Version May 2024
INTRODUCTION — Tonsillectomy is a well-established operative procedure in both children and adults. Most patients have an uncomplicated course, but bleeding and pain can be significant perioperative issues.
The surgical techniques and perioperative issues of tonsillectomy in adults are the focus of this topic. Adult indications for tonsillectomy are discussed in detail in another topic. (See "Tonsillectomy in adults: Indications".)
Tonsillectomy in children is discussed elsewhere. (See "Tonsillectomy and/or adenoidectomy in children: Indications and contraindications" and "Tonsillectomy and/or adenoidectomy in children: Preoperative evaluation and care".)
ANATOMY — The tonsils consist of lymphoid tissue covered by respiratory epithelium. "Tonsils" refers specifically to the palatine tonsils, and "adenoids" refers to the pharyngeal tonsils. In addition, there are lingual tonsils on the posterior tongue and tubal tonsils just posterior to the Eustachian tube opening. Waldeyer's ring is the ring of these four lymphoid tissues in the pharynx formed by the palatine tonsils ("tonsils"), pharyngeal tonsils ("adenoids"), tubal tonsils, and lingual tonsils (figure 1A-B).
The tonsils are positioned laterally in the pharyngeal wall between the palatoglossal arch and palatopharyngeal arch (the anterior and posterior tonsillar pillars), which merge superiorly to become the soft palate (figure 2). Each tonsil is contained within its own fascia. A potential space between the tonsil and the pharyngeal constrictor muscle can accumulate pus and become a peritonsillar abscess.
The tonsil is innervated by branches from the glossopharyngeal nerve. Lymphatic drainage includes the upper jugular and jugulodigastric lymph nodes.
The tonsillar vascular supply is from branches of the external carotid artery (figure 3).
●Superior pole: Descending palatine artery
●Mid-fossa: Ascending pharyngeal artery
●Inferior pole: Tonsillar branch of the lingual artery and ascending palatine branch of the facial artery
INDICATIONS FOR SURGERY — The indications for a tonsillectomy in adults are reviewed elsewhere. (See "Tonsillectomy in adults: Indications" and "Evaluation of acute pharyngitis in adults" and "Obstructive sleep apnea: Overview of management in adults", section on 'Hypoglossal nerve surgery'.)
The most common indications for tonsillectomy in adults include [1]:
●Recurrent or chronic pharyngotonsillitis [2]
●Recurrent peritonsillar abscess
●Suspected malignancy
●Obstructive sleep apnea refractory to less invasive treatment (eg, continuous positive airway pressure [CPAP])
PREOPERATIVE EVALUATION — Preoperative evaluation is important to identify individuals who are at higher risk of complications (eg, risk of bleeding or respiratory distress) because of their anatomy or other medical issues.
Medical risk assessment
●Anesthetic risk – Tonsillectomy is performed under general anesthesia. Thus, if an adult patient is at high risk for general anesthesia due to cardiac, respiratory, or neurologic problems, tonsillectomy should not be performed. In higher-risk patients with severe obstruction or a need to rule out malignancy as an indication for tonsillectomy (eg, unknown primary), the risks of anesthesia need to be weighed against any benefit derived from the procedure. Biopsy is an alternative approach and can potentially be performed in the clinic. (See "Evaluation of cardiac risk prior to noncardiac surgery" and "Evaluation of perioperative pulmonary risk" and "Anesthesia for head and neck surgery", section on 'Preoperative evaluation'.)
●Bleeding disorders – Bleeding is a potentially significant complication of tonsillectomy and may be serious; hence, the patient should be carefully questioned about a possible bleeding diathesis. (See 'Major bleeding' below and "Approach to the adult with a suspected bleeding disorder", section on 'Patient history'.)
If a thorough clinical history is negative, routine coagulation tests are not necessary, because an unidentified coagulation disorder leading to post-tonsillectomy hemorrhage is extremely rare [3,4]. If the clinical history suggests that a bleeding diathesis is or may be present (table 1), laboratory evaluation is indicated. (See "Approach to the adult with a suspected bleeding disorder", section on 'Laboratory evaluation'.)
Management of patients with known bleeding diatheses is reviewed separately. (See "Approach to the adult with a suspected bleeding disorder".)
Medication review — Prescribed and over-the-counter medications, vitamins, and herbal supplements should be reviewed.
