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Tonsillectomy and Adenoidectomy
WHAT ARE TONSILS AND ADENOIDS?
Tonsils and adenoids are lymphoid tissues located on the sides and the roof of the throat. Both the tonsils and adenoids are composed of large numbers of white cells, important soldiers in the human defense army. When foreign materials such as bacteria or viruses enter the nose and throat, they make contact with the tonsil and adenoid tissue. The foreign materials are taken into the tonsils and adenoids through deep valleys called crypts. The white cells within these tissues initiate the body's reaction to the foreign material and trigger a generalized defense reaction throughout the body.
During the course of a bacterial or viral infection, it is quite normal for the tonsils and adenoids to enlarge. This occurs because more white cells are being produced to aid in the defense against invading organisms. Because young children are constantly exposed to bacteria and viruses not previously encountered, their tonsils and adenoids remain enlarged. Enlarged tonsils and adenoids are usually not diseased. As individuals pass into adolescence and young adulthood, the tonsil and adenoid tissues tend to decrease in size. Adenoid tissues shrink by age 12 and become undetectable by age 20 in most persons.
Tonsils and adenoids also enlarge in patients with allergies. An allergy is an abnormal response by the body's immune system to common substances in the environment. Instead of recognizing these substances as harmless, the immune system of the allergic individual recognizes these materials as potential invaders and develops an intense immune response against them. This reaction can be manifest by a variety of symptoms including headache, nasal drainage, nasal congestion, throat soreness, wheezing, or various gastrointestinal reactions.
Pollens, animal hairs, and other associated chemicals or food are drawn into the nose or mouth and make contact with tonsil and adenoid tissue. If there is chronic stimulation, the tonsil and adenoid tissues become and remain large. It is common for adults with nasal allergy to maintain a significant amount of adenoid tissue.
WHY REMOVE TONSIL AND ADENOID TISSUES?
Removal of the tonsils and adenoids may become necessary for a variety of reasons. In the past, it was common to remove both the tonsils and the adenoids simultaneously. This is not as commonly done today as there are now specific reasons for removing either the tonsils or the adenoids alone.
Removal of the tonsils and any significant deposits of adenoid tissue is useful in the treatment of recurrent tonsillar and throat infections. Whenever the bacterial organisms are repeatedly cultured from the tonsil surface or when the tonsils begin to develop the appearance of chronically infected tissues, the tonsils may be the source of throat infections rather than the defense against them.
Tonsils and adenoids may also be large enough to severely obstruct breathing, speaking, or swallowing. The resultant symptoms of upper airway breathing obstruction are most evident at night with loud snoring, restless sleep, spontaneous arousals, sleeping with the neck extended, breathing pauses or apnea, difficulty getting up in the morning, and sleepiness or lack of energy during the day. Children deprived of effective sleep also tend to have attention and focus problems.
Large tonsils may also cause garbled speech or tongue placement problems which affect the quality of a child's articulation. Children may also choke on food, eat slowly, or refuse to eat certain foods.
Another indication for tonsil removal would be the abnormal enlargement of one tonsil compared with the other. In this case the tonsil would be removed and examined under the microscope to be certain that the involved tonsil does not contain a small tumor.
Indications for removal of the adenoids include evidence of recurrent adenoidal infection or obstruction of the nasal breathing passage by enlarged adenoidal tissue. In order to determine the necessity for adenoid removal, a careful examination of the front portion of the nasal airway must be made in addition to an evaluation of the amount of adenoid tissue present at the back of the nasal airway by a direct examination from the front or using a fiberoptic instrument. In some children and adults with small throats, the tonsils must also be removed in order to create a satisfactory space for breathing. Individuals with obstructed breathing or with abnormally long pauses in their breathing during sleep, usually referred to as apnea, should be considered for this type of combined procedure.
Recent controlled studies provide compelling evidence that adenoid removal will improve eustachian tube function and reduce the incidence of middle ear infections and middle ear fluid. If a child has middle ear disease as well as other indications for adenoid removal, the procedure is definitely worthwhile.
WHAT TO DO AT HOME TO PREPARE FOR THE HOSPITAL VISIT.
I highly recommend that your child attend one of the orientation sessions which are held by the hospital or surgicenter. This can be arranged through the hospital admissions office or the surgicenter administrative office. Such sessions help acquaint you and your child with the various areas and procedures at the facility. After such orientation, there will be fewer uncomfortable surprises on the day of surgery itself.
