Tonsillectomy

There has been controversy over the removal of tonsils for many decades, with strong opposition and equally strong protagonism. An extreme view defies reason and common sense and to deny tonsillectomy to a child may be to inflict much ill-health and loss of schooling. Equally, the decision to operate must be based on sound evidence that the benefit expected will justify the risk. It is not a trivial operation, and carries a small but real mortality rate. Indications for operation 1 Recurrent attacks of acute tonsillitis—three or four attacks over a period of a year, or five attacks in 2 years. Always remember that young children are likely to improve spontaneously but such improvement is less likely in adolescents and young adults. 2 Tonsillar and adenoidal hypertrophy causing airway obstruction. 3 Recurrent tonsillitis associated with complications, especially acute or chronic otitis media. 4 Carriers of haemolytic streptococci or diphtheria (a rare indication). 5 Following quinsy. 6 For biopsy in suspected malignancy—this is the only absolute indication for tonsillectomy. THE OPERATION 1 In the presence of current or recent infection, operation should be postponed. 2 Any suspicion of bleeding disorder must be investigated fully by the haematologist. 3 Any anaemia must be corrected before operation is carried out. 4 The risk of postoperative haemorrhage must be explained to the patient or his parents. It is a brave (or foolhardy) surgeon who embarks on tonsillectomy if blood transfusion is likely to be refused.The time to find out is before the operation. The operation is carried out under general anaesthetic with endotracheal intubation.The tonsils are removed by careful dissection and haemostasis is obtained by ligating the bleeding vessels. If the adenoids are to be removed at the same operation they are usually dealt with first. POST-OPERATIVE CARE The patient will be kept in the recovery area adjacent to the operating theatre until fully conscious. It is vital to ascertain that all bleeding has stopped before being returned to the ward. Once back on the ward, pulse and blood pressure are checked frequently. The pulse should be taken every half hour for the first four hours and then hourly until discharge. The patient is observed meticulously for any sign of bleeding or airway obstruction. The care of post-tonsillectomy patients calls for a high degree of vigilance and must never be delegated to inexperienced nurses. Several hours after operation, most patients are able to take oral fluids but should avoid blackcurrant cordial, which if vomited may look like blood. After operation, the temperature should be recorded 4-hourly and any rise noted. Pyrexia may be due to local infection, to chest or urinary infections or to otitis media. Although earache is common after tonsillectomy and is usually referred from the tonsil, do not omit examination of the ears. The appearance of the tonsillar fossa often gives rise to alarm. Within 12 h it is covered with a yellowish exudate, which persists for 10–14 days. It is quite normal and does not indicate infection. It is not pus. Following tonsillectomy, as normal a diet as possible is to be encouraged. Analgesics, such as soluble paracetamol prior to eating, are helpful. Eating normal food usually produces a reduction in pain afterwards (though not at the time!). COMPLICATIONS OF TONSILLECTOMY Reactionary haemorrhage The major risk from tonsillectomy is that of haemorrhage. Indications of reactionary haemorrhage are: 1 a rising pulse rate, though the blood pressure may remain constant initially; 2 a wet, gurgling sound in the throat on respiration, which clears on swallowing; 3 sudden vomiting of altered or fresh blood, which is often accompanied by circulatory collapse; 4 obvious bleeding from the mouth. Post-operative bleeding must be stopped urgently and delay may be fatal. Blood must be cross-matched and a drip set up. In a cooperative patient the bleeding may be arrested by the careful removal of clot, followed by pressure from a rolled-up gauze held in forceps. Usually, however, a return to theatre without delay is called for especially in children, when the bleeding point can be identified and ligated.The anaesthetic for such a procedure is hazardous and should not be delegated to a junior anaesthetist. Secondary haemorrhage Secondary haemorrhage occurs between the fifth and tenth postoperative days and is due to fibrinolysis aggravated by infection. Such bleeding is rarely profuse but the patient should be readmitted to hospital for observation. Usually the only treatment required is mild sedation and antibiotics, but an intravenous line should always be set up and the blood saved for grouping. It is only rarely necessary to return the patient to the operating theatre to control the bleeding. Otitis media Otitis media may occur following tonsillectomy—earache is not referred pain until you are sure the ears are normal. Infection Infection may occur in the tonsillar fossae and is marked by pyrexia, foetor and an increase in pain. Secondary haemorrhage is a potential danger and antibiotics should be given. Pulmonary complications Pulmonary complications such as pneumonia or lung abscess, are rare and may be caused by inhalation of blood or fragments of tissue.

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