●In general, antiplatelet agents (eg, aspirin and clopidogrel) should be avoided for one week prior to surgery. For patients who take these drugs chronically, the risks and benefits of cessation of therapy versus perioperative bleeding need to be discussed with the prescriber. Herbal supplements that can increase the risk of bleeding should also be stopped one week prior to tonsillectomy. (See "Perioperative medication management", section on 'Medications affecting hemostasis' and "Perioperative medication management", section on 'Herbal medications'.)
●Similarly, nonsteroidal anti-inflammatory drugs (NSAIDs) should also be avoided for one week prior to tonsillectomy. Perioperative administration of NSAIDs may increase the risk of postoperative hemorrhage. A retrospective review of 10 studies found that adults receiving intravenously administered ketorolac had a fivefold increased risk of hemorrhage compared with patients not administered ketorolac [5]. (See "Perioperative medication management", section on 'Nonsteroidal antiinflammatory drugs'.)
●Anticoagulants (eg, vitamin K antagonists, direct oral anticoagulants [DOACs]) should be held before tonsillectomy. In discussion with the prescriber, bridging strategies with unfractionated or low-molecular-weight heparin may be required [4]. The perioperative management of anticoagulated patients is discussed elsewhere. (See "Perioperative management of patients receiving anticoagulants".)
Anatomic risk assessment — Anatomic factors that increase the risk of complications include cervical spine (atlantoaxial) instability, severe trismus, aberrant carotid artery, and severely enlarged tonsils.
●Atlantoaxial instability – There is a risk of neurologic symptoms from head extension during the surgery in patients with cervical instability. Atlantoaxial instability must be identified preoperatively in high-risk patients (eg, those with Down syndrome or rheumatoid arthritis) with spine films. If needed, evaluation and clearance by a spine specialist should be undertaken prior to proceeding with tonsillectomy. (See "Down syndrome: Management", section on 'Atlantoaxial instability' and "Cervical subluxation in rheumatoid arthritis".)
●The surgeon should evaluate patients for severe trismus, which can limit operative exposure.
●Intraoperative or postoperative hemorrhage due to an aberrant carotid artery is a rare and potentially catastrophic complication. Palpation of the tonsillar bed for pulsations is usually sufficient for detection of an aberrant carotid artery; preoperative imaging is rarely necessary. (See 'Complications' below.)
●The surgeon should evaluate for the presence of severely enlarged tonsils.
Role of prophylactic antibiotics — While some studies suggest that antimicrobial prophylaxis should be used for head and neck surgery [6-11], there is no scientific evidence showing benefit from routine pre- or perioperative antibiotics for tonsillectomy. A 2012 Cochrane review that included 10 trials of both adult and children found that routine antibiotics did not reduce pain, requirement for analgesics, or postoperative bleeding but did reduce postoperative fever [12].
However, antibiotics may be given perioperatively in select patients undergoing tonsillectomy in the context of [12,13]:
●Severe recurrent tonsillitis
●Peritonsillar abscess (quinsy tonsillectomy)
OPERATIVE MANAGEMENT
Patient positioning — The tonsillectomy procedure begins with the patient being placed in a supine position and provided general anesthesia with endotracheal intubation. The mouth gag retractor is placed on the tongue and positioned on the upper teeth. The retractor is opened to allow the mouth to be held open, with the tongue retracted inferiorly. The mouth gag is then suspended off the Mayo stand or a tonsil suspension device. The mouth gag holds the mouth open during retraction of the tongue and endotracheal tube. The surgeon and the anesthesiologist share the same region of the patient's anatomy for airway maintenance and surgical field [14]. Thus, the surgeon must take care to prevent kinking of the endotracheal tube or accidental extubation during manipulation of the mouth gag.
Anesthesia — The procedure is performed under general anesthesia. The patient must be intubated in order to protect the airway and prevent aspiration of secretions or blood. Most surgeons prefer an oral right-angle endotracheal (RAE) tube positioned in the midline and bent inferiorly to allow the tube to be positioned over the tongue, lower lip, and toward the chin. The endotracheal tube is secured with tape, and a mouth gag (eg, Crowe-Davis, McIvor) is placed (figure 4). (See "Anesthesia for tonsillectomy with or without adenoidectomy in children".)
