Tonsillectomy/adenoidectomy surgery education and preparation

Tonsillectomy/adenoidectomy surgery education and preparation

We take surgery very seriously and so should you. Please read (and re-read) the following summary. It would be impossible to cover every possible scenario, so never hesitate to ask questions. Good communication with your surgery team is critical to a successful and safe surgery.

Background

Tonsils are located on the sides of your throat and are part of your immune system. We need them for the first year of our life, but after that they are redundant. In some people they are over-reactive and become too large. This may cause snoring, mouth-breathing, and even obstructive sleep apnea. They can also trap bacteria such as strep and cause recurrent strep throat.

The most common reason for tonsil removal is obstructive sleep apnea (OSA) due to large tonsil size. OSA is a serious health problem because it can affect ones heart, lungs, and brain. Pauses in breathing cause oxygen levels to drop. The heart and lungs have to work extra hard to maintain normal oxygenation and respiration. The sleep pattern is continuously disrupted. This can lead to daytime sleepiness, bad mood, restless sleep, and, in kids, even bed-wetting.

Other reasons to remove tonsils are recurrent strep throat infections, peri-tonsillar abscess, chronic throat pain, or, in adults, suspicion of cancer. Removing your tonsils does not weaken your immune system.

Adenoids are similar to tonsils. They are located at the back of the throat above your palate. They are usually removed in children at the same time as the tonsils because they can also cause blockage of breathing.

There are numerous techniques for removing tonsils and each surgeon has reasons for using their technique. Feel free to discuss this with your surgeon.

Scheduling and Logistics

If you haven’t met with our scheduler yet, expect a call within the next day. If you have insurance questions, they can help you answer them. Keep in mind that you should also talk to the hospital about their charges as the majority of the fees are from the hospital.

For most patients the location of surgery will be PMC (Physicians Medical Center), 2990 Rodeo Park Dr E., Santa Fe (505) 428-5400. The hospital requires a pre-anesthesia screening with you before surgery. In healthy children this is usually over the phone. In adults or those with underlying medical conditions, this may require a visit at PMC (in the pre-anesthesia testing [PAT] clinic). If your surgery has been scheduled and you haven’t heard from PAT within 2 days, call them: (505) 913-4444. Our clinic number is (505) 982-4848.

The government requires that you are seen by your surgeon within 30 days before your surgery. If your surgery is scheduled more than 30 days out, you will need to return to clinic before surgery.

Preparation

Adults: If you are on a blood thinner (aspirin, warfarin, Coumadin, Plavix, etc) discuss discontinuing this with your doctor. If it is not safe to stop your blood thinner, it is not safe to have tonsillectomy. Blood thinners should be stopped a week before and after surgery. Also please stop anything that might have vitamin E, ibuprofen (Advil), Alleve, or similar medications.

Everyone: Do not eat or drink after midnight. A small sip of water to take essential medications is ok. The pre-anesthesia clinic will tell you which medications are essential and should still be taken the morning of surgery.

Please shower the night before or morning of surgery. Do not wear make-up, jewelry, or piercings.

If you feel that you are getting sick within 2 weeks of surgery, call our clinic right away so we can consider re-scheduling.

You must have a capable adult drive you home. Your surgery will be cancelled if you are having an outpatient surgery and you do not have someone to drive you and be with you that night. After tonsillectomy you should not be alone for two weeks. For children we recommend a parent or capable grandparent stay with the child constantly in case there is an emergency (bleeding).

Outpatient surgery

Most patients undergoing tonsillectomy can go home the day of surgery. If you live outside of Santa Fe, consider staying in a hotel in town to be close the first night of surgery. There are several hotels that offer discounts and a list is available.

Recovery time and activity

While it is difficult to estimate your exact recovery time, we generally recommend having two weeks off from work or school. For two weeks, you should not exercise, lift anything heavy, or travel. Children tend to recover faster but still need to refrain from sports or physical education for the full two weeks. The main reason for this length of recovery is bleeding risk (see below).

