Tonsillectomy (with or without adenoidectomy) in children: Postoperative care and complications

INTRODUCTION — Tonsillectomy (with or without adenoidectomy) is one of the most common surgical procedures performed in children. General postoperative care and potential complications in children who have undergone tonsillectomy (with or without adenoidectomy) are reviewed in this topic.

The indications, contraindications, and preoperative and intraoperative care for tonsillectomy and/or adenoidectomy; postoperative care and complications of adenoidectomy alone; and adenotonsillectomy in children with obstructive sleep apnea (OSA) are discussed separately:

●(See "Tonsillectomy and/or adenoidectomy in children: Indications and contraindications".)

●(See "Tonsillectomy and/or adenoidectomy in children: Preoperative evaluation and care".)

●(See "Anesthesia for tonsillectomy with or without adenoidectomy in children".)

●(See "Adenoidectomy in children: Postoperative care and complications".)

●(See "Adenotonsillectomy for obstructive sleep apnea in children".)

SETTING OF CARE

●Outpatient setting – Most tonsillectomies (with or without adenoidectomy) are performed in an outpatient setting, and children are discharged a few hours after surgery.

●Inpatient admission – Children who are at higher risk for complications (particularly respiratory complications) may be admitted overnight for observation after tonsillectomy. Reasons for overnight hospitalization may include any of the following [1-3]:

•Age <3 years

•Complex medical history

•Sickle cell disease

•Persistent oxygen desaturations in the recovery room

•Obstructive sleep apnea (OSA) with any of the following:

-Severe OSA (as assessed by preoperative polysomnogram), defined as an apnea-hypopnea index >10 obstructive events/hour, oxygen saturation nadir <80 percent, or both (see "Evaluation of suspected obstructive sleep apnea in children", section on 'Assessment of severity')

-Cardiac complications of OSA

-Failure to thrive

-Obesity

-Craniofacial anomalies

-Chromosome anomalies associated with OSA (eg, Down syndrome)

-Mucopolysaccharidoses

-Neuromuscular disorders (eg, cerebral palsy)

-Current respiratory infection

The appropriate setting for postoperative monitoring in children with OSA is discussed in further detail separately. (See "Adenotonsillectomy for obstructive sleep apnea in children", section on 'Operative setting'.)

COMPLICATIONS — Complications associated with tonsillectomy (with or without adenoidectomy) include adverse effects related to anesthesia, bleeding, infection, and dehydration. Major complications (eg, delayed bleeding requiring intervention) occur in approximately 3 percent of cases [4-9]. Postoperative respiratory complications are common and range in severity from transient desaturations requiring supplemental oxygen to severe airway obstruction and/or apnea requiring positive pressure ventilation. Respiratory complications are more likely in children with obstructive sleep apnea (OSA). (See 'Hemorrhage' below and 'Respiratory complications' below.)

Approximately 7 to 13 percent of patients have revisits to the emergency department or outpatient setting following tonsillectomy, of which approximately 15 percent require inpatient admission [10-12]. Revisits are most commonly due to bleeding (24 to 30 percent); pain (15 to 18 percent); and nausea, vomiting, and dehydration (25 to 37 percent).

Pain is an expected outcome and therefore is not considered a complication per se. Similarly, nausea and vomiting are common sequelae of anesthesia and are also discussed below. (See 'Pain' below and 'Nausea and vomiting' below.)

Anesthesia-related — Serious anesthesia-related complications of tonsil and adenoid surgery occur rarely but can be life-threatening. The most common of these potentially serious complications are airway problems, such as laryngospasm and/or bronchospasm. In addition, oral endotracheal intubation and mouth gag placement may result in injuries to teeth or to the temporomandibular joints [13]. Anesthesia-related complications are discussed in greater detail separately. (See 'Respiratory complications' below and "Anesthesia for tonsillectomy with or without adenoidectomy in children" and "The difficult pediatric airway for emergency medicine" and "Malignant hyperthermia: Diagnosis and management of acute crisis" and "Respiratory problems in the post-anesthesia care unit (PACU)".)