Measures to prevent complications — The local complications of tonsillectomy are prevented with vigilance during prepping, draping, and intraoperative manipulation.
●Place the sterile drapes to expose the intraoral and pharyngeal structures without injuring the eyes or face. Globe injury has been reported with the use of penetrating towel clips around the face [15].
●Avoid damage to teeth (ie, chipping or dislodgement) during either airway placement or with manipulation of surgical instruments in the mouth. Obtain a chest radiograph if there is any suspicion that a tooth or a portion of tooth is missing.
●Avoid temporomandibular joint dislocation by limiting the extent to which the jaw is opened by the mouth gag during the procedure. Once the mouth gag is removed, the surgeon should palpate the joint and check dental occlusion. A depression noted in the preauricular area indicates that the mandibular condyle is trapped in front of the articular eminence. The most common sign of this problem postoperatively is an inability to close the mouth or malocclusion (figure 5A-B). (See "Temporomandibular joint (TMJ) dislocation", section on 'Clinical features'.)
●Avoid excessive hyperextension of the neck during intubation and the procedure. If there is concern for cervical instability, maintain the neck in a neutral position during the operative procedure to decrease the potential for atlantoaxial subluxation. (See 'Anatomic risk assessment' above.)
Tonsillectomy — There is no consensus as to a standard tonsillectomy technique [16]. The instruments used are either cold (knife), hot (electrodissection), coblation (radiofrequency wave), or a combination. Well-designed randomized trials are underway to determine the optimal method for tonsillectomy [17,18].
Techniques — In contemporary practice, there are mainly two types of tonsillectomy techniques: total or subtotal tonsillectomy. The Guillotine technique is rarely performed.
●Total tonsillectomy – A complete or total tonsillectomy removes the entire tonsil. In this technique, an Allis clamp is used to grasp the upper portion of the tonsil (movie 1). As it is pulled anteriorly and medially, the anterior tonsillar pillar mucosa is divided superiorly to inferiorly (figure 6). As the mucosa is divided, the plane between the tonsil capsule and the tonsil fossa (pharyngeal constrictors) can be identified. With the superior pole of the tonsil freed, the Allis clamp can be repositioned as needed to grasp the inferior tonsil, and the tonsil is dissected out of its bed. Care is taken to control (tie or cauterize) the perforating vessels as they are encountered. The dissection is carried out ideally in a plane superficial to the muscle layer; however, scar and infection often make finding this dissection plane especially difficult in adults compared with children. Electrocautery or suture ligation will usually control bleeding. Once the tonsil is released from the tonsillar fossa, the inferior mucosa is divided and the tonsil removed. Care must be taken not to enter into the base of the tongue, where bleeding may be difficult to visualize for hemostasis.
●Subtotal tonsillectomy – Subtotal tonsillectomy (ie, tonsillotomy, partial tonsillectomy, and intracapsular tonsillectomy) involves removing most of the tonsil but not reaching the capsule or muscle layer, thus avoiding significant pain.
●Guillotine tonsillectomy – Guillotine tonsillectomy is a cold technique of predominantly historic significance that was performed in the clinic setting on an awake patient [19]. A special instrument with a loop of wire was placed over the tonsil. The wire was tightened, then pulled through the tonsil to amputate it from the tonsillar fossa. While the path of least resistance for the wire should be through the anatomic plane between the capsule of the tonsil and the pharyngeal muscles, chronically infected tonsils have severe scarring, limiting the usefulness of this procedure.
There are both adult and pediatric data to suggest that subtotal tonsillectomy may be associated with less postoperative pain and bleeding risk [20,21]. A systematic review and meta-analysis of nine randomized trials of adults found reduced postoperative pain and analgesia requirement as well as a reduced rate of secondary postoperative bleeding in patients undergoing intracapsular dissection tonsillectomy versus extracapsular dissection tonsillectomy (5.5 versus 13 percent) [22].
However, the current standard of care for adults remains total tonsillectomy. Total tonsillectomy is the most commonly performed technique for adults. A subtotal tonsillectomy is typically performed to treat tonsillar hypertrophy for pediatric patients with sleep apnea. It is infrequently performed in adults with recurrent tonsillar infections because it is associated with regrowth of the tonsil remnant (up to 36 percent) and may cause hypertrophy or recurrent infections (3 to 16 percent) [16,20,22-24].
