Tonsillitis / Tonsillectomy

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The tonsils are a part of the body’s Lymphatic system. These masses of lymphoid tissue are located in the upper back of the mouth (oral cavity) and function to filter and protect the respiratory and alimentary tract from harmful bacteria. They also play a role in antibody formation. Children typically have larger tonsils than adults because it is thought to be a protective mechanism since younger children are prone to get upper respiratory infections. There are several types of tonsils located in the human body. The type that is visible during an oral examination is known as the palatine tonsils. The pharyngeal tonsils, also known as the adenoids, are located above the palatine tonsils on the back (posterior) wall of the nasal-oral cavity. Tonsillitis is the inflammation (swelling) and infection of the tonsils. The agent responsible for the infection may be a virus or a bacteria.

Clinical Manifestation

As the palatine tonsils become enlarged, they meet in the midline which results in the obstruction of the passageway for air and food. The child may have difficulty swallowing and breathing. As the adenoids become enlarged, the space behind the back nasal passageway becomes blocked, which also makes it extremely difficult for air to pass from the nose to the back of the throat.

Therapeutic Management

With tonsillitis, it is important to differentiate between viral and bacterial infection. A throat cultures is done and if positive for bacteria, then the infection is treated with antibiotics. Most infections are caused by a virus, and since antibiotics are useless against a virus, you basically treat the symptoms.

A tonsillectomy is the surgical removal of the palatine tonsils. The procedure is an absolute essential if there is recurrent infections and abscesses, airway obstruction involvement or if the infection results in fever leading to convulsions. Others indications for the procedure includes tonsillitis that doesn’t respond to the antibiotics.

An adenoidectomy is the surgical removal of the pharyngeal tonsils. The surgery is recommended for children whose tonsils obstruct their nasal breathing and for those who experience recurrent adenoid, sinus and ear infections.

After Surgery Care

The goal of after care is to minimize discomfort and minimize activity in order to avoid bleeding. Those children who have a sleep-disordered breathing will require close monitoring of their airway and breathing. This may include an overnight stay in the hospital.

Any oral intake is avoided until your child is fully awake. Initially, you will want to start with cool, clear liquids. Cold water, popsicles, gelatin, and diluted fruit juice is recommended to start. Avoid citrus juice because they may cause discomfort to the surgical site and avoid red or brown colored beverages so that you can distinguish fresh or old blood in vomitus from the ingested liquid. Avoid straws as well. Fluids are strongly encouraged to avoid dehydration because the pain from the surgery may cause your child to be reluctant to drink anything. Soft foods are started the next day, if your child is tolerating the liquids. Items such as gelatin, sherbet, mashed potatoes, and soups are foods to consider. Some doctors will have you avoid some milk product such as ice cream, pudding, and milk because these items will coat the throat and may cause your child to cough in order to clear the throat, which can cause the surgical site to bleed.

Your child will be instructed to engage in light activity only for a few weeks. They are to avoid frequent coughing, clearing the throat, blowing their nose or any activity that may cause tension to the surgical site. NO RUNNING / NO JUMPING. Normal activity may be resumed after you are cleared by your doctor.

Pain control is vitally important in order to avoid malnourishment and dehydration. An ice collar should be used for the first 48 hours to minimize swelling. Pain medication should be given regularly, even during the night for the first few days, because the pain from the surgery is continuous. Afterwards, you will need to assess for pain and give it as needed. Combination non-opioids and opioid elixirs are usually prescribed. Eventually, over the counter acetaminophen will be effective in controlling the pain. Other measures for you to consider include, warm salt water gargles and throat lozenges.

Active bleeding from the surgical site is uncommon but has been recognized in 5% of patients and as far as 14 days after the procedure. You will want to observe the site directly to assess for bleeding and you will need to have a good source of light to do that. So, be sure to have a good flashlight available. You want to be observing your child for frequent swallowing, particularly in the toddler age child who may not be able to verbalize or who may not be aware of the fact that they are bleeding. Other signs that they may be bleeding includes a fast heart rate, pallor, frequently clearing of the throat and vomiting of bright red blood. Surgery may be required to cauterize the bleeding vessel. Some secretions are common and may present in the form of blood tinged saliva. Their vomit content may include some dark brown (old blood) and this may also be present in nose secretions and around their gum and teeth.

Airway obstruction is a potential complication as well. This is a result of swelling (or edema) and / or accumulated secretions that may have occurred. You will know this if you observe signs of respiratory distress which will present itself in the form of labored breathing, restlessness, agitation, fast breathing rate, stridor, and cyanosis (turning blue). Suctioning equipment and oxygen needs to be available if this occurs.