Tonsillectomy — Procedure Guide, Recovery & Risks | MyMedicPlus

Tonsillectomy is the surgical removal of the palatine tonsils, performed under general anaesthesia via cold steel dissection, electrocautery, or coblation (bipolar radiofrequency energy at 40-70°C) technique. The palatine tonsils are lymphoid tissue masses located in the lateral walls of the oropharynx that form part of Waldeyer's ring, contributing to mucosal immunity in early childhood. It is one of the most common surgical procedures worldwide, particularly in children aged 5-15 years with recurrent infections or airway obstruction. The procedure eliminates recurrent tonsillar infections and relieves airway obstruction from hypertrophic tonsils. Adults also undergo tonsillectomy, though they experience greater post-operative pain and higher rates of secondary haemorrhage than children.

Adenotonsillectomy (simultaneous removal of the adenoids and tonsils) is performed for children with both recurrent tonsillitis and obstructive sleep apnoea with nasal obstruction from adenoid hypertrophy, as both contribute to upper airway obstruction. The UK SIGN 117 guidelines and NICE guidance confirm tonsillectomy is effective and safe in appropriately selected patients. Tonsillectomy rates have declined significantly since evidence showed it is overperformed for mild/moderate tonsillitis — current guidelines reserve it for those meeting specific frequency and severity thresholds.

Tonsillectomy is indicated for recurrent tonsillitis meeting published threshold criteria (7 or more documented episodes in 1 year, or 5 per year for 2 consecutive years, or 3 per year for 3 consecutive years — the Paradise criteria); obstructive sleep apnoea (OSA) in children where tonsillar hypertrophy contributes to airway obstruction confirmed on polysomnography; peritonsillar abscess (quinsy), particularly recurrent episodes; chronic tonsillitis with persistent halitosis and tonsillar crypts discharging caseous debris; febrile convulsions associated with recurrent tonsillitis; and suspected tonsillar malignancy in adults requiring histological examination. Children with growth retardation or severe behavioural disturbance attributable to OSA may also be considered.

Clinical documentation of tonsillitis episodes is critical before referral: each episode should be documented by a healthcare professional with a diagnosis of tonsillitis, associated fever, and sore throat interfering with normal activities. Unverified parental recall of sore throat episodes is insufficient without clinical documentation. NICE 2020 guidelines (NG30 update) specify that watchful waiting for 6 months should be offered to children with 4–6 documented episodes before tonsillectomy is offered. OSA with polysomnography-confirmed moderate-to-severe disease (AHI greater than 5) is a stronger indication.

Under general anaesthesia with a reinforced oral endotracheal tube, the patient is positioned supine with a shoulder roll to extend the neck. A Boyle-Davis mouth gag is inserted to retract the tongue and expose both tonsils simultaneously. For cold steel dissection, the mucosa overlying the tonsil is incised, the tonsil is dissected from the peritonsillar fossa using scissors and a blunt dissector, and haemostasis is secured with bipolar diathermy or suture ligation. For coblation, radiofrequency energy precisely ablates tonsil tissue at low temperatures (40-70°C), reducing thermal spread to adjacent structures. The procedure takes 30-45 minutes. Both sides are completed before reversal of anaesthesia, and the patient is nursed in the recovery position until fully awake.

For paediatric coblation tonsillectomy, careful attention to haemostasis at the tonsillar fossa is essential before extubation; residual bleeding may cause airway compromise in young children. Intraoperative dexamethasone (0.15 mg/kg IV) is standard to reduce post-operative nausea, vomiting, and pain. Post-operative oxygen saturation monitoring is particularly important in children with severe OSA, who may have worsening hypoxaemia in the immediate post-operative period from residual sedation and upper airway oedema before the benefits of airway relief are established.

The upper pole of the tonsil is grasped with Allis forceps and medially retracted while dissection proceeds in the plane between the tonsil capsule and the tonsillar bed (superior constrictor muscle). Bleeding vessels are secured with bipolar diathermy. The procedure is repeated on the opposite side. Operative time is 20–30 minutes.

Symptom resolution is achieved in 80-90% of patients with recurrent tonsillitis; substantial reduction in frequency and severity of throat infections is reported in most patients within the first year after surgery. Obstructive sleep apnoea resolves in 75-85% of paediatric patients after adenotonsillectomy, with normalisation of polysomnographic parameters, behavioural scores, and growth velocity. Coblation is associated with lower post-operative pain scores in multiple randomised trials compared to electrocautery, although cold steel dissection remains the reference standard at many centres. Quality of life assessments using validated instruments (Child Health Questionnaire, SF-36) show significant improvement after tonsillectomy, particularly in children with OSA.

For childhood obstructive sleep apnoea, the CHAT trial demonstrated that early adenotonsillectomy normalised the AHI in 79% of children, compared to 46% with watchful waiting, and significantly improved attention, executive function, behaviour, and quality of life. Caregiver-reported quality of life (OSA-18 questionnaire) shows dramatic improvement at 7 months post-surgery. Children with severe OSA may show improvements in neurocognitive testing, school performance, and growth following treatment of the underlying airway obstruction.

Primary haemorrhage (within 24 hours of surgery) occurs in less than 1% of cases and usually requires return to theatre for haemostasis under general anaesthesia. Secondary haemorrhage occurs at days 5-10 in approximately 2% of patients as the post-operative wound slough separates; it may require hospital readmission, transfusion, or return to the operating theatre for diathermy or suture ligation. Secondary bleeding risk is higher in adults than children and may be increased by non-steroidal anti-inflammatory drug use. Dehydration from inadequate oral intake is common in children. Rare complications include airway oedema, dental injury from the mouth gag, and post-operative nausea and vomiting from anaesthesia.

Post-tonsillectomy secondary haemorrhage is the most serious risk in children, occurring in approximately 2% at days 5–10 when the wound slough separates. Unlike adults, children often have smaller blood volumes and may develop haemorrhagic shock more rapidly. Parents must be given written emergency instructions and advised to attend A&E immediately for any bleeding. Velopharyngeal insufficiency — nasal escape of air during speech — is a rare complication (less than 0.5%) from adenoidectomy, more likely in children with a submucous cleft palate which must be excluded before surgery.

Patients are monitored in the recovery area for 2-4 hours before discharge as a day case. Children under 3 years, those with significant OSA, or those with comorbidities may require overnight admission. Soft, cool diet, adequate hydration, and regular analgesia (paracetamol plus ibuprofen) are essential for 10-14 days. Throat pain typically peaks at days 5-7 as the post-operative slough separates from the tonsillar fossae. Adults should anticipate 2 weeks off work; school-age children 1-2 weeks off school. Strenuous physical activity should be avoided for 2 weeks to minimise haemorrhage risk. Patients and families are advised to seek immediate emergency care for any significant bleeding from the throat, including blood in saliva.

Adequate hydration (cool fluids — milk, water, diluted juice, ice lollies) is the most critical factor in recovery and prevention of haemorrhage; dehydration concentrates wound secretions, delays healing, and may precipitate secondary bleed. Returning to school is typically at 1 week for young children and 10–14 days for older children and teenagers. Post-operative follow-up is not routinely required for uncomplicated tonsillectomy; parents should contact the surgical team directly for any concerns including bleeding, prolonged fever, or difficulty swallowing.