Instruments — There are a variety of instruments used to perform a tonsillectomy. Tissue temperatures and collateral thermal tissue injury vary greatly by instrumentation [25]. (See "Overview of electrosurgery".)
●Cold dissection is performed with a tonsil knife and tonsil dissector (figure 7).
●Electrodissection can be performed using a needle tip or spatula tip (monopolar) or forceps/scissors (bipolar). Tissue temperatures up to 600ºC are attained [25]. A suction cautery can also be used. (See "Overview of electrosurgery".)
●Coblation refers to a form of diathermy introduced for tonsillectomy in the 1990s (movie 1). Radiofrequency (low-energy) waves pass from the coblation wand through saline to produce a plasma field with lower tissue temperatures (<70ºC) [26]. The energy breaks organic molecular bonds, resulting in tissue disintegration. Coblation is purported to accurately reduce the volume of target tissue with minimal damage to surrounding tissues.
●The microdebrider instrument is often used to perform a subtotal tonsillectomy in children [27]; however, this procedure is rarely performed in adults.
The superiority of one instrument type over another has not been clearly demonstrated. Furthermore, the choice of instrumentation can affect the risk and timing of postoperative pain and bleeding. As an example, according to a 2017 Cochrane review of both adult and pediatric studies, coblation was associated with less pain than other tonsillectomy techniques on postoperative days 1 and 3 but not on postoperative day 7. The primary bleeding risk was similar, but coblation had a slightly higher risk of secondary bleeding (risk ratio 1.36, 95% CI 0.95-1.95) based on low quality of evidence [28]. Thus, the choice of surgical instruments is by surgeon preference.
POSTOPERATIVE MANAGEMENT
Outpatient surgery versus admission — Same-day surgery appears to be safe for the majority of otherwise healthy patients [15]. Postoperative admission is indicated for the following patients with:
●An elevated cardiac risk
●Bleeding diathesis, specifically patients with sickle cell anemia
●Obstructive sleep apnea as the indication for tonsillectomy
●Congenital disorders with a higher risk of cervical spine or respiratory complications (eg, Down syndrome, cerebral palsy)
Oral diet and hydration — Postoperative dietary recommendations vary. Many clinicians advocate a soft diet for up to two weeks since hard foods might irritate the surgical site and induce bleeding. Acidic foods (eg, citrus, tomato) may cause pain. Optimal food temperature is purely a patient preference.
Drinking plenty of liquids in the first 72 hours is important to prevent dehydration; keeping the area moist also reduces pain. Analgesics should be taken 20 to 30 minutes before meals to reduce pain from swallowing; otherwise, decreased oral intake can lead to hypovolemia. Up to 5 percent of post-tonsillectomy patients are seen in the emergency room for issues relating to hypovolemia and/or pain [29].
Role of postoperative antibiotics — Routine postoperative antibiotic therapy is unnecessary. A Cochrane review found little or no evidence that antibiotics reduce the main morbid outcomes following tonsillectomy (pain, need for analgesia, hemorrhage) [12]. (See 'Role of prophylactic antibiotics' above.)
Nevertheless, antibiotics may be used in patients with active or chronic infection. The optimal perioperative antimicrobial coverage for head and neck surgery (specifically whether to cover gram-negative organisms) is controversial [7]. In general, the inherent risk for infection in head and neck surgery is related to the bacterial load of oral flora (typically 100,000,000 colony forming unit/mL) (table 2) [8,30]. A beta-lactam/beta-lactamase-inhibitor combination such as ampicillin-clavulanate provides adequate coverage of these organisms [7]. Clindamycin plus gentamicin or clindamycin plus levofloxacin are good alternatives for penicillin-allergic patients.
Pain management — Significant throat pain is to be expected but may be delayed in onset until one to two days after the surgery. Cool compresses, ice collars on the neck, and ice chips also help to decrease throat pain. We recommend appropriate use of liquid analgesics for pain in the first week postoperatively. Analgesics should be taken 20 to 30 minutes before meals to reduce pain from swallowing.
●For adult patients with severe pain, codeine-based medications can be used on a limited basis. All patients should be advised to avoid driving or operating heavy machinery while on narcotics.
