, the surgeon must be informed of all medications that the patient is currently taking. In some cases taking medication may be temporarily stopped. For a few days before surgery, patients are told not to take any medications that contain a blood thinner, such as aspirin. The patient must also tell the surgeon of any family history of anemia, clotting disorders, unusual bleeding, heart and lung problems, and problems with anesthesia. The surgeon needs to know any allergies to medications or latex.

Different Types of Surgery

There are a few types of tonsillectomy options available. The surgeon will use the method that they are most comfortable with and that will most benefit the patient. The doctor will explain the procedure to the patient in the pre-operative appointment. In the majority of tonsillectomies, the patient is put under general anesthesia. Often the patient is intubated so that breathing will not be impaired during the procedure. The mouth is held open during surgery. Some procedures last as few as 20 minutes.

• Cold Knife (Steel) Dissection: Removal of the tonsils by use of a scalpel is the most common method practiced by otolaryngologists today. The procedure requires the patient to undergo general anesthesia. The tonsils are completely removed with minimal post-operative bleeding.

• Electrocautery: Electrocautery burns the tonsillar tissue and assists in reducing blood loss through cauterization.

• Harmonic Scalpel: This medical device uses ultrasonic energy to vibrate its blade at 55,000 cycles per second. Invisible to the naked eye, the vibration transfers energy to the tissue, providing simultaneous cutting and coagulation.

• Radiofrequency Ablation: Monopolar radiofrequency thermal ablation transfers radiofrequency energy to the tonsil tissue through probes inserted in the tonsil. After the treatment is performed, scarring occurs within the tonsil causing it to decrease in size over a period of several weeks. Tonsillar tissue remains after the procedure but is less prominent. This procedure is recommended for treating enlarged tonsils and not chronic or recurrent tonsillitis.

• Carbon Dioxide Laser: The Otolaryngologist employs a hand-held CO2 or KTP laser to vaporize and remove tonsil tissue. This technique reduces tonsil volume and eliminates recesses in the tonsils that collect chronic and recurrent infections. This procedure is recommended for chronic recurrent tonsillitis, chronic sore throats, severe halitosis, or airway obstruction caused by enlarged tonsils.

• Microdebrider: The microdebrider is a powered rotary shaving device with continuous suction. The endoscopic microdebrider is used in performing a partial tonsillectomy, by partially shaving the tonsils. This procedure entails eliminating the obstructive portion of the tonsil while preserving the tonsillar capsule. The partial tonsillectomy is suggested for enlarged tonsils – not those that incur repeated infections.

• Bipolar Radiofrequency Ablation (Coblation): This procedure produces an ionized saline layer that disrupts molecular bonds without using heat. This mechanism can be used to remove all or only part of the tonsil. It is done under general anesthesia in the operating room and can be used for enlarged tonsils and chronic or recurrent infections.

Risks of Surgery

Most surgical procedures share the general risks of anesthesia, bleeding, and infection. The anesthetic risk is, in general, proportional to the health of the patient. Serious problems should be very rare. There is a small risk (2 to 3% of cases) of bleeding. If bleeding does occur, it is usually delayed, about five to ten days after surgery, when the scabs come off or if the area becomes infected. Post-operative bleeding is more likely in teenagers and adults, as opposed to younger children. Very rarely, another operation may be needed to stop the bleeding. The risk of bleeding can be minimized by avoiding surgery during and immediately following an infection and by avoiding anti coagulant medicines such as aspirin. The area where the tonsils were removed always becomes colonized with a large number of bacteria, which often causes a low-grade fever. Serious infections are very rare. If tonsils are very large, speech may be different post-operatively.

What to Expect After Surgery

Many procedures are now done on an out patient basis. After the surgery, the patient will remain in the hospital or surgical center for anywhere from 3 to 10 hours. Some doctors prefer that their patients stay overnight.

There are usually 3 stages of Recovery:

1. Stage 1: Moderate Pain- (Days 1 through 3) These days are painful. The pain medication should be used to control the pain (about 6-8 on the pain scale after medication). Drinking water is extremely important. Sometimes there is nausea after the surgery, which is often from medicaiton and the anesthetic leaving the body. Many surgeons will prescribe an anti-nausea medication. The surgeon will also prescribe an antibiotic (usually in chewable or liquid form) to prevent infection. Sometimes the tongue and uvula are swollen so breathing and sleeping become difficult. Because of the swelling, the patient may need to sleep in a recliner or with lots of pillows. The patient may experience some mild to moderate referred ear pain. If the patient looks in the back of their throat they will see a white covering; these are the scabs. Keeping them moist (e.g. drinking water, sleeping with a humidifier) is important. Despite the "You'll get to eat a lot of ice cream!" theory, avoid it. Dairy products increase the mucus that sits in the back of the throat and on the wounds. There are certain foods and liquids that will be less painful than others. It is suggested that the pain medications be taken every 4 hours for the first few days to control the pain. Ice packs can be put on the neck to relieve some pain.
2. Stage 2: Moderate to Severe Pain- (Days 4 through 9) This is when the scabs start to come off. This can be an extremely painful experience for the patient (about 8 to 10 on the pain scale). Eating, especially cold things, is very hard. The pain is not only in the throat, but also in the ears. This is often a discouraging stage because just as the patient thinks the pain is about to subside and they are starting to be weened off of the pain medications, the pain increases. The pain, however, is a sign of healing. This is also the stage where the risk of bleeding is increased, so it is very important that the patient continues to drink water despite the pain. An ice pack on the neck can somtimes relieve some of the pain.
3. Stage 3: Moderate to Minor Pain and Discomfort- (Day 10) At about day 10 the patient tends to feel significantly better (about 4 to 6 on the pain scale). Eating and drinking is usually a little less painful. There will continue to be some minor pain and discomfort and possible residual affects for weeks to come. Even though the pain is gone, the throat is still healing. Strenuous physical activity should be avoided for 2 weeks after surgery.

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