Tonsillectomy, Adenoidectomy, Adenotonsillectomy

What are tonsillectomy, adenoidectomy, and adenotonsillectomy?

These are common surgeries to remove the tonsils and adenoids, tissues in the throat and behind the nose that can cause health problems in children.

• Tonsillectomy is a surgery (operation) to remove the tonsils, two small lumps of tissue in the back of the throat. 
• Adenoidectomy is a surgery to remove the adenoids, small glands located higher up, behind the nose. 
• Adenotonsillectomy is a surgery to remove both the tonsils and adenoids during the same operation.  

The tonsils and adenoids are part of the body’s immune system, which helps to fight infections.  

Germs enter your child’s body through their mouth and nose. Tonsils and adenoids trap germs and protect your child from infection. But tonsils and adenoids can also become swollen or infected. Examples of infections include strep throat and tonsillitis. 

Infections can:

• Make the tonsils or adenoids swell and hurt 
• Make it harder to swallow or breathe
• Cause ear and hearing problems

Sometimes the tonsils, adenoids, or both need to be removed.

Reasons for tonsil and adenoid surgery 

Medicines like antibiotics can heal a tonsil or adenoid infection. But if your child gets these infections often or has breathing problems, they might need surgery. Your child’s health care provider may recommend surgery if your child has: 

• 7 or more infections in 1 year
• 5 or more infections a year for 2 years in a row
• 3 or more infections a year for 3 years in a row
• Has trouble breathing, especially at night (like loud snoring or sleep apnea)
• Has trouble swallowing because the tonsils or adenoids are too big
• Infections that do not get better with medicine
• Has other problems, like frequent earaches or hearing trouble caused by swollen adenoids

Before the surgery

Your child’s care team will talk with you about the risks and benefits of surgery. You will also meet with members of the surgery team. They will talk with you about the surgery and give you instructions on how to prepare for the surgery.

• Vaccines: At least 2 weeks before surgery, your child will get any vaccines they need. 
• Fasting guidelines: Your care team will give instructions for when your child needs to stop eating and drinking before the surgery. These guidelines are also known as NPO instructions. 
• Medicines: Your care team will let you know if your child’s medicines need to change.

During the surgery

Your child will be given general anesthesia before surgery. This will cause a complete loss of consciousness, like a deep sleep. Your child will not be aware of pain during surgery. The surgery takes 30 minutes to one (1) hour. Plan to be at the hospital or surgery center for about 5 or 6 hours. 

Tonsillectomy

There are 2 main ways doctors can remove tonsils:

• Traditional tonsillectomy: The surgeon takes out both tonsils completely.
• Intracapsular tonsillectomy: The surgeon removes most of the tonsil tissue but leaves a thin layer to protect the throat muscles.  

During surgery, the surgeon will use special tools to gently hold your child’s mouth open. They will then remove the tonsils using one of several common methods:  

• Heat (electrocautery): The surgeon uses a special tool that gets very hot to remove the tonsils and stop bleeding.
• Surgical knife (cold knife): The surgeon cuts out the tonsils with a special knife and uses heat or stitches to stop the bleeding.
• Snare: A thin wire loop gently removes the tonsils, which helps reduce bleeding.
• Ultrasound tool (harmonic scalpel): This tool uses fast vibrations to cut out the tonsils and stop bleeding at the same time.

Sometimes, surgeons may also use lasers, radio waves, or special tools that cut and suction at the same time. The surgeon cuts, burns, or shaves away the tonsils. The wounds usually heal without stitches.

Kids who have intracapsular tonsillectomy usually heal faster, feel less pain, need less pain medicine, and have a lower chance of bleeding. They can also eat and drink more easily after surgery. However, the leftover tissue can sometimes grow back or get infected. If that happens, your child may need more surgery.

Your surgeon will choose the safest method for your child. If you have questions, ask your care team.

Adenoidectomy

If the adenoids need to be removed, the surgeon will usually do that during the same surgery. The surgeon will gently hold your child’s mouth open with special tools. The surgeon may:

• Remove the adenoids using a spoon-shaped tool (curette), microdebrider, or another tool that helps cut away soft tissue.
• Use electricity to heat the tissue, remove it, and stop bleeding. This is called electrocautery. 
• Use radiofrequency (RF) energy (coblation) to remove adenoid tissue. 

