Tonsillectomy

Pain/Pain Control

Unfortunately you or your child will be badly sore for quite a few days, but almost all are back to near normal by day 14. This is usually much quicker in kids (5-7 days), worse in teenagers/young adults (7-14).

The pain often builds to a maximum around day 4-5, due to tissue swelling and therefore stretching pain. Once the pain peaks there should be progressive improvement. Please contact me if the pain reverses course and worsens again: this is unusual and may indicate tonsil bed infection (thankfully rare)

A significant portion of patients will experience earache. Some will recognize this as similar to the earache they had with tonsillitis. This is called referred otalgia, due to “cross wiring”, in that the main supply nerve to the tonsil has a side branch to the ear canal. Overactivity in this nerve (from the surgery) is misinterpreted by the brain as earache. It will settle

Children:

Panadol is the mainstay and usually adequate. Nurofen can be used as a fallback. Please check the correct dose for weight/age. The key is to give the Panadol regularly and pre-emptively, so 30 min before each mealtime and 30 min before sleep.

Adults:

Panadeine Forte or Endone, depending on the anaesthetist’s preference. Again, please take regularly and pre-emptively. Check with the chemist as to safe maximum dose per 24 hrs. For average weight adults (70kg+) with normal liver function up to 8 tablets of panadeine forte per day (NB: general rule of thumb only)

Hydration

Maintaining adequate body hydration is critically important; the more dry, the worse pain, hence even less intake, and so it spirals. Happily, we rarely need to readmit patients for intravenous rehydration (with IV pain relief). Push yourself or your child to drink. Cordial, water, diluted juice, soup are all good. Be aware that orange and apple juice are acidic and can sometimes irritate: you may have to dilute a bit

Food intake

There is nothing categorically forbidden after tonsillectomy, of course you will not be attempting a steak, or Thai curry. Eat sensible soft food: potato mash, pasta, non-toasted bread, etc. You can step up towards normal food as the pain eases

Voice change

Some patients will note a temporary period of altered vocal nature. This is due to stiffening of the throat tissues from surgery related oedema (tissue swelling). One can expect gradual return to the usual vocal quality and resonance as this oedema resolves.

Bleeding

There is a 4-5% risk of bleeding in the first 2 weeks post-op. The window of bleeding closes once the tonsil beds are fully healed, and it is very unusual to bleed beyond 2-3 weeks.

The bleeding occurs if one of the sealed vessels (vein or small artery) “pops”; this may be due to the vessel plug giving way, perhaps due to a small point of weakening or infection.

This is the one emergency after tonsillectomy. Unless it bled for only 10 seconds then completely stop, please go to the nearest emergency department (ED). Calling an ambulance is the safest default. All ED doctors take this seriously, as do ENT surgeons: at the very least they will contact the ENT registrar, and patients should be admitted for observation even if bleeding has stopped, and kept overnight. Ongoing bleeding may require a trip back to operating theatre, especially if all simple measures fail to achieve control

I will not be involved in this control if you end up at a hospital where I have no affiliation: that hospital’s ENT staff will look after you, just as I look after my colleagues’ bleeders presenting at my hospitals. Please do inform my rooms though.

Exercise

Take it easy for at least 2 weeks. You won’t feel like exercise in the first week anyway. Overexertion is a potential trigger for bleeding. On the other hand, it is not so delicate that a cough/sneeze/laugh will pop a vessel. This applies to sports and any other strenuous physical activity

Infection/ White slough in the Mirror/Antibiotics

The tonsil beds will be coated in a whitish layer of slough in the days just after surgery. This is NOT infection, but a fibrinous exudate coating the raw tissue. It is analogous to the black scab forming over skin abrasions. The white slough will fall off returning to pink ~7-10 days post op.

Tonsil bed bacterial infection is happily rare. It needs to be considered though if there is unexpected worsening of pain after a period of improvement, or if the throat becomes increasingly smelly (despite adequate hydration).

There is strong literature showing negligible benefit for routine antibiotic use after tonsillectomy, with no significant benefit in terms of pain or bleeding rates. I have stopped routine post tonsil antibiotic use since 2012 (see: CochraneDatabase review 2012: Antibiotics to reduce post-tonsillectomy morbidity)