Anesthesia effects

You will have general anesthesia which may make you nauseous or drowsy, particularly the first day. For a full discussion of anesthesia risks, you will meet and talk to your anesthesia team the day of surgery. Adults: Do not drive a car, operate heavy machinery, or sign legal documents for at least 24 hours AND until you are no longer taking prescription pain medicine. Alcohol should be avoided during the recovery period. The combination of alcohol and acetaminophen (Tylenol) can be toxic to the liver.

Follow-up

We typically do not schedule a follow-up appointment after tonsillectomy. You are always welcome to be seen. If there are any issues, call our clinic (982-4848) to arrange an appointment.

Diet

After having anesthesia, you will want to advance your diet slowly the first day to avoid nausea. Focus on liquids the first day (popsicles, Gatorade, or Pedialyte). Cold items generally hurt less. When you are ready for solid food, you are restricted to soft food for 14 days: noodles, soups, mashed potatoes, apple sauce, yogurt, etc. Some people advise to not have dairy products after tonsillectomy. The only reason this has been suggested is because dairy can make mucous thicker. Our view is that staying hydrated trumps everything. Ice cream is ok.

Pain

Pain is best controlled by staying ahead of it. The pain medications we recommend are over-the-counter liquid acetaminophen 160mg/5ml (Tylenol) and ibuprofen 100mg/5ml (Advil or Motrin). They are unique and can be given together. Administering these two medications on a schedule for the first few days is recommended. Setting an alarm in the middle of the night is wise. See the instructions section at the end for the exact dosing. The frequency of acetaminophen and ibuprofen is every four hours using the doses below. During the day they can be alternated so that every two hours either acetaminophen or ibuprofen is given. If you are prescribed a narcotic, it is “as needed”. If it is not needed, or if there are side effects, don’t take it.

Age under 12: In younger children narcotics are unsafe and they do not work any better than ibuprofen and acetaminophen. 1-5

Age 12 and up:   In addition to the ibuprofen and acetaminophen mentioned above, we will prescribe a narcotic for breakthrough pain (typically oxycodone). You may not always need it. Your primary mode of pain control will still be the ibuprofen and acetaminophen combination mentioned above.

Dosing: It is important to be accurate with the dosing. A syringe should be used to measure the exact amount in ml. We recommend avoiding teaspoons because they are not accurate and they can be confused with tablespoons. If you are not sure about the dosing, talk to your pharmacist or call our nurses.

Narcotic pain medicine tips and safety:

  • Don’t take narcotic prescription on an empty stomach. Wait at least 10 minutes after eating.
  • If you become nauseous, don’t take any more narcotic pain meds until you feel better.
  • Narcotics can cause sedation. They can be dangerous if overdosed or combined with other sedating medications. Do not take narcotics when drowsy.
  • Narcotics can cause constipation. You can prevent this by taking docusate (an over-the-counter stool softener). You may also need a suppository such as dulcolax if you become constipated.
  • Narcotics can cause itching. If this occurs, take a lower dose or take a non-sedating antihistamine (such as Claritin) to reduce this.
  • Narcotics are not meant for long term use and can cause tolerance and dependence. We generally will not prescribe narcotics beyond 10 days after surgery.

 

Bleeding

There is a small but real risk of bleeding after tonsillectomy, which is about one-two out of 100 (1-2%). This can happen at any time during the two weeks of recovery, but is most common after about one week when the scabs fall off internally. (You cannot feel when this happens.) Because of this risk we recommend light activity, soft diet, and being with a parent, spouse, or grandparent for the full two weeks, even if you feel better.

Bleeding can be a life-threatening emergency. If bleeding occurs, you should call 911 and proceed to the emergency room. We may have to cauterize the site of bleeding under anesthesia so do not eat or drink anything. While proceeding to the ER, you can try gargling and spitting out ice water to get the bleeding to stop. Call our on-call doctor as well so we can help you get medical attention faster.

Remnant tonsil or adenoid tissue

It is possible, particularly in younger children, for adenoids to regrow over time. It also possible, although less common, for tonsil tissue to be left behind. This is partially intentional because to remove every small speck of adenoids and tonsils would require a bigger surgery with greater complication risk.