●In the United States, nonsteroidal anti-inflammatory drugs (NSAIDs) are usually avoided because of concerns about bleeding; however, NSAIDs are routinely prescribed in Europe because, at least in children, they can significantly reduce nausea, vomiting, and narcotic use [31]. The use of NSAIDs is helpful for relieving pain but controversial regarding bleeding [16,32]. A 2013 Cochrane review of 14 randomized trials associated the use of NSAIDs with a nonsignificant increase in the risk of bleeding requiring surgical intervention (odds ratio [OR] 1.69, 95% CI 0.71-4.01), but the effect on minor bleeding was not evaluated [33]. These data should not be generalized to adult patients, since bleeding after tonsillectomy is more common in adults.
●Narcotics should not be prescribed to patients with sleep apnea. Such patients may require hospitalization for pain control if acetaminophen alone is not adequate, as NSAIDs are generally contraindicated after tonsillectomy, as stated above.
Ear pain also may occur; it is "referred" pain from the glossopharyngeal nerve (which innervates the pharyngeal muscles); anecdotally, ear pain may be relieved by chewing gum.
Nausea and vomiting — Nausea and vomiting can result from general anesthesia or postoperative medications, such as narcotics or antibiotics. (See "Overview of post-anesthetic care for adult patients", section on 'Postoperative nausea and vomiting'.)
In the operating room, we suggest giving a one-time dose of glucocorticoids (dexamethasone 6 to 10 mg intravenously) to reduce postoperative nausea and vomiting. It can also help with reducing swelling in the oropharynx or soft palate. In 2011 Cochrane review of 19 pediatric trials, children receiving a single intraoperative dose of dexamethasone (0.15 to 1.0 mg/kg) were half as likely to vomit in the first 24 hours compared with children receiving placebo (risk ratio [RR] 0.49, 95% CI 0.41-0.58) [34]. In a trial of 72 adults undergoing tonsillectomy, 10 mg dexamethasone at anesthesia induction reduced the incidence of postoperative nausea and vomiting by 62 percent [35].
Another trial compared a seven-day postoperative course of prednisolone (0.25 mg/kg/day) with no prednisolone following tonsillectomy in patients four or older [36]. For adult patients in the trial, although there was a significant increase in the area of re-epithelialization at 14 days postoperatively, prednisolone did not improve pain, activity, diet, or incidence of nausea/vomiting on postoperative day 1 or 7.
Minor bleeding — Minor bleeding is common following tonsillectomy. After the surgery, the tonsillar fossa develops a thick white patch (eschar) as it is healing. The eschar usually falls off after six to nine days, which may be associated with mild bleeding. Some experts feel the postoperative bleeding risks may be reduced by keeping a soft diet, reduced activity, and avoiding aspirin (or similar products).
Minor bleeding (no more than specks of blood in the saliva) is usually managed conservatively. Patients can be instructed to gargle with cold water. The patient should seek medical attention for persistent bleeding, coughing (sign of blood being aspirated), or vomiting blood clots.
In the clinic or emergency department setting, the application of pressure to the tonsillar fossa with a tonsil gauze may stop the bleeding. If this fails, the tonsillar fossa can be injected with a lidocaine/epinephrine mixture (1% lidocaine with 1:100,000 epinephrine). Cauterization with silver nitrate can be performed in a procedure room with appropriate equipment and lighting, provided the patient does not have an excessive gag reflex. Management of major bleeding is discussed below. (See 'Control of life-threatening hemorrhage' below.)
Follow-up — Patients are typically seen within four weeks of discharge, but this varies depending on postoperative course and symptoms. If the tonsils were sent for pathologic examination, the results are obtained and reviewed [37].
●Patient instructions – Patients are instructed to expect significant pain in the throat or ear or when opening the mouth. Patients should take pain medications as prescribed. Drinking plenty of liquids in the first 72 hours is important to prevent hypovolemia and limit pain.
Large amounts of bright red blood from the mouth or nose should be reported to the clinician immediately, or the patient should be instructed to be seen in the emergency department. High fever, persistent nausea and vomiting (or blood in the vomit), persistent coughing, inability to take fluids or excessive weakness, severe pain not relieved by prescribed pain medicines, or shortness of breath are also reasons to seek medical attention.
●Activity – Most patients can resume light activities postoperatively but should avoid activities that increase central pressure (eg, heavy lifting, straining, strenuous exercise) for two weeks [37]. After this period, the likelihood of bleeding is minimal.
