Index
It is a surgical procedure in which both palatine tonsils are extracted from a recess in the side of the pharynx called the tonsilar fossa.
The procedure is performed in response to the repeated occurrence of acute tonsillitis, sleep surgery for obstructive sleep apnea, nasal obstruction of the respiratory tract, diphtheria carrier status, snoring or peritonsillar abscess.
For children, tonsillectomy is usually combined with an adenoidectomy, which is the removal of the adenoid (also known as the pharyngeal tonsil or nasopharyngeal tonsil). The combination of these two procedures is called adenotonsillectomy.
Adenoidectomy is rare in adults in whom the adenoid is much smaller than in children and rarely causes problems. Although tonsillectomy is performed much less frequently today than in the 1950s, it remains a common surgical procedure in children in the United States and in many other Western countries.
However, tonsillectomy remains a controversial surgery since its benefits seem to be only modest and temporary in most cases, while there are some indications that tonsillectomy can compromise the immune system in the long term, especially when it is performed an early age
History
Tonsillectomies have been practiced for more than 2,000 years, with variable popularity over the centuries. The procedure is stated in some books as ” Hindu medicine ” around 1000aC (literature not based on evidence).
Others call it amygdala cleansing using the nail of the index finger. Approximately one millennium later, the Roman aristocrat Aulus Cornelius Celsus described a procedure whereby using the finger (or a blunt hook if necessary), the amygdala separated from the neighboring tissue before being cut.
Galen was the first to advocate the use of the surgical instrument known as the trap, a practice that would become common until Aetius recommended the partial removal of the amygdala, writing:
“Those that extirpate the totality The tonsils eliminate, at the same time, the structures that are perfectly healthy and, in this way, give rise to a serious hemorrhage”.
In the seventh century, Paulus Aegineta described a detailed procedure for tonsillectomy, which includes the treatment of the inevitable postoperative bleeding. They spend 1,200 years before the procedure is described again with such precision and detail.
The Middle Ages saw that tonsillectomy fell into disgrace; Ambroise Pare in 1509 wrote that it was ” a bad operation ” and suggested a procedure that involved a gradual strangulation with a ligature. This method was not popular among patients because of the immense pain it caused and the infection it usually followed.
The Scottish physician Peter Lowe in 1600 summarized the three methods in use at that time, which included trap, ligation and excision.
At that time, it was thought that the function of the tonsils was the absorption of secretions from the nose; it was assumed that the removal of large amounts of tonsillar tissue would interfere with the ability to eliminate these secretions, which would cause their accumulation in the larynx, which would cause hoarseness.
For this reason, doctors like Dionis (1672) and Lorenz Heister censored the procedure.
In 1828, physician Philip Syng Physick modified an existing instrument originally designed by Benjamin Bell to remove the uvula; The instrument, known as the guillotine of the amygdala (and later as a tonsilotome), became the standard instrument for the removal of the amygdala for more than 80 years.
In 1897, it became more common to perform the complete removal of the amygdala instead of the partial one after the American physician Ballenger noticed that the partial resection did not completely relieve the symptoms in most cases.
Their results using a technique involving the removal of the amygdala with a scalpel and forceps were much better than partial removal; Tonsillectomy with the guillotine finally fell into disfavor in the United States.
Signs and Symptoms of Tonsillitis
The most prominent symptom of tonsillitis is a sore throat. Other signs and symptoms of tonsillitis include:
- Fever.
- Bad breath.
- Congestion and nasal discharge
- Swollen lymph nodes in front of the neck.
- Swollen and red tonsils with pus spots (white spots).
- Pain or difficulty swallowing
- Loss of voice or muffled voice.
- Headache.
- Abdominal pain.
- Cough with blood.
If the tonsils are enlarged, breathing through the nose can be difficult and symptoms may include:
- Breathe through the mouth, especially in children.
- Noisy breathing in the day. Nighttime snoring is often observed.
- Voice that sounds nasal.
When there is sore throat and cold symptoms such as congestion, runny nose, sneezing and coughing, the cause is most likely a virus. The viral infection of the tonsils or adenoids usually resolves without treatment within two weeks.
A sore throat with a sudden, mild fever, without symptoms of an upper respiratory tract infection, may indicate a bacterial infection.
If these symptoms are present, consult a doctor to obtain a diagnosis due to the risk of strep throat infection.
Although strep throat usually goes away even without treatment, an untreated streptococcal infection can cause complications, such as rheumatic fever , which can permanently damage the heart.
Is Tonsillitis contagious?