Respiratory complications

Postoperative respiratory complications — Respiratory complications in the immediate postoperative period are common and range in severity from mild desaturation to life-threatening airway obstruction. In a meta-analysis of 17 studies, the estimated incidence of respiratory complications following adenotonsillectomy was 9 percent; however, there was wide variation in the types and severity of complications reported in individual studies [8]. The risk of respiratory compromise is greatest among children with OSA. (See "Adenotonsillectomy for obstructive sleep apnea in children".)

Respiratory compromise following tonsil and adenoid surgery can result from a number of mechanisms, including [8,14-17]:

●Common:

•Upper airway obstruction

•Laryngospasm

•Airway edema

•Central apnea/hypoventilation (including breath holding and narcotic-associated hypoventilation)

●Less common:

•Bronchospasm (more common in children with underlying history of asthma)

•Negative pressure pulmonary edema (also called postobstructive pulmonary edema)

Risk factors for postoperative respiratory complications include [2,8,14,18-22]:

●OSA

●Obesity

●Age <3 years

●Craniofacial anomalies affecting the pharyngeal airway

●Sickle cell disease

●Down syndrome

●Neurologic disorders (eg, cerebral palsy)

●Mucopolysaccharidosis

●History of asthma

●Recent upper respiratory infection

Most respiratory complications occur in the immediate postoperative period and usually can be managed with simple interventions such as providing supplemental oxygen, suctioning, or repositioning. Rarely, patients may require positive pressure ventilation or intubation. In one study, factors that were predictive of need for postoperative oxygen or positive pressure ventilation included [23]:

●Intraoperative laryngospasm requiring treatment

●Oxygen desaturation (<90 percent on room air) in the postanesthesia care unit (PACU)

●PACU stay >100 minutes

In another study, an apnea-hypopnea index of >15 and oxygen saturation nadir <80 percent on preoperative polysomnogram was associated with increased risk of postoperative desaturation, oxygen requirement, and prolonged length of stay (>24 hours) [24].

The management of acute pulmonary complications in the immediate postoperative period is discussed in greater detail separately. (See "Overview of the management of postoperative pulmonary complications", section on 'Acute upper airway obstruction' and "Respiratory problems in the post-anesthesia care unit (PACU)".)

Prevention — For children who are at increased risk for postoperative respiratory complications (eg, children with moderate to severe OSA, recent upper respiratory infection, or history of asthma), prophylactic pretreatment with an inhaled short-acting beta-2 agonist may reduce the likelihood of perioperative respiratory complications. This issue is discussed in greater detail separately. (See "Anesthesia for tonsillectomy with or without adenoidectomy in children", section on 'Preoperative inhaled short-acting beta-2 agonist (SABA)'.)

Hemorrhage — Postoperative hemorrhage following tonsillectomy can be classified as either primary/early (within 24 hours of surgery) or secondary/delayed (greater than 24 hours after surgery). Reported rates of primary hemorrhage range from 0.2 to 2.2 percent and secondary hemorrhage between 0.1 and 3 percent [8,25-28]. Estimated rates vary somewhat depending on how hemorrhage is defined. In studies using a very broad definition, rates as high as 7 percent have been reported [29]. Secondary hemorrhage most commonly occurs 5 to 10 days postoperatively (median postoperative day 6) [7] and is caused by premature separation of the eschar (picture 1), which may be precipitated by an underlying infection or dehydration [30].

Children with bleeding disorders are at increased risk of postoperative bleeding complications, including delayed bleeding up to two weeks after surgery. They therefore require close monitoring for a prolonged duration. (See "Tonsillectomy and/or adenoidectomy in children: Preoperative evaluation and care", section on 'Children with a bleeding disorder'.)

Other factors that may influence the risk of postoperative hemorrhage include:

●Age – Older children and adolescents appear to have an increased risk compared with young children (<6 years old) [7,29,31].

●Body mass index (BMI) – Children with BMI ≥85^th percentile are at increased risk [32].

●Indication for surgery – Patients undergoing tonsillectomy for chronic tonsillitis appear to be at increased risk compared with those undergoing tonsillectomy for OSA [33]. This is due to the fact that children with chronic tonsillitis have more scarring between the tonsil and the surrounding tissue, making removal more difficult.

