What parents should know before -- and after -- a tonsillectomy
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For baby boomers growing up in the '60s, getting your tonsils removed was almost a rite of passage.
Today nearly half a million children under the age of 15 have their tonsils removed each year, making the procedure the second most common reason for care in children's hospitals.
However, experts say the surgical procedure used to treat childhood sleep apnea and chronic, debilitating throat infections isn't necessarily a risk-free endeavor. Tonsillectomy surgery was in the news in recent months as a 13-year-old California girl was left on life support and declared brain dead following complications from the procedure.
Tonsillitis is especially common in children, with bacterial and viral infections frequently cited as a cause. The bacterial streptococcus infection typically occurs in children ages 5 to 15, and viral tonsillitis is more common younger children. Tonsillitis is rare in those under age 2.
Symptoms include throat pain and tenderness, redness of tonsils, a white or yellow coating on the tonsils, painful blisters or ulcers on the throat, hoarseness or loss of voice, headache, loss of appetite, ear pain, difficulty swallowing or breathing through the mouth, swollen glands in the neck and jaw area, fever and chills. Nausea, vomiting and abdominal pain also are common signs in children.
"As specialists, we frequently see patients after long-term chronic problems with recurring tonsillitis," according to Dr. Lon J. Petchenik, a board-certified ear, nose and throat specialist treating both children and adults at the seven-physician Suburban Ear, Nose & Throat Associates, Ltd., practice in Arlington Heights and Hoffman Estates. "If tonsillitis is recurrent or persistent, or if enlarged tonsils cause an upper airway obstruction, surgical removal of the tonsils can be an effective treatment."
According to the American Academy of Otolaryngology-Head and Neck Surgery, nearly 80 percent of childhood tonsillectomies are due to obstructive sleep apnea -- snoring and irregular breathing -- the rest are due to infection.
"If your child has seven or more bouts of recurring tonsillitis in a year, or five to six bouts each year for two years, national AAO-HNS guidelines issued in 2011 indicate tonsillectomy may be advised," said Petchenik, who has performed the procedure nearly a thousand times in his 20-year career at St. Alexius Medical Center and Northwest Community Hospital.
While not without risk, the tonsillectomy procedure does offer many benefits, according to Petchenik. "For children this means sleep apnea often can be cured, infections reduced, and fewer sick days at school," he states. "In other less common post-op instances, parents have reported their child being more alert, fewer symptoms of attention deficit and even less frequent bed-wetting."
Differences in post-op care
According to a recent study published in the February issue of Pediatrics, the quality of care of children after a tonsillectomy varies significantly among hospitals.
"Bleeding, vomiting and dehydration are among the most common reasons children return to the hospital for care following tonsillectomy," Petchenik said, who noted "pain also may be severe and can be described as the 'worst sore throat of your life.'"
The retrospective study tracked low-risk children undergoing same-day tonsillectomy at 36 children's hospitals between 2004-2010, with researchers taking a close look at whether hospitals followed current practice guidelines calling for the use of a corticosteroid to reduce nausea, vomiting and pain on the day of surgery and no antibiotics. Ninety-one percent of hospitals followed the guidelines, while others provided no patients with the dexamethasone and no antibiotics.
"The corticosteroid given during or after the procedure helps decrease inflammation, decreases the chances of early postoperative nausea and vomiting, and limits pain for a couple of days," Petchenik explained. "Antibiotics are not given unless there is an infection already present."
The study also tracked how likely patients were to return to the hospital in a 30-day period following their surgery.
Of the 131,715 children studied, 7.8 percent returned for care within the time period, most commonly for bleeding, vomiting and dehydration. Older children between 10 and 18 years of age were at higher risk for return visits due to bleeding, and at a lower risk for vomiting and dehydration compared to children ages 1-2 years old.
Petchenik said the greatest post-op risk for bleeding occurs five to 12 days after surgery, can be sudden, and frequently requires a return to the operating room to stop the bleeding.
Post-op risks parents should know
Postoperative risks and Petchenik's recommendations include:
• Bleeding. Rarely occurs within the first 24 hours. Three to five percent of children and 6 to 10 percent of adults experience significant postoperative bleeding,
• Pain. Usually moderate for a few days, pain escalates on days three to eight and dramatically improves. Narcotic pain medications often are prescribed. "Cepacol sore throat lozenges and ice packs to the outside of the neck also can provide soothing relief," suggested Petchenik.
• Burn. There is a remote risk of burn injury with electric cautery or coblation surgery.
• Hydration. Patients are advised to drink plenty of fluids to help prevent dehydration and fever. Avoid citrus juices as they can sting. "Water, Gatorade, apple juice, orange or grape drink and dairy products all are great," Petchenik said.
• Eating. Poor eating may occur for up to 10 days, with a five- to 10-pound weight loss not uncommon.
• Fever. Low grade temps of up to 101 will be most noticeable in the mornings. Increased fluid intake can help.
• Bad breath. Caused by scabbing in the throat, can last for 10 days. Avoid gargling.
• Stiff neck. Can be caused by neck muscle spasms and should subside as healing progresses.
• Other possible side effects: Temporary tongue numbness, ear pain, voice changes and taste changes.
Know before you go
If your child needs to have tonsils out, don't be afraid to ask questions, discuss techniques being used, bleeding rates, regrowth potential, side effects, postoperative care and more.
"For instance," Petchenik said, "there are many ways to remove tonsils and cutting devices used by surgeons may include a knife, electro-cautery, laser or a radio-frequency hand piece called a coblator.
"While all methods are acceptable, many studies show the coblator causes less postoperative pain, leading to a faster recovery. The hand piece is designed to constantly irrigate the throat while it cuts, operating at a lower temperature."
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