Tonsillectomy and adenoidectomy

Tonsillectomy is the surgical removal of the tonsils. Adenoidectomy is the surgical removal of the adenoids. When the adenoids are removed with the tonsils, the procedure is called a T and A.


Anatomy
The tonsils are two clearly visible masses of tissue in the back of the throat. The adenoids are also in the back of the throat, located above the tonsils and close to the eustachian tubes (the tubes connecting the middle ear to the back of the nose and throat) and nasal passages.
The tonsils and adenoids are part of the lymphatic system -- the system that helps protect the body from invasion by bacteria or other organisms. These glands play an especially important infection-fighting role from birth until about age 3. As children grow older and their immune systems become more efficient, these glands tend to shrink. After age 3, tonsils and adenoids may have questionable value. Researchers continue to study their possible function and benefit.


Indications
With the success of nonsurgical treatments, tonsillectomies and adenoidectomies are becoming less common. The surgeries may be necessary, however, under certain circumstances. For example:
Acute tonsillitis (sudden inflammation of the tonsils) that obstructs breathing or creates an abscess (collection of pus) in the tissues around the tonsils may require a tonsillectomy. Although acute infections are most common in children, especially from ages 4 to 7, they can also affect adults. Symptoms typically include a sore throat, headache, fever, chills and swollen neck glands. You may notice a hoarse or muffled voice as well.

Surgery may be needed if prolonged antibiotic treatment for tonsillitis isn't effective or you develop recurrent strep infections.

A tonsillectomy may be needed if the tonsils are enlarged enough to obstruct breathing during sleep. This may lead to disruptive snoring or even sleep apnea (a condition in which breathing is recurrently disrupted during periods of sleep). In some cases, a surgical procedure to treat the sleep apnea may be done along with the tonsillectomy.

In some cases, prolonged mouth breathing related to enlarged adenoids may require surgical treatment. Left untreated, persistent mouth breathing may eventually change the facial bone structure. For example, you may develop an overbite that requires orthodontic intervention.

In other cases, abnormal speech patterns may benefit from surgical treatment. For example, muffled speech may be caused by large tonsils, and a lack of nasal resonance may be related to large adenoids.

Recurrent middle ear infections or persistent middle ear fluid with adenoiditis (inflammation and enlargement of the adenoids) may require an adenoidectomy with ear tubes. Adenoiditis is often caused by an infection or allergy. Because the adenoids are near the eustachian tubes, adenoid enlargement may obstruct these tubes and possibly contribute to middle ear infections. Children with persistent mouth breathing and nasal obstruction are often candidates for an adenoidectomy with ear tubes.

Recurring sinusitis or nosebleeds caused by adenoid enlargement may be treated through adenoidectomy.

The adenoids or tonsils may need to be removed if a tumor or cancerous growth is present. Tumors in the tonsils tend to cause one tonsil to be much larger than the other. These tumors are rare, however, especially in the adenoids.
Tonsillectomies and adenoidectomies are typically done by ear, nose and throat surgeons or general surgeons. Some general practitioners with training and experience in this area may also perform these surgeries.


Patient preparation
To determine what tests you'll need before surgery, the doctor will review your medical history and do a physical exam. Remember to mention any medications you're currently taking. You may need to avoid certain over-the-counter or prescription medications before surgery. For example, aspirin can interfere with the body's ability to stop bleeding, so your doctor may ask you to avoid aspirin for seven to 14 days before surgery. (Note: Aspirin or any product containing aspirin should not be used by anyone age 19 or younger due to the risk of Reye's syndrome, a rare but serious illness.) Follow your doctor's instructions for stopping any prescription medications.
To determine what tests you'll need before surgery, the doctor will review your medical history and do a physical exam. Remember to mention any medications you're currently taking. You may need to avoid certain over-the-counter or prescription medications before surgery. For example, aspirin can interfere with the body's ability to stop bleeding, so you may be told to stop aspirin use seven to 14 days before surgery. (As a general reminder, aspirin or any product containing aspirin should not be used by anyone age 19 or younger due to the risk of Reye's syndrome, a rare but serious illness involving the brain and liver following a viral infection.) Always consult your doctor before you stop taking any prescription drugs.