When speaking with your child, you should answer all questions about the upcoming hospital stay as honestly aspossible. Indicate that certain aspects of the hospital stay will be associated with pain. Assure your child that the doctors, nurses, lab technicians, and other personnel all work at the hospital because they love children and wish to help them.
Your child should take NO IBUPROFEN CONTAINING MEDICATIONS (Motrin™ or Advil™) or ASPIRIN CONTAINING PRODUCTS (Bufferin™, Alka-Seltzer™, etc.) FOR TWO WEEKS PRIOR TO AND TWO WEEKS FOLLOWING SURGERY. Aspirin and ibuprofen interfere with platelet function and may cause significant bleeding problems.
If your child is receiving any medication for other medical problems, he or she should continue to take it through the day before surgery. When your child arrives at the hospital, be certain to notify the staff about any medications that your child should continue taking while at the hospital. If the medication has not been ordered, the nurses will notify me so that I may arrange for your child to receive it.
DURING THE PRE-OPERATIVE PERIOD.
Most children do not require an overnight stay at the hospital unless they have other medical problems which require observation or special pre-operative management. The exception would be those children under the age of three.
All children are seen at my office for a pre-operative evaluation several days prior to the scheduled surgery. At this pre-operative visit, all necessary paperwork will be processed to make your child's entry on the day of surgery as smooth as possible. You will also be given prescriptions for antibiotics and pain medications to be taken prior to and after the surgery.
Certain laboratory tests will be performed prior to surgery. These include a red and white blood cell count to determine if your child is anemic or has evidence of a reaction to infection. Your child's blood clotting capability will be tested. I do not routinely determine your child's blood type or prepare blood for transfusion during tonsil surgery. There is usually minimal blood loss and the precaution of having blood in readiness is unnecessary.
If you feel that your child should have additional laboratory tests or that one of the above mentioned tests should be omitted, please communicate this to me or to other members of the staff.
WHAT IS THE PARENTS’ ROLE DURING A CHILD’S HOSPITALIZATION.
I encourage you to stay with your child as much as possible during the time at the hospital. If an overnight stay is planned, the hospital has facilities available for you to stay as nearby your child's bed as possible.
It is necessary for a parent to be present during the entire period while your child is at the hospital or surgicenter. You should be prepared to wait in the surgical area until the operation has been completed so that I can speak with you about the events in the operating room and what to expect during the post-operative period. After awakening in the recovery room, all children feel more comfortable if a parent is present.
A parent or interested and familiar adult is the best advocate for the child's well being and care while at the hospital. Such an individual is most familiar with the child's unique personality, general state of health, and particular preferences. For this reason you will be of immense value in helping the medical staff better care for your child.
The most important purpose of this booklet is to inform you about the general plan of treatment for your child. I cannot stress too strongly that you are a key member of your child's health care team. Keep your eyes and ears open to all that is going on about you and about your child.
If you are concerned about the course of your child's treatment and recovery, please do not hesitate to discuss this with the nurses and other facility staff. If you do not receive satisfactory answers to your questions or are still concerned, please contact me day or night. Good communications between you, your child, the hospital staff, and myself will be important in obtaining an optimal result during and after your child's sojourn at the hospital.
BEFORE THE OPERATION.
IT IS ABSOLUTELY NECESSARY THAT YOUR CHILD HAVE NOTHING TO EAT OR DRINK FOR A PERIOD OF FOUR TO EIGHT HOURS PRIOR TO THE SCHEDULED SURGERY. THIS IS REQUIRED IN ORDER THAT YOUR CHILD'S STOMACH BE EMPTY. DURING THE INDUCTION OF GENERAL ANESTHESIA, AN EPISODE OF NAUSEA OR VOMITING COULD CAUSE FOOD MATERIAL IN THE STOMACH TO ENTER THE WINDPIPE AND LUNGS. SUCH AN OCCURRENCE COULD BE LIFETHREATENING.
Please bring your child to the admitting area at the appointed time. Leave yourself sufficient time to travel, park, and find the office. There will be playthings available in the admitting area to help entertain your child during the pre-operative period. You may choose to also bring along a favorite toy or book for your child.
Your child must come to the hospital on the day of surgery 60 to 90 minutes before the scheduled time for surgery. During this time spent in the pre-operative waiting areas, your child will meet the anesthetist who will put your child to sleep and other doctors on the team who may assist me in performing the operation and will help with post-operative care.