●Return to work – Patients are often instructed that they may return to work two to three weeks following tonsillectomy; however, this varies from one to three weeks depending on the individual's postoperative course.
COMPLICATIONS — The main procedure-specific complications following tonsillectomy are bleeding, pulmonary-related complications, and tonsillar bed infection. The indications for and technique used for performing tonsillectomy may have implications for the incidence and type of morbidity, primarily pain and bleeding. (See 'Tonsillectomy' above.)
Incidence and financial impact — In a prospective, multicenter cohort study with 9405 adult and pediatric patients, the overall risk of hemorrhage (minor and severe) was 7.9 percent [23]. Twenty-nine percent of all episodes of hemorrhage were severe, requiring general anesthesia and intraoperative management.
The impact on health care expenditure from complications of tonsillectomy was reported in a 2014 cohort study of 36,210 adult patients who underwent tonsillectomy. Postoperative emergency department visits and hospitalizations as well as total per capita costs were analyzed. Ten percent of patients visited the emergency department, and 1.5 percent were admitted within 14 days of tonsillectomy, with 6 percent treated for hemorrhage (one-half requiring return to the operating room), 2 percent for dehydration, and 11 percent for pain. The cost for uncomplicated tonsillectomy was $3832, $6388 for hemorrhage, $5753 for dehydration, and $4708 for pain [38].
Major bleeding — Postoperative bleeding can be severe, even lethal [39]. Hemorrhage sufficient to require specific treatment has been reported in up to 6 percent of cases following tonsillectomy [39-42]. Up to 50 percent of patients who bleed require control of oropharyngeal bleeding in the operating room. Multiple bleeding episodes are common among those who bleed [42,43] and can herald a more significant life-threatening hemorrhage [43]. Patients with a negative history and/or normal coagulation studies preoperatively who experience bilateral diffuse tonsillar bleeding may warrant further coagulation evaluation [3]. (See "Approach to the adult with a suspected bleeding disorder".)
Risk factors — Risk factors for bleeding include older age (adult versus child) [25,40], the presence of inflammation (chronic tonsillitis, peritonsillar abscess) at the time of tonsillectomy [41], tonsillectomy instrumentation (cold versus hot), and the extent of the surgery (total versus partial).
●In a prospective, multicenter cohort study with 9405 adult and pediatric patients, adult patients over age 15 years (n = 3291) undergoing a tonsillectomy with/without an adenoidectomy were more than twice as likely to experience hemorrhage compared with children under 6 years of age (17 percent [562 patients] versus 7 percent [16/230 patients]) [23]. The removal of chronically scarred tonsils can be more difficult owing to the lack of a distinct dissection plane, which may be the reason that the overall hemorrhage rate for tonsillectomy is greater in adults than in children (4.5 versus 2.6 percent in one study), who typically do not have scarring [40].
●The presence of inflammation (chronic tonsillitis, peritonsillar abscess) at the time of tonsillectomy is another major risk factor for bleeding [41]. The risk of hemorrhage in patients with infectious mononucleosis was 20 percent in one study, illustrating why tonsillectomy is generally avoided in this population [41]. (See "Tonsillectomy in adults: Indications".)
●Cold instrument techniques have been associated with more intraoperative blood loss and less pain [44,45], while hot techniques may result in more secondary bleeding. Combined techniques (eg, cold dissection plus hot techniques for hemostasis) have intermediate rates for these morbidities [25]. However, it should be noted that the risk of postoperative hemorrhage becomes greater as diathermy power increases with mixed techniques (ie, cold dissection and bipolar diathermy for hemostasis) [46]. (See 'Instruments' above.)
In one study using mixed tonsillectomy techniques, hemorrhage occurred in 389 of 11,796 patients (3.3 percent of procedures); hemorrhage was primary in 0.5 percent and secondary in 2.9 percent [25]. When "cold" techniques are used alone, primary hemorrhage occurs more frequently than secondary hemorrhage, but the overall rate of hemorrhage is reduced compared with use of mixed or primarily hot techniques [25,41]. Excessive use of "hot" techniques may cause more thermal damage and a larger area of eschar that is more prone to secondary bleeding when it sloughs.
