Tonsils and adenoids
Tonsils and adenoids are part of the body’s lymphatic immune system. Lymphatic tissue “samples” bacteria and viruses that enter the body through the mouth or nose, but they sometimes become infected. However, the role of the tonsils and adenoids is relatively minor in defending against infections. At times, they become more of a liability than an asset and may even cause airway obstruction or repeated bacterial infections. It has been shown in large clinical studies that the removal of the tonsils and adenoids does not lead to a reduced ability of the body to defend itself. Dr. Dagan can suggest the best treatment options.
What are tonsils and adenoids?
Tonsils and adenoids are similar to the lymph nodes or “glands” found in the neck, groin, and armpits. Tonsils are the two round lumps of soft tissue located in the back of the throat on either side of the back of the tongue. Adenoids are located on the ‘second floor’ high in the throat behind the nose and the roof of the mouth (soft palate). They are not visible through the mouth or nose without the use of endoscopes. An endoscope is a very thin flexible fiber that can be advanced through the nose to visualize the back of the nose where the adenoids are located or the lower part of the throat where the vocal cords are. Contrary to a common myth, the removal of tonsils or tonsils and adenoids does not affect our ability to fight off disease. The lymphatic system has hundreds and hundreds of lymph nodes that participate in this role and does not require the presence of these tissues at all.
What affects tonsils and adenoids?
The two most common problems affecting the tonsils and adenoids are recurrent infections known as “strep throat”, an infection with an organism called streptococcus which is a type of bacterial organism. The danger of having the streptococcal bacteria remain in the throat for prolonged periods of time is the spread of this bacteria to the valves of the heart slowly causing their destruction and leading to congestive heart failure.
Otherwise, significant enlargement of tonsils or adenoids can cause a nasal obstruction and/or breathing, swallowing, and sleep problems such as obstructive sleep apnea where the patient gasps for air at night leading to chronic fatigue, memory loss and attention deficit as well as a myriad effects on the body like hypertension, eye disease and even diabetes.
Abscesses that develop around the tonsils pose a more severe form of swallowing difficulty that is often accompanied by the inability to open the mouth (trismus). A peritonsillar abscess often requires surgical drainage and may lead to hospitalization.
Chronic tonsillitis ore recurrent tonsillitis is a condition where the tonsils become infected so often that they require removal.
Sometimes, infections in the tonsils may lead to the formation of small pockets within the tonsils that produce foul-smelling white deposits (tonsil stones) that are really just bits of food that get trapped in the crypts of the tonsils. This can lead to constant bad breath (Halitosis) and discomfort in the throat or the sensatino of a foreign body in the throat especially after meals. The most effective treatment for tonsil stones is the use of a waterpik. In cases where the waterpik is not effective, we recommend to take tonsils out.
Cancers of the tonsil, while uncommon, require early diagnosis and aggressive treatment.
When should I see a doctor?
You should see Dr. Dagan when you or your child experience the common symptoms of infected or enlarged tonsils or adenoids. A high fever and enlargement of both tonsils with whitish coating over large kissing tonsils and a severe difficulty swallowing may indicate infectious mononucleosis. We recommend whenever you see that the tonsils are enlarged and covered with a whitish coating and acccompanied by pain upon swallowing to come in so that a quick strep test may be performed and a culture swab of the throat is taken. Please avoid taking antibiotics that may be laying around the house. Not culturing a bacterial infection can lead to the inability to diagnosis the source of infection and may make the treatment more challenging.
Dr. Dagan will ask about you specifically about complaints relating to the ear, nose, and throat and examine the head and neck. He may use a thin flexible lighted instrument called an endoscope to examine hard to reach areas that are not commonly seen on exam at your primary care physician’s office.
Other methods used to check tonsils and adenoids are:
- Medical history
- Physical examination
- Throat cultures/Strep tests – helpful in determining the source of the infection in the throat
- X-rays – helpful in determining the size and shape of the adenoids especially in children
- Blood tests – helpful in diagnosing infections such as infectious mononucleosis or the Epstein Barr Virus
- Sleep study, or polysomnogram-helpful in determining whether sleep disturbance is occurring because of large tonsils and adenoids.
Tonsillitis is the term we use for an infection of the tonsils (not just strep). One sign is swelling of the tonsils. Other symptoms include:
- Redder than normal tonsils
- A white or yellow coating over the tonsils
- A slight voice change due to swelling (often resembling having a hot potato in the mouth), this may be the early indicator of an abscess in the throat
- Sore throat, sometimes accompanied by ear pain. The era pain usually is present with every swallow effort.
- Uncomfortable or painful swallowing
- Swollen lymph nodes (glands) in the neck. These lumps in the neck which are mislabeled tonsils are really a result of the body’s effort to fight the infection. They usually resolve slowly after the infection goes away.
