Tonsillectomy

The two most common reasons for removing tonsils are obstructive sleep apnoea and recurrent tonsillitis.  Other less common indications for tonsillectomy are: problematic drooling (dribbling), asymmetric tonsils (one significantly larger than the other), difficulties with speech pronunciation, and feeding/swallowing problems. 

 

Tonsils (and adenoids) are made from lymphoid tissue, and sit on either side of the uvula (the dangly part) in the back of the throat.  In infants the tonsils offer a small contribution to the immune system, however as children grow their function is negligible.  We do not see an increased risk of infections, or problems with the immune system, after tonsil removal and this is supported by current research.  There are two methods I use regularly to remove tonsils: Coblation intra-capsular tonsillectomy and Bipolar tonsillectomy.  The difference between the two techniques is what happens to the capsule (lining) around the tonsil during surgery.

 

Coblation Intra-capsular Tonsillectomy

This technique uses a Coblation wand to remove the tonsil tissue, but leaves the “capsule” of the tonsil behind to protect the sensitive muscles, nerves and blood vessels behind the tonsils.  Coblation intra-capsular tonsillectomy is a less invasive approach, using saline (salty water) dripping over the end of the instrument to create a plasma field (highly energized ions).  This dissolves tonsil tissue very precisely at a low temperature, with minimal bleeding or injury to surrounding structures.

This approach is known as an intra-capsular technique because the tonsil capsule is preserved, and is used in many children’s ENT centres around the world.  The feedback from hundreds of parents is that the pain is far less than the traditional technique of bipolar tonsillectomy.  Children often complain of relatively little pain after Coblation surgery, are frequently eating a normal diet within a few days, and require some pain medication for an average of 5 days.  The typical return to school or nursery is 5-7 days after surgery, although some children are even ready to go back before this.

An additional benefit of the coblation intra-capsular technique is the reduced rate of bleeding following surgery.  Bleeding is seen in around 1 in 400 (0.5%) children when I operate using coblation intra-capsular tonsillectomy, versus a bleeding rate of around 1 in 30 (3%)  after traditional bipolar technique. 

There is a small chance of regrowth of the tonsils, or ongoing tonsillitis when using Coblation, as a very small amount of tonsil tissue may remain.  But this risk is low and is usually offset by the reduced risk during and after surgery.

Bipolar (traditional) Tonsillectomy

This technique uses heated forceps to separate the tonsil with its “capsule” from the muscles of the throat behind the tonsils.  The bipolar method removes all of the tonsil tissue very effectively and allows any blood vessels to be sealed accurately. 

Children often experience moderate pain in the throat and ear-ache (referred pain) with this technique, and the pain may increase for around 5-6 days before improving.  Children typically require 10-14 days away from nursery or school to allow time to recover.  I recommend taking pain medication (paracetamol and ibuprofen) regularly for 7 – 10 days, and in most cases send children home with 5 days of oral antibiotics to minimise the chance of infection. 

The most significant risk after bipolar tonsillectomy is bleeding, which can occur up to about 2 weeks following surgery in around 3% of children.  Rarely the bleeding can be more severe and an operation or blood transfusion may be required.

Other Small Risks

  • Occasionally a tooth may be very loose at the time of surgery, and would need to be removed to prevent aspiration into the lungs. However, it would always be returned for the benefit of the tooth fairy. Damage to lips/teeth/gums is rare.

  • If tonsils and adenoids are very large, there may rarely be some change in pitch of the voice once this bulky tissue is removed. If this occurs it is usually because the tonsils were falsely lowering the pitch of the voice (by affecting palate vibrations), and the voice is returning to its “more normal” higher pitch.

  • The risk from anaesthesia in paediatric centres where I work, for children undergoing routine ENT procedures and who are otherwise well, is very low.

 

Post-Operative Advice

  • The operation lasts about 30-40 minutes, and most children will be able to be discharged home on the same day after a period of observation on the ward. Young children, those with additional medical problems, or those living far away are more likely to stay overnight.

  • Children are discharged with paracetamol and ibuprofen, and are encouraged to take this regularly for several days, or until the pain has resolved. Mild earache after tonsil surgery is also common, and will settle.

  • Occasionally children require additional pain medication, and Difflam throat spray can be purchased from the local pharmacy. The numbing action of the spray wears off quickly, but it can be used several times per day and helps with eating.

  • Children will often have mucous in the throat and nasal discharge, and this improves as they recover.

  • A strong smell on the breath is common after surgery, as the healing area is covered in saliva all the time. This resolves as the throat heals.

  • Some children will also be discharged with 5 days of oral antibiotics, but this isnt usually needed routinely unless there is evidence of infection.

  • I encourage children to eat a normal diet from day 1, with no restrictions on what they eat.

  • If there is more than a tea-spoon of fresh blood, or a blood clot, from the mouth then the child should be taken to A+E where they will be admitted and observed overnight. Very rarely a transfusion or operation to stop bleeding could be required, but this risk is far lower with the Coblation technique.

  • Children will often have fluctuating temperatures for 3-5 days after surgery, and these temperatures are controlled with use of regular paracetamol and ibuprofen.