Tonsillitis may or may not be contagious, depending on the cause. If the cause is viral, it is usually contagious, but this depends on whether or not a person has been exposed to that particular virus before.
Mononucleosis, a viral cause of sore throat, is contagious the first time a person is exposed to the virus, usually in childhood or adolescence. If the cause of tonsillitis is bacterial, it is also contagious.
For example, streptococcal pharyngitis is highly contagious. If tonsillitis is caused by a chronic condition, such as sinusitis , hay fever, or chronic rhinitis , it is probably not contagious.
Doctors treating tonsillitis
A primary care provider, such as a family doctor, an internist, or a pediatrician of a child can diagnose and treat simple tonsillitis and adenoid infections.
If your tonsillitis is severe enough to go to an emergency department, an emergency medicine specialist will see it.
If the infections are severe, chronic or recurrent, you may be referred to an otolaryngologist for further treatment or surgical removal of the tonsils.
Diagnosis
The diagnosis of tonsillitis is based on a medical history and a physical examination.
If the symptoms suggest a strep throat, the doctor may request a throat culture or a rapid strep test, which is done by rubbing the back of the throat and looking for Streptococcus bacteria.
This can be done in the doctor’s office. If it is suspected that Epstein-Barr virus , which can cause mononucleosis, is the cause of tonsillitis, a blood test may be performed to detect mononucleosis.
Streptococcal pharyngitis is more likely if at least three of the following signs or symptoms are present:
- Fever.
- White or yellow spots or covering in the throat and / or tonsils (tonsil exudates).
- Red spots on the roof of the mouth (upper vane).
- Swollen or tender lymph nodes in the neck.
- Absence of coughing or sneezing
Antibiotic treatment may be necessary if the infection is caused by bacteria. In more severe, recurrent or chronic cases, surgery may be recommended to remove the tonsils to cure the condition.
Treatment
Bacterial infections of the tonsils are treated with various antibiotics. Tonsillitis caused by Streptococcus bacteria can cause serious complications.
Once the treatment begins, it is important to take the full cycle of antibiotics as prescribed, because if you stop taking the drugs before they are finished, it can cause adverse consequences and re-grow the bacteria.
Surgical removal is considered in situations resistant to medical therapy or in frequently recurrent infections.
Viral causes of tonsillitis are often treated only with supportive care (hydration and control of fever). Antibiotics are not effective for viral infection of the tonsils.
A peritonsillar abscess should be drained either by withdrawing fluid with a needle and syringe (needle aspiration), open cut with a scalpel (incision), or tonsillectomy.
Chronic stones in the amygdala can be removed with a clean finger or a blunt probe.
The massive enlargement of the tonsils that causes airway obstruction can be treated with prolonged treatment with antibiotics, or even a short cycle of steroids to reduce inflammation (cortisone-related medications, such as prednisone and prednisolone ).
When should the tonsils be removed?
Tonsillectomy is indicated for people with repeated or persistent infections, particularly if they interfere with daily activities.
The American Academy of Otolaryngology defines repeated infections in children as seven episodes in a year, or five episodes in each of two years, or three episodes in each of three years.
Tonsillectomy is also justified in situations in which there is enlarged tonsils in such a way that it causes severe sleep problems (snoring and breath retention), sleep apnea, dental anomalies and difficulty swallowing.
The tonsillar enlargement can cause nasal obstruction, recurrent ear infections or sinusitis. If these conditions are resistant to medical therapy, surgery is indicated to cure them.
A significant episode of tonsillitis is defined by one or more of the following criteria:
- Temperature higher than 101F (38.3 C).
- Enlarged or sensitive lymph nodes of the neck.
- Pus material that covers the tonsils.
- A positive streptococcal test.
In adults, the severity, frequency and difficulties associated with repeated infections are considered more important than the absolute number. Chronic infections characterized by bad breath and / or tonsil stones that cause significant disability are also indicators of tonsillectomy.
Tonsillectomy is very considered in those patients who suffer or may suffer serious complications of infection.
These include peritonsillar abscess, a history of streptococcal complications (rheumatic heart disease, glomerulonephritis), or neck abscess. The suspicion of cancer (malignancy) or tumor is a definitive reason for surgery.
It should be emphasized that all decisions for or against removing tonsils depend on the particular situation of the individual patient.
Additional factors, such as tolerance to antibiotics, concurrent medical problems, school performance / progress and family preferences are also important factors in the decision process.
What happens before the Surgery?