The surgical team may use some packing material to control bleeding. The surgical team will check to make sure any bleeding is stopped before the surgery is finished. Patients usually do not need stitches for adenoid removal.

After the surgery

After the procedure, your child will go to the recovery room until they wake up. 

When your child wakes up and can drink clear liquids, they can usually go home. Your child may need to stay 1 night or more at the hospital if they are:

• Younger than age 3
• Have other serious illnesses
• Have severe sleep apnea (stop breathing when they sleep)

Possible risks of surgery

Like any surgery, there are some risks of tonsil or adenoid removal. During the procedure, the main risks are problems with anesthesia or injury to nearby organs. After the procedure, the most common problems are: 

• Bleeding: Your child should not bleed a lot from the nose or mouth. Sometimes they might have a small amount of slow bleeding from the nose. Heavy bleeding needs medical help right away.
• Pain: Throat and ear pain are common, especially 3–7 days after surgery.  Ear pain (known as referred pain) is from a nerve that goes to the tonsils and ears. This pain will be most severe 5–7 days after surgery. Make sure your child drinks plenty of fluids during this time.
• Trouble eating and drinking: Some children may not want to eat or drink because of pain.
• Constipation: Pain medicine or not eating much may cause constipation.
• Fever: Your child may have a mild fever after surgery.
• Bad breath: Your child may have bad breath from a white or yellowish “scab” at the surgery site. 

Care at home

You can do several things to help your child recover at home after surgery. Most children start to feel back to normal in a few days, but it may take up to 2 weeks to fully recover.

Rest and return to activities

Encourage your child to rest for the first few days after surgery. Your child may be less active than usual for several days. They might have trouble falling asleep at night or may not sleep well. 

Your child should avoid vigorous physical activity for 14 days after surgery as this can cause bleeding. Vigorous activity means running, jumping, rough play, riding a bike fast, or playing sports. Follow your care team’s instructions for when your child can return to their usual activities. 

Pain management

The care team will give your child medicines to reduce pain and help them feel more comfortable. Give pain medicines as prescribed. You can also reduce your child’s pain by:

• Putting ice packs or cool, wet cloths on your child’s neck, jaw, or cheek area 
• Letting them have cold foods or Popsicle® ice pop or suck on ice chips if they are old enough 

Saltwater gargle

Your child can gargle with a mild saltwater solution to help clean their mouth and freshen their breath. You can make this solution by mixing 1 teaspoon of regular table salt in 8 ounces of cool water. Have your child gargle gently for 15-30 seconds and then spit out the solution.

Hydration

Drinking plenty of liquid is important to prevent dehydration (not having enough fluid in the body). While your child is awake, give them small amounts of liquid every hour. Start with cool, clear liquids like:

• Fruit juice
• Sports drinks like Gatorade^®
• Rehydration solution like Pedialyte^®
• Frozen ice pops

This table shows you how much liquid your child should drink each day. The  amount depends on how much your child weighs. You can use a measuring cup, marked in ounces, to track how much they drink.

If your child does not drink enough liquid, they may need to go back to the hospital until they can drink enough.

Foods

After tonsillectomy or adenoidectomy, it’s important to start with soft foods to help reduce pain and promote healing. Start with liquids and gradually introduce food when pain and nausea is under control.

• Start with small amounts of soft foods at first, like mashed potatoes, scrambled eggs, pudding, or applesauce. 
• Cold foods (like ice cream, yogurt, smoothies, or JELL-O gelatin can help soothe the throat.
• Slowly move to a normal diet.  
• Avoid sharp or crunchy foods (like chips, pretzels, popcorn, or raw vegetables) for about 2 weeks after surgery. 

Going back to school

Each child is different. Your child may go back to school when they eat a near-normal diet and can do regular activities (usually 7 to 10 days after surgery). Ask your care team if you have questions about what your child can do.

When to call your care team

You should seek medical help if your child develops fever and signs of infection. An infection can be life-threatening if not treated immediately.

Call your care team if you notice any of these signs in your child:

• Fever
• Unusual bleeding
• Problems drinking
• Trouble breathing
• Pain that does not get better

Questions to ask your care team

• Why does my child need this surgery, and what are the benefits?
• What should we do to get my child ready for surgery?
• What can I expect during and right after the surgery?
• How can I help my child feel better and heal at home?
• What signs should I watch for, and when should I call the care team?