●Surgical technique – It is unclear whether the risk of hemorrhage is impacted by surgical technique. Techniques that use heat or cautery to achieve hemostasis may have a lower bleeding risk compared with "cold" techniques; however, as previously discussed, they appear to do so at the cost of greater postoperative pain (see 'Pain' below). Some studies have reported lower bleeding rates with partial (intracapsular) tonsillectomy (also called tonsillotomy) compared with total (extracapsular) tonsillectomy [28,34]. Differences between these and other surgical techniques are discussed in greater detail separately. (See "Adenotonsillectomy for obstructive sleep apnea in children", section on 'Surgical techniques'.)

●Experiencing a minor bleed in the immediate postoperative setting appears to increases the likelihood of a subsequent severe bleeding episode [29,35].

Children who have experienced a bleeding episode should be hospitalized overnight for observation [36]. Postoperative hemorrhages usually stop spontaneously, but they sometimes require a return to the operating room for hemorrhage control. They seldom require blood transfusion. In rare cases, they can be life-threatening [37]. In addition, postoperative hemorrhage can cause difficulty in securing the airway by intubation, leading to an anoxic injury [25]. This is discussed in greater detail separately. (See "Anesthesia for tonsillectomy with or without adenoidectomy in children", section on 'Post-tonsillectomy hemorrhage'.)

The possibility of an underlying bleeding disorder should be considered if a patient experiences multiple hemorrhages [38]. (See "Approach to the child with bleeding symptoms".)

Dehydration — The inevitable throat pain following tonsillectomy surgery can cause children to have a decrease in oral intake, leading to dehydration. Nausea and vomiting following anesthesia can also be a contributing factor. Readmission to the hospital for intravenous hydration following surgery occurred in 5 percent of patients in one series and was most common in young children [39]. (See 'Fluid intake and diet' below and 'Nausea and vomiting' below.)

Infection — Superficial infection at the surgical site is common and is the cause of postoperative halitosis (see 'Halitosis' below). This infection resolves spontaneously. More serious infections are rare. Transient atelectasis and mild aspiration are relatively common after tonsillectomy, but true pneumonias are rare in the absence of gross aspiration during emergence from anesthesia [40,41].

Uncommonly, bronchopulmonary infection may also result from extension of a preexisting upper respiratory tract infection. (See "Anesthesia for the child with a recent upper respiratory infection".)

Burn injuries — A burn injury to the lip or oral commissure can occur due to defective electrocautery devices, surgeon error, or conduction through a metal instrument (picture 2) [25].

Temporomandibular joint dysfunction — A mouth gag is used to keep the mouth open during the tonsillectomy/adenoidectomy. Rarely, this may cause dysfunction of the temporomandibular joint [13]. Reduced mouth opening is not a common problem following surgery [42].

Velopharyngeal insufficiency — Velopharyngeal insufficiency (VPI), which is characterized by hypernasal speech, nasal air emission, and nasal regurgitation of fluids in severe cases, is a potential complication of adenoidectomy. Patients with 22q11 deletion syndrome and Prader-Willi syndrome are at increased risk for postoperative VPI [43,44]. VPI is discussed in greater detail separately. (See "Adenoidectomy in children: Postoperative care and complications", section on 'Velopharyngeal insufficiency' and "Tonsillectomy and/or adenoidectomy in children: Indications and contraindications", section on 'Velopharyngeal'.)

Postoperative mortality — Mortality post-tonsillectomy is a rare event. In the available studies examining this, reported mortality rates ranged from 0.006 to 0.008 percent (ie, 1 death per 12,000 to 17,000 surgeries) [11,15,45].

Children with complex chronic medical conditions (eg, Down syndrome, cerebral palsy, other neurologic or neuromuscular disorders) are at increased risk for death following tonsillectomy. In one study, the mortality rate among children with complex chronic medical conditions was 30 times higher than those without complex medical conditions (0.12 versus 0.004 percent, respectively) [45].