You may need to avoid eating or drinking after midnight the night before surgery. Your doctor or anesthesiologist may give you additional instructions as well.

At the hospital or surgery center, you may need to sign a surgical permit or consent form. You may also need blood tests to measure your body's ability to stop bleeding. Specific organ function tests or additional tests may be needed depending on your general health status. Remember to share any questions or concerns you may have with your doctor.

Keep in mind that enlarged and recently infected tonsils pose a greater risk of bleeding problems during and after surgery. Surgery may need to be postponed if you develop a new tonsil infection near the time of a scheduled tonsillectomy. Antibiotics may be prescribed to treat acute strep tonsillitis. If an infection behind and around your tonsils creates an abscess, surgical drainage may be needed.


Procedure
Although every surgery has its own standard procedure, your individual health history could play a role in any variation to the procedure. Discuss these issues with your doctor.
Anesthesia
You'll begin by talking with the anesthesiologist. This is the chance to clear up any remaining concerns about the procedure. Before the general anesthetic is given, you may be given an injection to dry up excess fluids and encourage relaxation.

Airway control
After you've been given anesthesia, a tube will be placed into your nose and through the trachea (the tube that connects the throat to the bronchial tubes in the lungs) to provide an airway during surgery. Your throat will be packed with absorbent material to prevent blood from drainingdown the back of your throat. Excess blood may need to be suctioned.

Surgical procedure
The surgeon will use a forceps to grasp each tonsil while making an incision to expose the tonsils. Each tonsil will be carefully cut and removed. If the adenoids are to be removed as well, they'll be done next. To stop the bleeding, the blood vessels may be cauterized (sealed with a device that uses electrical current to stop bleeding) or tied with sutures. After surgery, the packing and airway tube will be removed. The entire procedure generally takes about an hour, possibly less for adults.


Postprocedure care
In the recovery room, you'll be closely monitored until the anesthesia begins to wear off and consciousness returns. Your vital signs will be taken about every 15 minutes, and you'll be watched for any signs of bleeding. As the anesthesia wears off, nausea and vomiting are possible. Your throat will be very sore, and you may have ear pain as well. You'll be encouraged to start drinking fluids when you're more fully awake and less likely to vomit. If there are no complications, you'll be sent home after several hours.
Your doctor may ask you to avoid vigorous activity for up to six weeks. You may have travel restrictions for a few weeks as well. Expect to have an extremely sore throat for up to five days after surgery. Some level of pain or discomfort may continue even longer, especially after eating. While you're recovering, it's best to eat soft foods and drink cool, nonacidic beverages.


Benefits
A tonsillectomy can reduce or eliminate repeated episodes of tonsillitis, as well as swallowing or breathing difficulties. An adenoidectomy should eliminate repeated episodes of adenoid enlargement, as well as relieve persistent nasal congestion, ear infections and airway problems.

Risks
A tonsillectomy doesn't eliminate the possibility of future throat infections. For the first few days after surgery, a painful throat may interfere with getting enough fluids. After an adenoidectomy, adenoid regrowth is possible.

Complications
Complications may include:
anesthesia complications
bleeding from the surgical site
nausea and dehydration
infection
constriction of the throat passages
The following factors may increase the risk of complications during or after surgery:

current infection
personal or family history of prolonged bleeding or bruising disorders (such as sickle cell anemia, hemophilia, other blood factor deficiencies or von Willebrand's disease) or cardiac problems
neurological conditions that lead to poor coordination of the airway and swallowing (such as cerebral palsy or Down syndrome)

Considerations
Laser tonsillectomy may be an option in some cases. The laser technique evaporates rather than cuts tissue, making recovery less painful. Often, local rather than general anesthesia may be used. If you're interested in a laser procedure, discuss the option with your doctor.

Pregnancy-specific information
During pregnancy, the risks and benefits of any surgery must be carefully weighed. Discuss any specific concerns with your doctor.

Senior-specific information
Tonsillectomies and adenoidectomies are unusual for older adults. As with any surgery, chronic illness may increase the surgical risks. Discuss any specific concerns with your doctor.