Blood clots

Adults: Blood clots are uncommon, but can be deadly. A blood clot in the legs is called a deep vein thrombosis (DVT). They can be deadly if the clot travels to the lungs (pulmonary embolism). People are at risk for DVTs up to a month after surgery. The risk is greater with any of the following: lack of movement, age over 40, obesity, dehydration, pregnancy, use of oral contraceptives, or prior blood clot. Some people are more likely to develop a DVT due to a genetic defect, but may not discover this until a DVT happens. Swelling or pain in your lower leg or behind your knee is usually how a DVT presents. If this happens, you should go to an emergency room immediately for evaluation. To prevent a DVT, wear compression stockings and start walking at least three times a day beginning the evening of your surgery. The quicker you regain mobility and the more mobile you are, the lower your risk.

Other possible complications

  • Swallowing problems: since tonsil and adenoid surgery is affecting the throat, swallowing problems are a possible complication. After adenoidectomy, especially in children with very large adenoids or a weak palate, velo-pharyngeal insufficiency (VPI) can develop. VPI is when the palate doesn’t close all the way and food or drink can come out of the nose. This is rare and usually temporary.
  • Scarring: scarring can cause narrowing of the throat. This is extremely rare.
  • Taste disturbance: nerves that affect taste travel near the tonsils and can be damaged. This is rare.
  • Burns: during surgery bleeding is controlled with cautery. This creates the potential for an airway fire or tissue burn. These are rare.
  • Hoarseness: Since a breathing tube will be placed during surgery, it is common to wake up with a raspy voice. Permanent hoarseness from intubation is possible, although rare.
  • More surgery: Additional surgery could be required. Examples of when this may occur include bleeding, regrowth of adenoid tissue, or remnant tonsil tissue.
  • Infection:   Infection after adenoidectomy or tonsillectomy is rare but possible. Antibiotics are not routinely used because the chance of side effects is greater than the benefit from the antibiotic.
  • Breathing problems:   It is possible, although rare, to have life-threatening breathing problems after tonsillectomy.   If this were to occur re-intubation or a tracheotomy (a breathing tube through the neck skin) may be necessary.
  • Death: With any surgery there is a small chance of death. Potential causes are bleeding, breathing problems, narcotic overdose, and anesthesia problems. We do not have good data on this risk because it occurs so rarely. One study estimates the risk of death from tonsillectomy to be one out of 12,000. We know that the more unhealthy a person is (obesity, heart or lung problems, etc), the greater the risk; conversely, healthier people will have a lower risk.6,7

Reducing your risks

What can you do to reduce your risks with surgery?

  • If you are obese, losing weight will help. You should consider delaying surgery to lose weight.
  • If you smoke, stop for at least one week before and 2 weeks after surgery
  • Be aware and communicate

Every surgery has inherent risks that are impossible to completely eliminate. The important thing is recognizing a problem and calling or seeking medical attention promptly. It is your responsibility to communicate with your doctor and medical team. We cannot help you if we do not get information and feedback from you. If you do not understand anything, you must speak up until you do. If you think we do not understand something, speak up until we do. When in doubt, ask. We are always happy to talk to or see you any time after surgery. If your surgeon is not available, one of the other doctors will be.

 

I have read and understand the above. I have discussed the risks, benefits, and alternatives to surgery with my doctor. My questions have been answered to my satisfaction.

Patient /Parent signature: ________________________________Date: ____________

Pre-op nurse signature:   _________________________________Date: ____________

Physician signature:       __________________________________Date:____________

 

