Aftercare Following Adenotonsillectomy
Return to Normal Activities
It takes most children 7 to 10 days to recover. However there is wide variability in this. Some children feel better after a few days (especially younger children) whereas others will take 14 days to recover.
It is best to keep your child home away from child care, kindergarten, school, or other large groups of children for 7-10 days to decrease the chance of picking up an infection during the recovery phase. Keep them home longer if they are still requiring pain medication and/or are not eating and drinking normally.
General activities can be recommenced when your child feels up to it, but they should not exert themselves for the first two weeks when there is a risk of bleeding. Playing sport, swimming, heavy lifting, or rough play should all be avoided during this time.
Most children experience a fair amount of throat pain during this time. There can also be ear pain, jaw pain, and neck pain. Ear pain occurs because a nerve that supplies the throat also supplies the ears, and this nerve can get confused as to where the pain is coming from. It is unlikely that this pain is due to an ear infection.
Your child will need regular pain medication and it is important that this is given regularly, particularly during the first few days. Indeed it is best to give regular Paracetamol every 4 to 6 hours for the first few days. I would even recommend waking your child during the night if they are due for a dose to ensure that you stay on top of the pain. As long as you follow the dosage guidelines, Paracetamol can be continued for as long as it’s required. Paracetamol can also be given as a suppository, which is particularly useful in gaining control of pain in children who initially refuse any oral intake.
Paracetamol tends not to completely cover the pain, and so Ibuprofen (Nurofen) can be added in – up to every 8 hours, as required. Both Paracetamol and Nurofen can be given at the same time, but it is often best to try to stagger and alternate them. Ensure that you don’t exceed the maximum daily dose for either medication. Although Nurofen is to be avoided prior to surgery, there is no convincing evidence that it causes increased bleeding after Adenotonsillectomy. If a bleed does occur, it is possible that a child who has had Nurofen may have a slightly higher rate of needing to go back to the operating theatre to control the bleeding.
If your child is still experiencing pain then Oxycodone is sometimes added into the mix, and there is no interaction between these three medications so it is safe to give all three at the same time (ensuring that the maximum dose for each is not exceeded). When giving the first dose of Oxycodone, it is best to monitor your child to ensure that it does not over-sedate them. There are some situations where Oxycodone is contraindicated, such as significant Obstructive Sleep Apnoea – if you have not been provided with a script for Oxycodone, and your child’s pain is not under control despite regular Paracetamol and Nurofen, please contact Dr Wabnitz’s rooms for further advice.
Other strategies include using anti-inflammatory gargles (Difflam) or local anaesthetic/antiseptic gargles (Cepacaine Mouth Wash Solution).
Note that the pain may worsen around day 5 to 7 after the operation. This is not uncommon and does not mean that there is an infection or any other concern developing.
If all strategies at providing pain relief fail and a child refuses to drink, then they will need to be readmitted for rehydration with intravenous fluids. This occurs in up to 3% of children having their Tonsils out.
Children need to be encouraged to drink over the course of the first week following Tonsillectomy to prevent dehydration and other complications. Ice-blocks are often well accepted by children. In fact, children can drink any fluid they wish although it is best to avoid hot fluids.
With regard to food, any food is acceptable but it is best to avoid spicy foods, anything that is acidic (such as oranges and tomatoes), and anything that is hot. Greasy foods may lead to nausea and/or vomiting. Children often prefer softer foods, like the traditional ice-cream and jelly. Another favourite is toast, and as this is more solid it tends to move any stagnated secretions, fluid, and debris away from where the Tonsils were and as such may prevent infection. If your child refuses food while recovering but maintains a good intake of fluid, then that is acceptable. The small amount of weight that may be lost during this time is quickly regained.
Chewing gum or chewing on lollies if the child is old enough is also helpful as it stimulates the production of saliva, and the movement of the throat muscles helps pump away swelling from the back of the throat.
It is not unusual to have a mild fever during the first day or so after the operation. Antibiotics are routinely prescribed if the Adenoids have been removed (see next section on Bad Breath). If there is a persistent fever of 38.5°C or over, please call Dr Wabnitz’s rooms to discuss this further and/or arrange a review.
Bad Breath / Malodorous Smell
This is almost universal and can be surprisingly bad. Although it can be quite offensive to an adult that enters the child’s room, it almost never bothers the child!
Antibiotics are routinely prescribed to minimize the smell that comes from the surgical site at the back of the nose. Most children will be prescribed Augmentin – an alternative will be prescribed if they are allergic to this.
The teeth should continue to be cleaned as normal.
Appearance of the Throat
During the first 10 days you may notice a creamy or yellowish layer covering the area where the Tonsils once were. This often gets misdiagnosed as an infection. It is not an infection, but is simply the way that a “scab” appears in the continuously moist environment of the mouth. It gradually fragments and falls off during the first week after surgery and is swallowed.
There may be tied black string seen in the location where the Tonsils were, especially at the sides of the back of the tongue. These are “surgical ties” and these will fall off by themselves and then be swallowed.
Snoring and Mouth Breathing
This is due to swelling of the tissues surrounding the Tonsils and Adenoids. There can be an associated increase in nasal secretions and general messiness of the nose. This settles quite quickly as the swelling resolves.
Avoid forceful nose-blowing for a few days after surgery.
Bleeding usually means that the scabs in the throat have fallen off too early, exposing a blood vessel that then bleeds. If there is any bleeding, proceed immediately to the nearest Emergency Department for assessment.
The risk of bleeding is present for the first 2 weeks after surgery. If you live in a Rural/Remote region, it is best to stay in the Adelaide metropolitan area during this time – so that you can quickly obtain medical attention if a bleed occurs.
Transient voice change is common often because pain and swelling can limit the movement of the back of the roof of the mouth (the Soft Palate). This settles as the days pass.
If the Tonsils and/or Adenoids were very big, it is possible that your child’s voice may change permanently. Parents often find that their child’s voice sounds higher pitched. What really has happened is that the muffling effect of the Tonsils and/or Adenoids has been removed and the child’s voice now has increased clarity – in a sense, what you are now hearing is a truer representation of what their voice was always meant to sound like.
After recovering from this operation, your child may still get mild sore throats due to viral infections just like anyone else.
Follow Up Appointment
A follow up appointment is usually booked for 4-6 weeks after surgery.