Causes of death in these reports included respiratory events (eg, respiratory failure, pulmonary edema, pneumonia, aspiration), medication-related events, hemorrhage, perioperative events, other cardiopulmonary events (eg, sudden cardiac arrest), and factors related to the child's underlying disease [45,46]. In a substantial subset of cases, the cause of death could not be determined.

Long-term adverse effects — It is unclear if children undergoing a tonsillectomy and/or adenoidectomy have an altered risk of developing respiratory or allergic illnesses after the procedure. Several studies have reported an association of adenotonsillectomy with asthma [47,48], but it is unclear whether the association is causative. The most common diagnosis leading to adenotonsillectomy is OSA. Since both OSA and childhood asthma are considered disorders of airway inflammation, a common mechanism causing both upper and lower airway disease might explain why children who have symptoms severe enough to warrant tonsillectomy and adenoidectomy are also at increased risk of asthma and atopic disease.

Observational studies have demonstrated that children with underlying asthma who undergo adenotonsillectomy may experience reduced asthma severity following surgery [49]. One large administrative database study found that children with asthma who underwent adenotonsillectomy (n = 13,506) experienced a 30-percent reduction in the rate of acute asthma exacerbations in the first year following surgery [50].

Studies evaluating rates of asthma and other respiratory and allergic diseases following adenotonsillectomy in unselected populations are conflicting. In a follow-up study of 166 children with recurrent or persistent otitis media who were enrolled in a randomized trial comparing tympanostomy tube insertion plus adenoidectomy with tympanostomy tube insertion alone, lung function tests at three years following surgery were similar in both groups [51]. Three children in the trial were diagnosed clinically with asthma during follow-up; all three were in the control group. The proportion of children with positive skin testing for allergic disease was also similar in both groups. Thus, based on the findings of this trial, adenoidectomy does not appear to increase the risk of developing asthma or allergic disease within the first few years after surgery. In contrast, a population-based cohort study of >1 million children born in Denmark between 1979 and 1999 found that children who underwent tonsillectomy (n = 11,830), adenoidectomy (n = 17,460), and adenotonsillectomy (n = 31,377) in the first nine years of life had higher rates of certain respiratory and allergic illnesses (eg, asthma, eczema, upper respiratory illness, pneumonia) during the subsequent 10 to 30 years compared with children who did not undergo surgery [47]. As would be expected, long-term rates of sleep disorders (eg, OSA) were lower in children who underwent adenoidectomy and long-term rates of tonsillitis were lower in children who underwent tonsillectomy or adenotonsillectomy. While this study suggests that children who undergo tonsillectomy and/or adenoidectomy may be at risk for developing respiratory and allergic illnesses later in life, it does not establish causation and it is possible that these findings may be due to confounding or reverse causation.

COMMON POSTOPERATIVE MANAGEMENT ISSUES — General issues in postoperative care include pain relief, return to normal diet and activity, and management of nausea and vomiting.

Pain — The following sections discuss pain management for children who have undergone tonsillectomy (with or without adenoidectomy). Interventions that are provided intraoperatively and perioperatively (ie, in the postanesthesia care unit [PACU]) are discussed in greater detail separately. (See "Anesthesia for tonsillectomy with or without adenoidectomy in children", section on 'Analgesia'.)

Expected course — Throat pain, particularly pain on swallowing, is common following tonsillectomy [52-55]. Throat pain may lead the patient to restrict intake of liquids, resulting in dehydration and, potentially, admission to the hospital [56]. (See 'Dehydration' above.)

The pain typically persists for 7 to 14 days and is described as moderate to severe [57]. Otalgia is also a frequent complaint following tonsillectomy and adenoidectomy [53]. The ear pain is referred from the pharynx and can be more severe than the throat pain in some children.

Factors that are reported to be associated with increased postoperative pain include:

●Preoperative anxiety – Children with anxiety and/or behavioral difficulties preoperatively often have a more painful postoperative recovery [58,59].

●Age – Adolescents often have more pain and a longer recovery than younger children.

●Obesity – In a retrospective series of 462 patients, children with a high body mass index (BMI) were more likely to experience severe early postoperative pain compared with those with a normal BMI (49 versus 14 percent, respectively) [60].