- Bad breath or halitosis
- Difficulty opening the mouth or trismus is an indication that tonsillitis may have become become complicated with an abscess around the tonsils (peritonsillar abscess). The difficulty opening the mouth is a result of the infection spreading into the muscles of the jaw that make completely lock the jaw closed.
Enlarged tonsils and/or adenoids and their symptoms If your or your child’s adenoids are enlarged, it may be hard to breathe through the nose. If the tonsils and adenoids are enlarged, breathing during sleep may be disturbed. Other signs of adenoid and or tonsil enlargement are:
- Breathing through the mouth instead of the nose most of the time (open mouth breathing)
- Nose sounds “blocked” when the person speaks, this is also called closed rhinolalia and is commonly due to the obstruction of the back of the nose with enlarged adenoid tissue. Children will often present with open mouths and very runny noses constantly.
- Noisy breathing during the day is usually a sign of an obstruction of both the nasal airway as well as the oral airway with tonsillar and adenoid tissue.
- Recurrent ear infections
- Snoring at night
- Restlessness during sleep, pauses in breathing for a few seconds at night (may indicate sleep apnea).
How are tonsil and adenoid disease treated?
Bacterial infections of the tonsils, especially those caused by streptococcus, are first treated with antibiotics. The first line of defense is penicillins although we may also use sulfa type antibiotics or clindamycin. Removal of the tonsils (tonsillectomy) and/or adenoids (adenoidectomy) may be recommended if there are recurrent infections despite antibiotic therapy, and/or difficulty breathing due to enlarged tonsils and/or adenoids. Such obstruction to breathing causes snoring and disturbed sleep that leads to daytime sleepiness, and may even cause behavioral or school performance problems in some children.
We generally recommend the removal of tonsils if there are 6 or more infections per year or if the duration of the infections affects the overall quality of life and causes prolonged abscess from school or work.
Chronic infections of the adenoids can affect other areas such as the eustachian tube–the passage between the back of the nose and the inside of the ear. This can lead to frequent ear infections and buildup of fluid in the middle ear that may cause temporary hearing loss. Studies also find that removal of the adenoids may help some children with chronic earaches accompanied by fluid in the middle ear (otitis media with effusion).
In adults, the possibility of cancer or a tumor may be another reason for removing the tonsils and adenoids. In some patients, especially those with infectious mononucleosis, severe enlargement may obstruct the airway. For those patients, treatment with steroids (e.g., prednisone) is sometimes helpful.
How to prepare for surgery
- Talk to your child about his/her feelings and provide strong reassurance and support.
- Encourage the idea that the procedure will make him/her healthier.
- Be with your child as much as possible before and after the surgery.
- Tell him/her to expect a sore throat after surgery, and that medicines will be used to help the soreness. We generally recommend a soft and chilled diet like cold Jello, yoghurt or ice cream.
- Reassure your child that the operation does not remove any important parts of the body, and that he/she will not look any different afterward.
- It may be helpful to talk about the surgery with a friend who has had a tonsillectomy or adenoidectomy.
- There are two things that Dr. Dagan does differently from the the rest of the pack when it comes to removing tonsils.
- The use of plasma energy. Generally tonsils may be removed by either the use of a scalpel or an electric device called suction electrocautery which is composed of a long tube coated in plastic with a small metallic end that emits an electric current that causes the heating of the tissue by burning. The resulting charring can prolong healing and increase pain post operatively. Instead, Dr. Dagan uses a device that also employs heat created as plasma within a stream of water that prevents the dissipation of the heat to the surrounding muscles of the throat. This can minimize the pain after the surgery and reduce the healing time.
- The use of Exparel. Just prior to the removal of the tonsils, when you are already asleep, an injection of lyophillized bupivacaine or Exparel will provide pain relief for up to 72 hours after the surgery. It is well studied that the peak of pain after tonsillectomy is in the first 24 to 48 hours and the use of this special pain reliving medication can reduce the post operative pain and discomfort that can be so traumatic for adults undergoing tonsillectomy.
Adults and children
For at least two weeks before any surgery, the patient should refrain from taking aspirin or other medications containing aspirin and non steroidal anti inflammatory medications like ibuprofen, advil or naproxen. (WARNING: Children should never be given aspirin because of the risk of developing Reye’s syndrome). Dr. Dagan may ask to you to stop taking other medications that may interfere with clotting.
- Tell Dr. Dagan if the patient or patient’s family has had any problems with anesthesia or clotting of blood. If the patient is taking medications, has sickle cell anemia, has a bleeding disorder, is pregnant, or has concerns about the transfusion of blood, Dr. Dagan should be informed.
- A blood test or medical clearance by your primary medical doctor may be required prior to surgery to verify you are in good health prior to surgery
- Due to the heightened awareness and safety measures taken to prevent the spread of Corona Virus, a PCR test for corona virus is necessary within three days of surgery. Failture to have the results available on the day of surgery may lead to non admittance to the hospital.