Prior to leaving for the operating room, some children receive medications as ordered by the anesthesiologist. These may include a sedative which will make separation easier for both your child and you. The medications may be administered by mouth, as injections, or as rectal suppositories and you should prepare your child for this procedure.
If you have any questions regarding the procedure itself, its benefits, risks, or complications which have not been previously answered by either reading this booklet or by our prior discussions, please be certain to contact me so that I may discuss your concerns in detail.
IN THE OPERATING ROOM.
After leaving the pre-operative area, your child will go to the operating room area. For most children, anesthesia will be induced in the operating room by breathing laughing gas through a mask. For selected older children, an intravenous needle may be placed in the hand or arm and then be used to induce anesthesia once the child is in the operating room proper. Some apprehensive younger children may have already been given a sedative agent while in the pre-operative area.
Once your child is asleep, inhalation and intravenous anesthetic agents are administered to maintain a deep level of general anesthesia. A breathing or endotracheal tube will be carefully placed by the anesthetist through the vocal cords and into the windpipe. This tube permits me to protect the airway and maintain adequate breathing during the operation. This preliminary induction of general anesthesia will take between fifteen and twenty minutes to accomplish.
The procedure itself will require between thirty to sixty minutes to perform, depending upon whether or not both the adenoids and tonsils are being removed and whether or not vent tubes are also being inserted. The amount of bleeding which occurs and must be controlled also affects the total operating time. The tonsils and adenoids are removed through the mouth. There are no external incisions on the face or neck. If tympanostomy tubes, "ear tubes," are also being placed, that will be accomplished through the ear canals.
During the procedure, all bleeding areas are treated with electrocautery or sutured. I insist that your child's throat be completely free of any bleeding spots before I permit the general anesthesia to be discontinued. A few additional minutes spent in the operating room will save needless worry later! During most tonsillectomy/adenoidectomy cases, I apply a topical agent, microfibrillar collagen, which seals tiny blood vessels on the raw surfaces which remain after the tonsils and adenoids have been removed. The use of this agent provides an added safety factor and reduces the chance of bleeding during the recuperation period.
AFTER THE OPERATION.
After the procedure is completed, your child will slowly emerge from general anesthesia. This may require up to fifteen minutes. This aspect of the procedure may prolong the stay in the operating room, but it is important that your child have a regular breathing pattern before the endotracheal tube is removed.
After leaving the operating room, your child will remain in the Post-anesthesia Care Unit (PACU) for observation. This phase usually requires several hours and continues until your child is sufficiently awake to permit discharge home from the hospital. In some cases, this period may be prolonged because of slow recovery from anesthesia. I will occasionally suggest that you and your child remain at the hospital for an extended stay in an observation unit.
During recovery, it may be necessary to restrain your child's hands. This is not unusual, and be assured that it is done only if necessary to prevent a disoriented child from injuring himself or herself. Your child will have an intravenous in place in the recovery room and during the early phases of recovery in the hospital room. This is necessary to administer antibiotics and fluids until oral intake is resumed.
Occasionally, if your child has an undue reaction to anesthesia, it may be necessary to leave the endotracheal tube in place in the PACU. If prolonged placement of the endotracheal tube is necessary, your child may remain in PACU or be transferred to one of the Surgical Intensive Care Units (SICU) for further observation during the night of surgery. Children who have had serious obstructive breathing problems prior to surgery may be observed for the first night following surgery.
THE RECUPERATION PERIOD.
Your child's recuperation period begins as soon as the recovery phase is complete. The main goal of this period is to gradually increase food and fluid intake by mouth in order to maintain a normal fluid balance and to promote healing. During the first hours of this period, your child will likely have a gastrointestinal reaction to the anesthesia. This will be manifest as nausea and vomiting. The anesthetist or I will order medication that the nurses may administer to reduce this response. If such reactions occur, please request this medication.
Your child's throat will hurt after the surgery! It will feel like a severe sore throat and swallowing will be impaired. This swallowing impairment may cause drooling and your child will tend to spit out saliva. You should encourage as much swallowing as possible during this early phase.
Two types of pain medications will be ordered to help lessen some of the associated pain. An aspirin-substitute such as Tylenol™ or a similar medication should be administered four times a day as a general pain reliever. In addition, later in your child's course, a narcotic medication such as Tylenol with codeine may be administered by mouth to reduce the throat and ear pain on swallowing at night. Do not use either ibuprofen (Motrin or Advil) or aspirin as these may cause bleeding!