●Black or African American race – In a prospective series of 194 patients, African American children had significantly higher postoperative pain scores and greater postoperative opioid requirements and analgesic interventions in the PACU (or recovery room) compared with White children [61]. However, White children had a higher incidence of opioid-related adverse events.

●Surgical technique – It is unclear whether the surgical technique impacts the degree of postoperative pain. Most studies report reduced postoperative pain with "cold" techniques as compared with those that heat tissue and cause thermal injury [62-64]. However, some studies have reported no difference in postoperative pain [65,66]. Likewise, studies comparing pain after total versus subtotal tonsillectomy (tonsillotomy or intracapsular tonsillectomy) report conflicting results [67-69]. Details of the different surgical techniques for adenotonsillectomy are discussed in greater detail separately. (See "Adenotonsillectomy for obstructive sleep apnea in children", section on 'Surgical techniques'.)

These factors do not predict severity of postoperative pain well enough to warrant modifying the analgesic dosing based upon them.

First-line analgesic therapy — Pain-relieving medication should be given on a routine schedule for postoperative throat pain and otalgia [1]. First-line therapy for postoperative analgesia following tonsillectomy includes acetaminophen and/or a nonsteroidal antiinflammatory drug (NSAID), such as ibuprofen [1,57,70-73]. In clinical trials, these medications have been shown to be equally effective in treating post-tonsillectomy pain compared with opioid medications such as morphine [70,74,75].

Postoperative ibuprofen use does not appear to be associated with higher rates of hemorrhage [76-79]. (See 'Hemorrhage' above.)

Practice regarding the use of ketorolac varies [1]. The advantage of using ketorolac, which is an NSAID, rather than an opioid in the perioperative setting is that it is not associated with respiratory depression, urinary retention, or sedation. The concern is the possibility, though unproven, that it may increase bleeding risk. Studies in adult patients suggest an increased risk of post-tonsillectomy bleeding associated with ketorolac use; however, it remains unclear whether the same applies to children [80]. Many providers avoid ketorolac in this setting due to the perceived risk of bleeding and because there are safe alternatives. Aspirin is also generally avoided in children.

Pain not responsive to other measures

●Glucocorticoids — Administration of a single dose of intraoperative dexamethasone is effective in reducing postoperative pain, as discussed separately. (See "Anesthesia for tonsillectomy with or without adenoidectomy in children", section on 'Dexamethasone'.)

A short course of oral glucocorticoid therapy given postoperatively (eg, dexamethasone 0.5 mg/kg twice a day for three doses or prednisolone 0.25 mg/kg daily for five to seven days) may improve recovery after tonsillectomy; however, studies are conflicting [1,81-84]. While it is not routine practice to prescribe postoperative glucocorticoid therapy for all children undergoing adenotonsillectomy, it may be reasonable for select children who are anticipated to have a more difficult recovery. (See 'Expected course' above.)

The available data on the efficacy of glucocorticoid therapy in this setting are limited. Some studies have shown improvements in pain, diet, activity, fever, and sleep [81,82], while others found similar pain scores, rates of nausea and vomiting, and time to return to normal activity in children treated with and without glucocorticoids [84].

●Opioids — Opioid medications, such as morphine, hydrocodone, or oxycodone, are reserved for pain not relieved by acetaminophen and/or NSAIDs or other measures. Opioids can cause sedation, nausea/vomiting, and constipation [85,86].

Caution should be used in prescribing opioids postoperatively in patients with underlying obstructive sleep apnea (OSA) since these medications can contribute to increased airway obstruction following surgery. In a randomized controlled trial evaluating postoperative pain management with acetaminophen and morphine compared with acetaminophen and ibuprofen in 91 children with OSA undergoing tonsillectomy, children treated with morphine experienced an increased number of desaturation events (14.3 episodes per hour postoperatively versus 3.6 episodes per hour preoperatively), whereas those treated with ibuprofen had improvement in desaturation events (3 episodes per hour postoperatively versus 4.5 episodes per hour preoperatively) [75]. No differences were seen in analgesic effectiveness or tonsillar bleeding.