●The risk of hemorrhage is also associated with the extensiveness of the procedure. In a prospective, multicenter cohort study with 9405 adult and pediatric patients [23], the risk of hemorrhage was higher for patients undergoing a tonsillectomy with/without an adenoidectomy compared with patients undergoing a tonsillotomy with/without an adenoidectomy or patients undergoing an adenoidectomy alone (15 percent [689/4594 patients] versus 2.3 percent [30/1319 patients] versus 0.8 percent [28/3492 patients], respectively). (See 'Techniques' above.)
Primary and secondary hemorrhage — Hemorrhage in most studies is defined as primary when occurring fewer than 24 hours postoperatively and secondary if occurring greater than 24 hours postoperatively.
●Primary hemorrhage occurs most commonly within six hours of surgery, with a mean of 5.3 hours in one study [41]. It is often severe and is more likely to require a return to the operating room than secondary hemorrhage.
●Secondary hemorrhage is most likely to occur between the 5th and 14th postoperative day [42,44]. This is the time period when the tonsillar bed eschar separates, exposing small surface vessels to local trauma [47].
Control of life-threatening hemorrhage — If conservative measures instituted in the clinic or emergency department fail to control bleeding, the patient should then be taken to the operating room for control under anesthesia (see 'Minor bleeding' above). Delivery of anesthesia to a patient with post-tonsillectomy hemorrhage is hazardous, and early intubation for airway protection should be considered in the patient with significant postoperative bleeding [15]. (See "Anesthesia for tonsillectomy with or without adenoidectomy in children", section on 'Post-tonsillectomy hemorrhage'.)
Electrocautery (monopolar, bipolar, or suction cautery), chemical cautery (silver nitrate), or suture ligation will usually control oropharyngeal bleeding. Persistent oozing from the tonsillar bed(s) can be controlled by suturing the tonsillar pillars together, which helps to tamponade surface bleeding.
Uncontrolled bleeding due to arterial injury requires a more aggressive approach (see 'Anatomy' above). In the extremely rare event that bleeding cannot be controlled transorally, the oropharynx is packed and the patient prepared for either angiographic embolization or external carotid artery ligation.
Pulmonary complications — Postoperative respiratory compromise can occur for several reasons. Aspiration of blood or secretions may cause postoperative pneumonia. (See "Strategies to reduce postoperative pulmonary complications in adults" and "Overview of the management of postoperative pulmonary complications".)
Patients undergoing tonsillectomy for obstructive symptoms (severely enlarged tonsils) have increased comorbidities and a greater incidence of postoperative pulmonary complications, including postobstructive pulmonary edema. The sudden relief of respiratory obstruction from the enlarged tonsils results in loss of positive end expiratory pressure (PEEP) [48]. This can lead to transudation of fluid into the interstitial and alveolar spaces and respiratory compromise. These patients require more vigilant respiratory monitoring postoperatively as they may require reintubation and ventilatory support with PEEP. (See "Overview of the management of postoperative pulmonary complications", section on 'Pulmonary edema'.)
Postoperative tonsillar bed infection — True postoperative tonsillar bed infection is rare. On physical examination, the normal appearance of eschar lining the tonsillar fossa appears white and can be mistaken as purulence.
Serious bacterial infections, although rare, do occur and require aggressive management. Grisel syndrome may occur as a result of extension of infection through the tissue adjacent to the tonsillar region to the paravertebral space and causes atlantoaxial instability [49].
Postoperative Candida infection causes increased pain and prolongs recovery. It is recognized by a characteristic thick white patch on the tongue and should be treated early with antifungal medications. (See "Oropharyngeal candidiasis in adults".)
Other complaints and complications — Surgical trauma can cause uvular edema, tongue numbness, dental trauma, and temporomandibular joint dislocation. Eustachian tube dysfunction from edema can result in middle ear effusions or otitis media [15].
Vocal changes, while more related to adenoidectomy, can occur following tonsillectomy. Reduced nasal resonance resulting in improved voice and speech quality following removal of large tonsils is more usual [50]. However, unwanted postoperative hypernasality may be caused by velopharyngeal incompetence, which can be a serious problem. Hypernasality usually resolves spontaneously, but if it persists for eight weeks, then speech therapy is recommended, and surgery may be indicated if the vocal disturbance persists for 6 to 12 months [51].