Once your child's stomach is settled and all signs are stable, you may take your child home. This usually occurs later on the day of surgery but occasionally may require an overnight stay. Parents often worry about taking a child home who has not yet begun regular fluid intake or who is groggy, but our experience shows that most children maintain better oral intake in the familiar home environment.
At the pre-op visit with me, you will be given prescriptions for all of the medications that your child will be taking after surgery. Be certain to fill them and to purchase all over-the-counter medications such as Tylenol so that you will have them available when you return home following the surgery. Your child will be taking an antibiotic, a dose of which I will give intravenously during the operation. I also recommend that you give your child a non-aspirin pain reliever, Tylenol™, four times a day for the first seven days after returning home. This will suppress throat pain, keep your child happier, and help to maintain oral intake at a high level. Use of narcotics such as codeine-containing medications should be kept to a minimum as they will create stomach cramps and constipation. I usually suggest using this type of medication at night to maintain restful sleep after the first days.
Over the first week to ten days, the bare zones of the throat created by the tonsil and adenoid removal will heal. This process is a gradual one and can occasionally be slowed by the presence of infection, which will be inhibited by the post-operative antibiotic. Be aware that the tonsil removal sites will look very peculiar over the first week to ten days after surgery. The raw surfaces will first appear very dark. After several days, the sites will become yellow or brown. The material coating these sites is a protein scab. Like all scabs, it provides protection to the healing tissues beneath. By ten days to two weeks after surgery, healing will progress to the point where a regular diet may be resumed.
RISKS AND COMPLICATIONS.
The major complication associated with tonsillectomy and/or adenoidectomy is bleeding from the operative site. This occurs most frequently either during the first three days or at six to ten days following the operation. Bleeding generally occurs when material striking the operative site dislodges a small fragment of the scab or healing tissue and exposes a blood vessel beneath. Although most bleeding is self-limited, I consider it to be a major complication requiring a doctor's examination and, in some cases, return to the operating room.
Post-tonsillectomy bleeding may be life-threatening. Usually the bleeding can be controlled with additional electrocautery or sutures placed during a second general anesthetic. Rarely, bleeding is due to a large blood vessel which is unusually close to the surface of the throat. In these cases, it may be necessary to enter the neck to control the bleeding by placing a tie around the blood vessel itself or around a larger blood vessel feeding it.
There is a possibility that your child may have an adverse reaction to the general anesthetic being administered. All anesthetic procedures employ drugs which must be either injected or inhaled. Undesirable or allergic reactions to these drugs have been reported. Such a reaction could, in turn, trigger reversible or, rarely, irreversible problems with any of the body's systems including the brain, heart, lungs, kidneys, and blood. If there is a reaction to the anesthetic, the offending drug will be discontinued and another substituted, if necessary. Occasionally, it is best to stop the procedure and awaken the child.
A third complication is the development of a post-operative infection. This is usually manifest by a significant, continuous throat pain or pain referring to the ears. Neck stiffness also indicates the possibility of an infection. If these symptoms occur, you should contact me at once. If an infection should occur, it may be necessary to change the antibiotic or to increase the dose of the drug that your child is currently taking.
Removal of large tonsils, with or without the adenoids, may produce a temporary or, rarely, a permanent change in your child's voice. This may occur because the enlarged tonsil and adenoid tissue may be aiding the soft palate in closing off the entry of air from the throat into the nasal cavity while speaking. For the same reason, some individuals have temporary or permanent problems with fluids leaking back through the nose. If these problems occur, they usually resolve spontaneously in four to six weeks. If they do not, an operation may be necessary to partially close the entrance into the back of the nose.
The tonsils are discrete tissues and, as such, may be entirely removed at the time of the operative procedure. Tonsillar tissue rarely regrows at the sites of removal. However, most individuals have tonsil tissue located behind the tongue. After removal of the tonsils on the sides of the throat, the tissue behind the tongue may grow to large proportions. Occasional patients have required later removal of this lingual tonsillar tissue.
Adenoid tissue, in contrast, is a bed of lymphoid tissue and must be removed piecemeal. For this reason it is not unusual for adenoid tissue to regrow, particularly in those patients who have allergies to inhaled materials. Should the adenoid tissues regrow, they may be removed again. Usually, regrown adenoid tissue is less abundant than the original adenoidal mass.
Scarring of the raw surfaces in the back of the nose occurs rarely after adenoidectomy. If it should, the scar could seal the entry way into the back of the nose. An operation would be required to reopen the nose.