Codeine and tramadol should be avoided because of variability in metabolism that can alter the level of active drug the child is exposed to, resulting in fatal overdoses in extreme cases [1,87-89]. With any opioid, there is an increased chance of an overdose in overweight/obese children if dosing is based upon total body weight rather than lean mass because there is a lower distribution of morphine to fatty tissue. This issue is discussed in greater detail separately. (See "Pain in children: Approach to pain assessment and overview of management principles", section on 'Agents not recommended'.)

Nonpharmacologic measures — Various oral rinses, mouthwashes, and sprays have been proposed to improve the recovery following tonsillectomy, but there is little evidence that they are effective [90,91]. There is limited evidence suggesting that acupuncture treatment, either intraoperatively or postoperatively, can reduce postoperative pain [92,93]. Adequate hydration is important for pain control [1]. (See 'Dehydration' above.)

Nausea and vomiting — Nausea and vomiting are common adverse events seen in the period immediately following anesthesia and may contribute to dehydration [30,94]. (See 'Dehydration' above.)

The administration of dexamethasone after induction of anesthesia appears to reduce the risk of postoperative nausea and vomiting [1,83]. Serotonergic antagonists (ondansetron, granisetron, tropisetron, and dolasetron) are also effective in preventing postoperative nausea and vomiting [83]. Prophylactic treatment with intraoperative glucocorticoids and antiemetics for patients undergoing tonsillectomy are discussed in detail separately. (See "Anesthesia for tonsillectomy with or without adenoidectomy in children", section on 'Antiemetics'.)

Fluid intake and diet — Parents/caregivers should be instructed to encourage fluid intake in the initial postoperative period to avoid dehydration. However, a mandatory trial of oral fluid should not be a required condition for discharge from the hospital. Mandatory oral fluid intake before discharge is not associated with a lower incidence of emesis, dehydration, or revisits to the emergency department or outpatient setting following discharge [95-97].

We do not advise restricting the diet in any way, because a restricted diet has not been shown to affect postoperative recovery [98,99]. Despite this, wide variability exists in the dietary instructions given to patients following tonsillectomy (with or without adenoidectomy). The most common advice is for children to start slowly due to the risk of postoperative nausea and vomiting secondary to anesthesia.

Halitosis — Significant halitosis following tonsillectomy and/or adenoidectomy is common and is a normal side effect of the surgery. It resolves spontaneously within two weeks. (See 'Infection' above.)

Activity — Restrictions on activity have not been found to affect postoperative recovery, although the data are limited [99]. In addition, no guidelines include recommendations regarding postoperative activity following tonsillectomy (with or without adenoidectomy). We generally advise avoiding competitive sports, swimming, and physical education class at school for two weeks postoperatively.

Most children are generally home from school/daycare for approximately a week. We allow children to return to school once they are eating well and their energy levels have returned to normal.

Sleep disturbances and emotional upset — Children may exhibit general anxiety and sleep disturbances, including problems falling asleep, problems staying asleep, and crying upon waking up, during the first few days after tonsil or adenoid surgery [100]. As with pain, the extent of these problems is related to the degree of anxiety before surgery [58]. (See "Tonsillectomy and/or adenoidectomy in children: Preoperative evaluation and care", section on 'Preoperative emotional and pain preparation'.)

No role for antimicrobial prophylaxis — Routine perioperative antimicrobial prophylaxis for children undergoing tonsillectomy is not recommended [1].

A meta-analysis of 10 randomized controlled trials (1035 patients) did not find significant reductions in postoperative pain, need for analgesics, hemorrhage rates, or time to resumption of normal diet and activity in patients who received perioperative prophylactic antibiotics compared with those who did not [101]. There was a reduction in the rate of postoperative fever (relative risk 0.63, 95% CI 0.46-0.85), most likely due to the amelioration of bacteremia.

In a large retrospective study that evaluated outcomes before and after implementation of guidelines advising against routine use of perioperative antibiotics for tonsillectomy, antibiotic use dropped by 87 percent and there were no changes in otolaryngology clinic visits, emergency department visits, or admissions, though surgery for bleeding increased slightly (from 1.4 to 3.5 percent before and after guideline publication, respectively) [102].

