TONSILS AND ADENOIDS
Tonsils and adenoids are made of lymphoid tissue and they are part of our defense mechanism against germs. When germs contact lymphoid tissue, antibodies are produced which then attach to the germ so our body can eliminate them. The spleen, as well as lymphoid tissue throughout our intestinal tract, has the same purpose and the tonsils are only one small part of this system of defense. The tonsils are located in the pharynx on either side of the tongue. The lingual tonsils are located at the back of the tongue. Adenoids are located above the soft palate within the nasopharynx.
At times the tonsils may become a site of recurrent infection or they may become chronically inflamed or they may grow so large they cause obstruction of the airway. When tonsils and adenoids become infected, symptoms of tonsillitis occur: fever, scratchy and painful throat, enlarged tonsils, fatigue, and at time abdominal pain and a skin rash.
When tonsils and adenoids are abnormally large, the nasal (adenoids) and oral (tonsils) airways may become obstructed causing snoring, mouth breathing, and apnea. The reason why tonsils become too large is not well understood but they reach the greatest size between four to six years of age. Because the adenoids are located by the eustachian tubes, large adenoids may also increase the risk of ear infections. It is unusual for a person over age twelve to have large adenoids and as we age our tonsils also become smaller and the risk of infection decreases significantly. Symptoms of chronic (cryptic) tonsillitis differ from those who have recurrent tonsillitis and include mild but chronic throat discomfort, bad breath, and accumulation of white-yellow debris within the tonsil crypts. This condition is more common in teenagers and young adults and is the leading reason for tonsillectomy for this age group.
Tonsillectomy and adenoidectomy are common procedures performed by Ear, Nose, and Throat Surgeons. Tonsils and adenoids are removed to treat recurrent infections, chronic sore throat, or to improve sleep disordered breathing due to airway obstruction. Indications for surgery follow national guidelines based on scientific studies:
Pediatric Tonsillectomy Indications (age one to 18):
1. Infection: seven episodes of tonsillitis/pharyngitis, viral or bacterial, within one year; five infections per year for two years; or three infections for each of three years. Certain other conditions may alter these guidelines including antibiotic allergies or intolerance, tonsil abscess, and significant effect on life.
2. Sleep Disordered Breathing: defined as recurrent partial or complete upper airway obstruction during sleep resulting in disruption of normal breathing and sleep patterns. This is the most common reason for pediatric tonsillectomy. Symptoms include observed sleep disturbances with apnea, gasping during sleep, snoring, attention deficit hyperactivity disorder, aggression, depression, sleepiness, open mouth breathing, bed wetting, growth retardation, failure to thrive, poor school performance, and other behavioral problems. Many of the above symptoms may resolve after tonsillectomy. Sleep disordered breathing is often caused by more than one condition. Cure of apnea occurs in 60-70 percent of patients with lower success in obese patients.
Adult Tonsillectomy Indications:
For adults, chronic tonsillitis and recurrent infections are the most common indications. Symptoms related to this condition include bad breath, chronic throat discomfort, cryptic tonsils with smelly debris, and frequent infections. The decision for tonsillectomy is more individual and considers quality of life and severity of illness.
Tonsillectomy is performed in the hospital under general anesthesia and takes about 30 minutes. Typically a child is taken to the operating room and given anesthesia gas. Once asleep, an IV is placed and a ventilation tube in inserted into the trachea. A mouth retractor is placed and tonsils and adenoids are removed through the mouth. There are several techniques used to perform tonsillectomy and adenoidectomy. Dr. Denys prefers to use Coblation, a technique that was unknown to Utah County before 2001 when he arrived. He introduced the technique to American Fork Hospital. It is now the most common technique to remove tonsils in the U.S. with over sixty percent of surgeons favoring the technique. Coblation uses high frequency sound transmitted through saline solution to cut tissue. The tissue is cut at about seventy degrees which reduced secondary tissue damage to surrounding structures. Tonsillectomy may be accomplished with minimal and at times no bleeding, while proving the least painful recover after surgery. After the procedure, the patient is taken to the recovery room, then back to same day surgery where you started. Most patients will be discharged home on the day of surgery. Discharge depends on the effects of anesthesia, fluid intake, and pain control. An average recovery in the hospital is between one and two hours.
Attempts have been made to determine the best method to perform tonsil surgery considering post-operative recovery, complications, and cost. A study in 2014 by Intermountain Health Care looked at all tonsillectomy patients in their hospitals and the surgeons who performed the surgeries over a six year period. The goal was to determine the complication rate and cost for various surgical techniques. American Fork Hospital had one of the lowest complication rates in Utah with an average of 5.8 percent. Complications were defined as post-op bleeding or any return to the hospital for care. Dr. Denys complication rate was lower than the Utah average and lower than the American Fork Hospital average indicating he has one of the lowest rates in Utah. Dr. Denys reviewed over 4,000 cases over the past ten years and has found his average rate of post-op bleeding in children is one percent and for adults is five percent.