In most cases, the surgery is performed on an outpatient basis in a hospital or surgical center. In both facilities, quality care is provided without the expense and inconvenience of a one-night stay.
An anesthesiologist will supervise the patient throughout the procedure. Usually, the anesthesiologist (or surgery staff) will call the night before the surgery to review the medical history.
If they can not communicate with the patient the night before surgery, they will talk with the patient the morning of the surgery. If the doctor has ordered preoperative laboratory studies, the patient must arrange for them to be done several days in advance.
The patient must make arrangements for someone to take them to the surgical facility, to their home, and to spend the first night after the surgery with the patient.
The patient should not take aspirin or any product that contains aspirin, within 10 days after the date of surgery.
Non-steroidal anti-inflammatory medications (such as ibuprofen, Advil, and others) should not be taken within 7 days after the date of surgery.
Many over-the-counter products contain aspirin or ibuprofen-related medications, so it is important to control all medications carefully. If you have any questions, call the office or ask a pharmacist.
Acetaminophen (Tylenol) is an acceptable analgesic. Usually, the doctor will give the patient several prescriptions at the preoperative visit. It is best to get them filled before the surgery date so that they are available when you return home.
If it is a child who will undergo surgery, it is recommended that you be honest and direct with them while explaining your next surgery. Encourage the child to think of this as something the doctor will do to make them healthier.
Let them know they will be safe and that they will be close. A reassuring and reassuring attitude will greatly facilitate the child’s anxiety. Tell the child that if he has pain, it will only last a short time and that he can take medication to help relieve it.
You may want to consider a visit to the surgical center or hospital several days in advance so that the child becomes familiar with the environment. Contact the surgical facility or the hospital to schedule a visit.
The patient should not eat or drink anything 6 hours before the time of surgery. This includes even water, candy or chewing gum. Anything in the stomach increases the chances of an anesthetic complication.
If the patient is ill or has a fever the day before surgery, call the surgeon’s office. If the patient wakes up sick the day of surgery, continue with the surgical installation as planned.
The doctor will decide if it is safe to proceed with the surgery. However, if your child has chickenpox, do not take your child to the office or surgery center.
What happens the day of the surgery?
It is important that the patient knows precisely what time they should consult with the surgical facility and that they allow sufficient preparation time.
Bring all documents, forms and insurance information, including preoperative orders and history sheets.
The patient must wear comfortable and loose clothing (the pajamas are fine). Leave all jewelry and valuables at home. Children can bring a favorite toy, a stuffed animal or a blanket.
The patient should not take any medication unless instructed by the doctor or anesthesiologist. Usually, in the preoperative waiting room, a nurse will start an intravenous (IV) infusion line and the patient can be given medication to help him relax.
What happens during surgery?
In the operating room, the anesthesiologist will usually use a gas mixture and an intravenous medication for general anesthesia.
In most situations, an intravenous line will be started in the preoperative waiting room or after the patient has received an anesthetic mask.
During the procedure, the patient will be continuously monitored with a pulse oximeter (oxygen saturation measurement) and a continuous heart rate monitor.
The surgical team is well trained and prepared for any emergency. In addition to the surgeon and the anesthesiologist, there will be a nurse and a surgical technician in the room.
After the anesthesia takes effect, the doctor will remove the tonsils and / or adenoids through the mouth. There will be no external incisions. The base of the tonsils and / or adenoids will be burned (cauterized) with an electric cautery unit.
The entire procedure usually takes less than 60 minutes. The doctor will come to the waiting room to talk with any family or friends once the patient transfers safely to the recovery room.
What happens after the surgery?
After the surgery, the patient will be taken to the recovery room where a nurse will control them. Family members are usually invited to the recovery room as the patient becomes aware of their surroundings, and if the patient is a child, they will look for their parents or caregiver.
The patient will be able to go home the same day of surgery once he has fully recovered from anesthesia. This usually takes several hours. The patient will need a friend or family member to pick them up from the surgical center and take them home.
A relative, caregiver or friend must spend the first night after the surgery with the patient. When the patient arrives home from the surgical facility, he should lie down and rest with his head elevated on 2 or 3 pillows.
Keeping the head elevated above the heart minimizes edema and swelling. Applying an ice pack on the neck can help decrease swelling. The patient can get out of bed with help to use the bathroom.
Visitors should be kept to a minimum as they may unconsciously expose the patient to an infection or cause excessive excitement. If the patient is constipated, avoid stretching and take a stool softener or a mild laxative.
Once the patient has recovered from the anesthesia, if it is tolerable, a light, soft and fresh diet is recommended. Avoid hot liquids for several days.