  1. FDA Drug Safety Communication: Safety review update of codeine use in children; new Boxed Warning and Contraindication on use after tonsillectomy and/or adenoidectomy. http://www.fda.gov/Drugs/DrugSafety/ucm339112.htm
  2. Prows CA, et al. Codeine-related adverse drug reactions in children following tonsillectomy: a prospective study. 2014 May;124(5):1242-50. doi: 10.1002/lary.24455. Epub 2013 Nov 13.
  3. Moir MS, et al. Acetaminophen versus acetaminophen with codeine after pediatric tonsillectomy. 2000 Nov;110(11):1824-7.
  4. St Charles CS, et al. A comparison of ibuprofen versus acetaminophen with codeine in the young tonsillectomy patient. Otolaryngol Head Neck Surg. 1997 Jul;117(1):76-82.
  5. Bedwell JR, et al. Ibuprofen with Acetaminophen for Postoperative Pain Control following Tonsillectomy Does Not Increase Emergency Department Utilization. Otolaryngol Head Neck Surg. 2014 Dec;151(6):963-6. doi: 10.1177/0194599814549732. Epub 2014 Sep 9.
  6. Cohen D, Dor M. Morbidity and mortality of post-tonsillectomy bleeding: analysis of cases. J Laryngol Otol. 2008 Jan;122(1):88-92. Epub 2007 Mar 12.
  7. Windfuhr JP. Serious complications following tonsillectomy: how frequent are they really? ORL J Otorhinolaryngol Relat Spec. 2013;75(3):166-73. doi: 10.1159/000342317. Epub 2013 Aug 22.

 


 

Instructions after tonsillectomy/adenoidectomy

x No scheduled follow-up necessary. If needed call 982-4848 for an appointment.

x Avoid heavy lifting, straining, exercise, or travel for 14 days.

x You must be with a responsible adult at all times for 14 days in case of emergency.

x Soft diet for 14 days

x Purchase liquid over-the-counter ibuprofen (Advil) 100mg/5ml. This should be given every 4 hours on a schedule the first 3 days and then every 4 hours as needed. The amount to give depends on your weight:

  • 9-14 kg (20-32 lbs) 3 ml every 4 hours
  • 15-22 kg (33-49 lbs) 5 ml every 4 hours
  • 23-29 kg (50-65 lbs) 5 ml every 4 hours
  • 30-37 kg (66-82 lbs) 10 ml every 4 hours
  • 38-44 kg (83-98 lbs) 5 ml every 4 hours
  • 45kg and up (99 lbs and up) 15 ml every 4 hours

x Purchase liquid over-the-counter acetaminophen (Tylenol) 160mg/5ml. This should be given every 4 hours on a schedule the first 3 days, then every 4 hours as needed. The amount to give depends on your weight:

  • 9-14 kg (20-32 lbs) 5 ml every 4 hours
  • 15-22 kg (33-49 lbs) 9 ml every 4 hours
  • 23-29 kg (50-65 lbs) 8 ml every 4 hours
  • 30-37 kg (66-82 lbs) 7 ml every 4 hours
  • 38-44 kg (83-98 lbs) 6 ml every 4 hours
  • 45kg and up (99 lbs and up) 6 ml every 4 hours

¨ Don’t take narcotic prescription on an empty stomach. Wait at least 10 minutes after eating.

¨ If you become nauseous, don’t take any more narcotic pain meds until you feel better.

¨ Narcotics can cause sedation. They can be dangerous if overdosed or combined with other sedating medications. Do not take narcotics when drowsy.

¨ Narcotics can cause constipation. You can prevent this by taking docusate (an over-the-counter stool softener). You may also need a suppository such as dulcolax if you become constipated.

¨ Narcotics can cause itching. If this occurs, take a lower dose or take a non-sedating antihistamine (such as Claritin) to reduce this.

¨ Narcotics are not meant for long term use and can cause tolerance and dependence. We generally will not prescribe narcotics beyond 10 days after surgery.

¨ Walk for several minutes at least 3 times a day. Wear compression stockings until you are moving around a normal amount.

¨ Avoid alcohol

¨ Do not drive or operate heavy machinery until off of narcotic pain medications.

¨ Do not sign legal documents until at least 24 hours after surgery and off narcotic pain medicine.

x If you vomit more than twice in one day, call your doctor.

x Call or return for fever over 101.5 more than a day after surgery, or increasing redness, pain or swelling.

x Call 911 and proceed to the ER :

  • for any bleeding.
  • for any breathing problems.
  • for swelling or pain in the calf or behind the knee.
  • for any other emergency

x Call you doctor with any other problems or concerns: (505) 982-4848

 

I have read and understand the above instructions.

Family member signature: _________________________________            Date:     _________________

PACU nurse signature:   __________________________________                Date:     _________________

Physician signature:       ___________________________________              Date:     _________________