An inability to close the mouth postoperatively or the presence of malocclusion is a sign of temporomandibular joint (TMJ) dislocation. If this is identified intraoperatively, the joint is reduced while still under anesthesia. If this is observed postoperatively, then mandibular imaging (plain films or a computed tomography [CT] scan) to examine the TMJ is indicated. If present, reduction of the TMJ usually needs to be done under sedation or general anesthesia in order to relax the temporalis and masseter muscles enough to push the mandibular condyle back into place (figure 5A-B).
Halitosis typically resolves within two weeks. Taste disturbance (eg, metallic, bitter parageusia) is usually minor and self-limited. It occurs in approximately 30 percent of patients two weeks after surgery but is rare long-term for most patients [52-55]. Rarely, the disorder will persist due to glossopharyngeal nerve injury [52]. (See "Taste and olfactory disorders in adults: Evaluation and management".)
Nasopharyngeal stenosis is a late complication and more likely if tonsillectomy is combined with adenoidectomy or uvulopalatopharyngoplasty (UPPP).
Eagle syndrome refers to elongation of the styloid process, presumably due to trauma to the styloid during the procedure, and causes persistent neck pain due to irritation of scar involving the surrounding tissues and nerves [56].
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Tonsillectomy in adults".)
SUMMARY AND RECOMMENDATIONS
●Surgical indications – In adults, tonsillectomy is usually performed for recurrent or chronic pharyngotonsillitis, recurrent peritonsillar abscess, suspected malignancy, or obstructive sleep apnea refractory to less invasive treatments. (See 'Indications for surgery' above.)
●Preoperative evaluation – Cervical (atlantoaxial) instability must be identified preoperatively in high-risk patients (eg, those with Down syndrome or rheumatoid arthritis) with spine films. Routine preoperative coagulation testing is unnecessary. Coagulation tests should be performed if the patient's clinical history suggests that a bleeding diathesis is or may be present. (See 'Preoperative evaluation' above.)
●Role of perioperative antibiotics – For most adult patients undergoing tonsillectomy, we suggest not administering prophylactic or postoperative antibiotics (Grade 2C). Antibiotics have not been shown to improve patient outcomes. However, antibiotics may be used selectively (eg, for recurrent or active infection or in patients with comorbidities). (See 'Role of prophylactic antibiotics' above and 'Role of postoperative antibiotics' above.)
●Patient positioning – Tonsillectomy is performed with the patient under general anesthesia. The local complications of tonsillectomy (eg, soft tissue injury, chipped teeth, temporomandibular joint dislocation, atlantoaxial instability) can be minimized with vigilance during prepping, draping, and intraoperative manipulation. (See 'Measures to prevent complications' above and 'Anesthesia' above.)
●Surgical techniques – In most adults, we suggest a total (extracapsular) rather a subtotal (intracapsular) tonsillectomy (Grade 2C). Although the latter has been shown to cause less pain and bleeding in some studies, the remnant tonsillar tissue can regrow and cause hypertrophy or recurrent infections. The choice of "cold" or "hot" instrumentation techniques (including coblation) or a combination of the two to dissect and provide hemostasis during removal of the tonsils is by surgeon preference. (See 'Tonsillectomy' above.)
●Postoperative management – Significant pain in the throat, ear, or when opening the mouth is expected. Patients should take liquid pain medications 20 to 30 minutes before meals and drink plenty of liquids in the first 72 hours to prevent hypovolemia. (See 'Postoperative management' above.)
•In most adults, we suggest avoiding nonsteroidal anti-inflammatory drugs (NSAIDs) because of bleeding risk (Grade 2C). Narcotics (eg, codeine) can be given to patients without sleep apnea. Patients with sleep apnea should not be prescribed narcotics; they may require hospitalization for pain control if acetaminophen alone is not adequate. (See 'Pain management' above.)
•In most adults, we recommend giving a one-time dose of glucocorticoids (dexamethasone 6 to 10 mg intravenously) in the operating room to reduce postoperative nausea and vomiting (Grade 1B). Additional steroid doses are not necessary or beneficial. (See 'Nausea and vomiting' above.)
●Complications – The main procedure-specific complications following tonsillectomy are bleeding, pulmonary-related complications, and tonsillar bed infection. Postoperative bleeding occurs in 3 to 5 percent of patients; approximately one-half of these patients will require transoral control of bleeding in the operating room. (See 'Major bleeding' above.)
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