Although the patient may be hungry immediately after surgery, it is best to feed slowly to prevent postoperative nausea and vomiting.
Occasionally, the patient may vomit once or twice immediately after surgery. However, if it persists, the doctor may prescribe medications to calm the stomach.
It is important to remember that a good diet in general with ample rest promotes healing. Weight loss is very common after a tonsillectomy. The patient does not have to worry about nutritional requirements during recovery, as long as he consumes adequate amounts of fluid.
The patient can receive antibiotics after surgery. The patient must take all the antibiotics prescribed by the doctor. Some type of narcotic (usually acetaminophen / Tylenol with codeine) will also be prescribed, and will be taken as needed.
If the patient requires narcotics, he is warned not to drive. If the patient has nausea or vomiting in the postoperative period, antiemetic medications such as promethazine (Phenergan) or ondansetron (Zofran) may be prescribed.
If the patient or caregivers have any questions or feel that the patient is developing a reaction to any of these medications, a doctor should be consulted.
Patients should not take or administer any other medication, either prescription or over-the-counter, unless discussed with the doctor.
Risks and Complications of Tonsillectomy
The patient’s surgery will be performed safely and carefully to obtain the best possible results. Surgery may involve risks of unsuccessful results, complications or injuries from known and unforeseen causes.
Because people differ in their response to surgery, their anesthetic reactions and their healing results, ultimately results or possible complications can not be guaranteed.
In addition, surgical outcomes may depend on pre-existing or concurrent medical conditions.
The following complications have been reported in the medical literature. This list is not intended to include all possible complications. They are listed here only for your information, not to scare you, but to inform you and learn more about this surgical procedure.
Although many of these complications are rare, all have occurred at one time or another in the hands of experienced surgeons who practice the standard of community care.
Anyone contemplating surgery should weigh the possible risks and complications against the potential benefits of surgery or any alternative to surgery.
Constant sore throat : inability to relieve each episode of sore throat, or resolve subsequent or concurrent sinus or sinus infections or nasal drainage. Possible need for additional surgery.
Bleeding : in very rare situations, there may be a need for blood products or a blood transfusion.
The patient has the right, if he / she prefers it, to have autologous blood or administered by a designated donor, prepared in advance in case an emergency transfusion is necessary.
Patients are encouraged to consult with a doctor if they are interested in this option.
Side effects : infection, dehydration, prolonged pain and / or healing problems that could lead to the need for hospital admission to control fluids and / or control pain.
Voice : a permanent change in the voice or nasal regurgitation (rare).
Breathing : does not improve the nasal airways or resolves snoring, sleep apnea or breathing through the mouth.
General Instructions and Care
An appointment should be scheduled for a checkup 10 to 14 days after the procedure. Call the office to schedule this appointment.
The most important thing that can be done after a tonsillectomy to prevent bleeding and dehydration is to drink lots of fluids. Sometimes it can be very difficult to swallow.
If the patient drinks, he will have less pain in general. Try to drink dilute, non-acidic diluted drinks or frozen popsicles. Soft foods such as gelatin, ice cream, custard, puddings and purees are useful for maintaining proper nutrition.
Spicy, spicy, and harsh foods such as fresh fruits, toast, crackers, and chips should be avoided as they can scratch the throat and cause bleeding. If dehydration occurs and attempts at home can not correct the problem, intravenous fluids will be admitted to the hospital.
Pain is common after a tonsillectomy. It is often difficult to predict who will recover quickly or who will have prolonged pain. Immediately after surgery, many patients report minimal pain.
The next day, the pain may increase and remain significant for several days. In a week after surgery, the patient often seems to relapse when the pain becomes significant again.
They usually report pain in the ears, especially when they swallow. Scabs often fall at this time. If it is going to bleed, this is the most common time.
This pain is usually the last time you will experience pain. In general, most patients will have fully recovered two weeks after surgery.
However, the patient will occasionally have tenderness in the throat with hot or spicy foods for up to 6 weeks after the operation.
The patient will notice white spots on the back of the throat where the tonsils were previously. These are temporary scabs, which occur during the healing process. They are not a sign of infection, and they will fall within the first two weeks after surgery and you should not try to eliminate them.
They will give the patient bad breath, which will be resolved once the area is completely healthy. The throat will take up to 6 weeks to return to the normal pink color. It is not unusual to have a stuffy nose after surgery.
Nasal congestion can last for several months as the swelling decreases. Saline nasal drops can be used to help dissolve clots and decrease edema.