After tonsils and adenoids are removed, an open sore remains in the throat which must heal. All patients have pain after their procedure and all patients will have areas in the throat that appear white. This material is called fibrin and comprises a scab; it is not an infection. Fever is not unusual in the first few days after surgery. Pain in the ears is also common and is caused by referred pain from the throat. The device used to hold the mouth open during the procedure pushes the tongue against the lower teeth and may cause the tongue to hurt or feel numb; these symptoms typically resolved within a few days.
Hydration is important. Patients who drink and stay well hydrated despite the natural tendency to resist will have less pain and recover faster. However, a cycle of increasing pain and dehydration follow in those who do not drink. Small sips of fluids like Gatorade, soda, or broth is well tolerated by nearly everyone. The diet may be advanced as tolerate and may include normal foods. There is no evidence to support a regimented diet but soft and cool foods are favored.
PAIN IN CHILDREN
The peak period for pain in a child is four or five days after surgery. Encourage your child to communicate with you if they are having pain, as it may not be expressed. Narcotic pain medications have received critical review and are discouraged in younger children. Most young children do well with Tylenol and/or Ibuprofen for pain control. The dose prescribed is based on their weight and should not be increased as it is written for the maximum dose of Tylenol they can safely tolerate. Tylenol alone is dosed at up to 15 mg per kilogram (kg) every 4 hours. (1 Kg = 2.2 pounds). For example, a 20 kg (44 pound) child should get 300 mg of Tylenol per dose. Ibuprofen is dosed at 10 mg per kg per dose and may be given every 6 hours. Many patients do well when the dose of Tylenol and Ibuprofen is alternated every three hours. Other products, like lollipops and sprays that numb the throat are available in children and adults.
PAIN IN ADULTS
Pain is caused by the immediate injury from surgery and from delayed inflammation. Pain is often at its peak between five and seven days after surgery. Narcotic pain medications are often given to adult patients to reduce the pain from the injury, but they do not have any anti-inflammatory effects. It is best to use a combination of products so both components of pain are treated. The quantity and type of narcotic are determined by the doctor and is based upon many years of experience treating this condition. Narcotics often cause nausea, which can be reduced when taken with food. Anti-nausea medication can be provided if necessary. On the day of surgery, the drugs used for anesthesia may cause nausea too. It is best to begin with fluids and when tolerated, advance the diet. The typical dose for ibuprofen is 10 mg per kilogram, about 600 mg every 6 hours for most adults. The maximum dose for Ibuprofen in adults who weigh above 80 kg (175 lbs.) is 800 mg every 6 hours. Narcotics like Lortab and Percocet are based on weight and specific dosing by the doctor is given. DO NOT exceed the prescribed dose as an overdose can cause death due to suppressed breathing.
Be aware that narcotic pain medications are controlled drugs. The state of Utah does not permit narcotics to be prescribed without a patient visit. This rule is intended to insure patient safety and to reduce narcotic abuse. I will not call-in a narcotic under any circumstances. If additional medication is needed, please call during office hours. If you fail to request a refill during regular office hours, you may not be able to get it until the office opens on the next business day.
1. Bleeding: Blood loss from tonsillectomy should be minimal; however there may be slight oozing of blood from the mouth or nose after surgery. A small spot of blood in the saliva or from the nose is not a concern. Significant post-operative bleeding may occur after tonsillectomy despite a well performed surgery and is more common in adults. Bleeding may occur at any time, but is most common between the seventh and tenth post-operative day. If active, bright red bleeding occurs, call the office immediately or go to the closest Emergency Room.
2. Activity: No vigorous activity is permitted for 14 days. Activity increases blood pressure which increases the risk of post-operative bleeding. Adults may return to work and child may attend school when they feel comfortable, usually after one week.
3. Voice: A "nasal" sounding voice may be evident after surgery, but usually will resolve as the throat heals and swelling decreases.
4. Smoking or Exposure to Smoke: This increases the intensity of pain and impedes healing.
5. Travel: The risk of bleeding is small, but unpredictable. Access to medical services (preferable coverage by an Ear, Nose, and Throat Surgeon) is important for three weeks after surgery.
6. Fever: This is common on the first or second day and relates to the anesthesia. Symptomatic treatment with Tylenol may be given.
7. Ear Pain: This is common, especially in children. Pain is referred to the ears and is almost never due to an ear infection.
8. Diet: Most foods are acceptable and should not harm the throat. Seasoned foods, acidic liquids, and spicy foods will increase pain, but some people still eat them. Soft nutritious foods and liquids are best.
Please call our office after the surgery to schedule a post-operative visit. For additional questions or medications refills, please call the office.