- You will be given specific instructions on when to stop eating food and drinking liquids before surgery. Generally, we ask to not eat or drink anything 8 hours prior to the surgery which is usually at midnight of the night before. These instructions are extremely important, as anything in the stomach may be vomited when anesthesia is induced and cause aspiration of food or water into the lungs.
We recommend arriving at the hospital or surgery center at least two hours before the procedure to allow enough time for registration followed by an evaluation by the anesthesiologist and nursing staff who will meet with the patient and family to review the patient’s history, take all the vital signs and perform a brief exam. You will meet Dr. Dagan to discuss the procedure and have time to ask last minute questions. The patient will then be taken to the operating room and given an anesthetic. Intravenous fluids are usually given during and after surgery. Removal of tonsils usually requires 20-30 minutes and the removal of adenoids usually requires 10 minutes of operative time. We usually book these procedures for 30 minutes to an hour because it takes time to fall asleep and wake up after the procedure.
After the operation, the patient will be taken to the recovery area. Recovery room staff will observe the patient closely until discharge. Under normal circumstances, a family member may join you in the recovery area although COVID-19 precautions may restrict the ability to join your loved one until they are discharged. A Parent can be present in the recovery area with young child during their recovery. Every patient is unique, and recovery time may vary.
Dr. Dagan will provide you with the details of preoperative and postoperative care and answer all your questions.
After surgery, there are several postoperative problems that may arise. These include discomfort or pain with swallowing, vomiting, fever, throat pain, and ear pain. Occasionally, bleeding from the mouth or nose may occur after surgery. If you or your child has any bleeding, notify Dr. Dagan immediately. It is also important to drink liquids after surgery to avoid dehydration. If bleeding occurs at home, gargle chipped ice water and remain calm. Bleeding from the surgical bed of the tonsils occurs in 1% or less of the cases and is commonly treated by cautery of the bleeding vessel either in the office or in the hospital under anesthesia.
Any questions or concerns you have should be discussed openly with Dr. Dagan. When the tonsillectomy patient comes home Most children take seven to ten days to recover from the surgery. Some may recover more quickly; others can take up to two weeks for a full recovery. The following guidelines are recommended:
Drinking: The most important requirement for recovery is for the patient to drink plenty of fluids. Starting immediately after surgery, children may have fluids such as water or apple juice. Some patients experience nausea and vomiting after the surgery although this is not common. This usually occurs within the first 24 hours and resolves on its own after the effects of anesthesia wear off. Contact Dr. Dagan if there are signs of dehydration (urination less than 2-3 times a day or crying without tears).
Eating: Generally, there are no food restrictions after surgery, but Dr. Dagan recommends a soft and cold diet during the recovery period. It is helpful to prepare ahead and have ice creams, popsicles, icicles, cold yoghurt, and drinks with electrolytes (e.g. Smart water, Gatorade) handy for the period after surgery. The sooner the patient eats and chews, the quicker the recovery. Tonsillectomy patients may be reluctant to eat because of throat pain; consequently, some weight loss may occur, which is gained back after a normal diet is resumed. The most important thing is not to become dehydrated. Try to avoid soda and acidic foods like orange juice although milk is fine.
Fever: A low-grade fever may be observed the night of the surgery and for a day or two afterward. Contact Dr. Dagan if the fever is greater than 102º.
Activity: Activity may be increased slowly, with a return to school or work after normal eating and drinking resumes, pain medication is no longer required, and the child sleeps through the night. Travel on airplanes or far away from a medical facility is not recommended for two weeks following surgery. Try to avoid any strenuous activity or heavy lifting until two weeks after surgery.
Breathing: In the early period after surgery snoring and mouth breathing due to swelling in the throat. Breathing should return to normal when swelling subsides, 10-14 days after surgery.
Scabs: A scab will form where the tonsils and adenoids were removed. These scabs are thick, white, and cause bad breath. This is normal. Most scabs fall off in small pieces five to ten days after surgery.
Bleeding: With the exception of small specks of blood from the nose or in the saliva, bright red blood should not be seen. If such bleeding occurs, contact Dr. Dagan immediately or go to the nearest emergency room.
Pain: Nearly anyone undergoing a tonsillectomy/adenoidectomy will have mild to severe pain in the throat after surgery. Some may complain of an earache (so called referred pain) and a few may have pain in the jaw and neck.
Pain control: Dr. Dagan will prescribe pain medication for the young patient such as acetaminophen, ibuprofen, acetaminophen with codeine, or acetaminophen with hydrocodone. The pain medication will be in a liquid form or sometimes a rectal suppository will be recommended. Pain medication should be given as prescribed. Contact Dr. Dagan if side effects are suspected or if pain is not well-controlled. If you are troubled about any phase of your child’s recovery, contact Dr. Dagan immediately.