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 and adenoidectomy in children".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or email these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient education" and the keyword[s] of interest.)

●Basics topic (see "Patient education: Tonsillectomy and adenoidectomy in children (The Basics)")

SUMMARY AND RECOMMENDATIONS

●Setting of care – Most tonsillectomies (with or without adenoidectomy) are performed in an outpatient setting, and children are discharged a few hours after surgery. However, children who are at higher risk for complications may be admitted overnight for observation after tonsillectomy. (See 'Setting of care' above.)

●Complications – Complications associated with tonsillectomy (with or without adenoidectomy) include adverse effects related to anesthesia, pain, bleeding, respiratory compromise, and nausea/vomiting with associated dehydration. Mortality is rare. (See 'Complications' above.)

•Respiratory complications – Postoperative respiratory complications are common and range in severity from mild desaturation requiring supplemental oxygen to severe airway obstruction requiring positive pressure ventilation. Respiratory compromise following tonsil and adenoid surgery can result from upper airway obstruction, laryngospasm, airway edema, central apnea/hypoventilation (including breath holding and narcotic-associated hypoventilation), bronchospasm, or negative pressure pulmonary edema. The risk of postoperative breathing difficulties is highest among children with obstructive sleep apnea (OSA). (See 'Respiratory complications' above.)

•Bleeding – Bleeding requiring blood transfusion or additional surgery occurs in approximately 3 percent of cases. Postoperative bleeding usually occurs within the first 24 hours following surgery (primary hemorrhage) or between 5 and 10 days after surgery (secondary hemorrhage). (See 'Hemorrhage' above.)

●Common management issues – Common postoperative management issues include pain management, ensuring adequate hydration, returning to normal diet and activity, and anticipatory guidance regarding halitosis and sleep disturbances. (See 'Common postoperative management issues' above.)

•Pain – Throat pain, pain on swallowing, and otalgia are expected following tonsillectomy. The pain typically persists for 7 to 14 days. Throat pain may cause the patient to restrict fluid intake, resulting in dehydration. (See 'Expected course' above and 'Halitosis' above.)

For treatment of throat and ear pain following tonsillectomy (with or without adenoidectomy), we suggest acetaminophen and/or a nonsteroidal antiinflammatory drug (NSAID; eg, ibuprofen) as first-line analgesic agents rather than opioids or no pain medication (Grade 2B). NSAIDs and acetaminophen are often sufficient. However, opioids (eg, morphine, oxycodone, hydrocodone) may be appropriate for treatment of pain that is not responsive to other measures. We recommend not using codeine and tramadol in this setting (Grade 1C), since they are associated with an unacceptably high risk of overdosing due to variable individual metabolism. Adequate hydration is also important for pain control. (See 'Pain' above and "Pain in children: Approach to pain assessment and overview of management principles", section on 'Agents not recommended'.)

•Fluid intake and diet – Parents/caregivers should be instructed to encourage fluid intake in the initial postoperative period to avoid dehydration. However, mandatory oral fluid intake before discharge is generally not necessary. We advise parents to start slowly and advance the diet as tolerated. We do not advise any specific restrictions to the diet. (See 'Fluid intake and diet' above.)

•Activity – Most children are generally home from school/daycare for approximately one week. Children can return to school once they are eating well and their energy levels have returned to normal. We advise avoiding competitive sports, swimming, and physical education class at school for two weeks postoperatively. (See 'Activity' above.)

•Anticipatory guidance – It is important to inform patients/caregivers about the expected course after tonsillectomy (with or without adenoidectomy), including common postoperative issues such as pain, halitosis, and sleep disturbances. (See 'Expected course' above and 'Halitosis' above and 'Sleep disturbances and emotional upset' above.)

•No role for prophylactic antibiotics – We recommend not routinely using perioperative prophylactic antibiotics for tonsillectomy in children (Grade 1B). (See 'No role for antimicrobial prophylaxis' above.)