The patient may notice persistent or even louder snoring for several weeks. A temporary change in voice is common after surgery, and will usually return to normal after several months.
Bleeding occurs in 1% -3% of patients after a tonsillectomy. Although it can occur at any time, it usually occurs 5 to 10 days after surgery.
Dehydration and excessive activity increase the chances of postoperative bleeding. If bleeding occurs, the patient should try to remain calm and relaxed. Rinse your mouth with cold water and rest with your head elevated. If the bleeding continues, call the doctor.
The treatment of bleeding can be simple. Rarely, it may require a trip back to the operating room for the cauterization of the bleeding area under general anesthesia. In very rare situations, a blood transfusion may be necessary.
On the contrary, bleeding is rare after an adenoidectomy. There may be some bleeding from the nose after surgery. If it occurs, pediatric nasal drops of Neosynephrine can be used. If it is persistent and bright red, call the doctor.
Natural remedies to relieve pain and swelling of tonsillitis
If a doctor has diagnosed tonsillitis, there are some home remedies that can help relieve the symptoms of sore throat.
Throat sprays and pills : these can cover and moisturize the throat, and many have a topical anesthetic to relieve pain (consult a doctor before giving pills to young children, but can be a choking hazard).
Salt water gargle : this helps eliminate mucus from the throat.
Take hot drinks : as tea with honey or broth can be soothing.
Eat cold foods : like ice cream or lollipops can help relieve pain.
Some alternative remedies can help relieve the symptoms of tonsillitis:
- Slippery elm in the shape of a rhombus can help with pain relief.
- Serrapeptase is an enzyme that has anti-inflammatory properties and can help decrease pain and help swallow.
- Papain is an enzyme that can help treat inflammation.
- Andrographis can help treat fever and symptoms of sore throat.
Consult your doctor before using any alternative remedy. Many of these home remedies are not recommended for use in children or adolescents, most have not been scientifically evaluated.
Back to School, Work or Exercise
Most patients require at least 7-10 days off from work or school. After 3 weeks, you can usually resume exercise and swimming, but do not dive for 6 weeks.
The patient should plan to stay in the local area for at least 2-3 weeks to allow postoperative care and in case of bleeding.
When to call the Doctor
Notify the doctor if the patient has:
- A sudden increase in the amount of bleeding from the mouth or nose that lasts more than a few minutes.
- Upper fever that persists despite increasing the amount of liquid they drink and the administration of acetaminophen (Tylenol and others). A child with fever should try to drink about a half cup of liquid every waking hour, and an adult should drink a cup per hour.
- Persistent acute pain or headache that is not relieved by prescribed pain medications.
- Increased swelling or redness of the nose, neck or eyes.
Effectiveness
Scientific evidence indicates that tonsillectomy is, on average, modestly effective in reducing the frequency and severity of sore throats, and does not completely eliminate sore throats.
The benefits also seem to last only one year after surgery. Some patients experience long-term results, although more information and studies are needed to portray the full picture on the subject.
This raises questions about which children benefit enough to justify carrying out the operation. In children who meet strict criteria that indicate they are severely affected by a sore throat, the evidence indicates that there is only a short-term benefit.
The strict criterion is that children must have experienced 7 sore throats documented in the previous year, or 5 each year in the previous two years, or 3 each year in the previous three years and that the documented sore throats must also have evidence documented of enlarged lymphatic glands.
Children with undocumented throat pains or sore throats that are not so severe do not seem to suffer so many sore throats in subsequent years and, therefore, tonsillectomy is not worth it.
In children who meet the strict criteria of surgery, the short-term benefit means that without a tonsillectomy a child who meets these strict criteria will probably have 6 sore throats in the next two years, while one who will have surgery will probably have 3 pains throat.
After two years, there is little difference in the frequency of sore throats.
Keep in mind that the term ” sore throat ” is preferable to ” throat infection ” or ” tonsillitis ” because without pharyngeal swabs, doctors can not reliably distinguish between sore throats caused by infection and those due to other causes
It is possible that the same patient suffers from tonsillitis or sore throat (pharyngitis) by different doctors, therefore, the use of one term instead of the other depends both on the doctor and the patient, so it is an unreliable reason for perform a surgery .
Since children must have many documented sore throats to make tonsillectomy worthwhile, there is surprisingly little published evidence about how many children who removed their tonsils actually meet these criteria.
A small study in the UK showed that most of the children whose tonsils were removed did not meet these criteria, which means that most of the children operated on did not really benefit from the procedure.
