The information on this page derives from an instructional pamphlet I give to patients (or their parents) who are going to have a tonsillectomy and adenoidectomy for obstructive sleep apnea syndrome. The information in this pamphlet is current (last checked August, 2008) and all factual statements are based on the medical literature.
For the Web version of this pamphlet, I have provided literature citations for statements that I feel need attribution. These citations are hyperlinked to a reference list at the end of this article.
Recommendations for postoperative care, included at the end of this article, are based upon my clinical experience and are not referenced, as these recommendations are a matter of personal style and will vary from doctor to doctor.
IMPORTANT: if you are scheduled to undergo a tonsillectomy/adenoidectomy, you should follow your doctor's instructions carefully, as he is most familiar with your special health concerns, as well as any unusual details of your operation.Other practitioners are welcome to copy and use this material, but by permission only please.
Sleep apnea is an illness in which breathing halts momentarily during sleep. Apnea is the medical term for this failure to breathe. Sleep apnea may be due to a problem with the brain ("central apnea") but is much more commonly due to collapse of tissues into the airway ("obstructive apnea"). In children, the usual cause for this obstruction is large tonsils and adenoids. (Adenoids are located high in the throat, behind the nose. If the adenoids are very large, they can obstruct the nasal airway.)
If your child has obstructive sleep apnea (OSA) due to large tonsils and adenoids, removal of these tissues is usually curative (1). The surgeries to remove the tonsils and adenoids are tonsillectomy and adenoidectomy, respectively. Treatments other than surgery include the use of steroids or the use of a special airway device known as CPAP (Continuous Positive Airway Pressure). Steroids tend to have only temporary benefit and have numerous potential side effects. CPAP may be tolerated by children, but may not work well if the tonsils and adenoids are very large. CPAP is usually reserved for children who are too sick to undergo surgery, or who continue to have significant OSA despite surgery (2). In particular, obese children may continue to have significant OSA despite having their tonsils and adenoids removed.
But why do anything at all? OSA can harm your child in many ways. Left untreated, severe OSA can lead to delayed growth and eventual heart and lung failure; less severe complications include excessive daytime sleepiness, poor school performance, hyperactivity, and developmental delay (1).
Tonsillectomy and adenoidectomy (T&A) usually takes about 60 minutes. It is performed under general anesthesia. If your child has a significant degree of OSA, he may need to remain in the hospital overnight, and will be closely monitored during this hospitalization. Children with moderate to severe OSA require hospitalization because these children have a somewhat greater risk of developing postoperative problems (3). Other children who are at particular risk of postoperative complications are those who have either cerebral palsy, Down's Syndrome, seizures, or a history of congenital heart disease; obese children and children under the age of 3 are also at risk (3-7). Please be advised that the indications for overnight observation (and the safety of early discharge) are constantly being reappraised; in general, the trend is towards fewer and fewer overnight admissions.
Things your doctor needs to know before proceeding with surgery:
1. Is there a family history of bleeding problems? Does your child bleed excessively from small cuts, or does he bruise easily?
2. Has your child used any blood-thinning medications within 3 weeks of surgery? (Examples are: aspirin, bufferin, motrin, advil, ibuprofen.)
3. Is your child under a doctor’s care for any reason? Does your child take ANY medications (prescription, nonprescription, herbal... anything)?
4. Has your child ever been hospitalized?
5. Has your child ever had general anesthesia?
6. Has anyone in your family (blood relative to your child) ever had a bad reaction to a general anesthetic?
What are the risks of surgery? (8)
1. Bleeding. This is the most serious risk of surgery. Bleeding that occurs during surgery is almost always very easy to control by the surgeon. Of greater concern is bleeding that may occur after the child goes home. Bleeding can occur up to 10 days after surgery. There is about a 5% risk of bleeding (1 child in 20). (Published statistics on the prevalence of bleeding vary greatly, from 0.1% to 8.1%; see Reference 8.) If you notice any bright red blood (or a large clot of dark blood) in your child’s sputum or vomit after you return home, you must return to the emergency room at once, day or night. If you have any concerns at all that your child may be bleeding, call Dr. Hoffman or call the emergency room at once.
2. Dehydration. Because of postoperative pain, some children refuse to drink fluids after surgery. If this occurs during your child’s hospitalization we can give intravenous fluids to compensate. If your child refuses to drink at home, he/she can rapidly become dehydrated. Dehydration tends to increase postoperative pain and also increases the chance of bleeding. It is very important that you encourage your child to drink as much as possible during the first 10 days after surgery. (Suggestions for this are given in the section Postoperative Care, below.) Signs of dehydration are: dry mouth, dark urine, sunken eyes, dry or loose skin. A dehydrated child looks and acts sick. If you think your child is becoming dehydrated, contact Dr. Hoffman or the emergency room at once.
3. Breathing problems after surgery. While not common, breathing problems after surgery can and do occur, particularly in patients with severe OSA or other health problems (discussed above.) This is the primary reason that children with OSA must be closely monitored in the hospital for one night after surgery; occasionally, a longer hospitalization is necessary because of such breathing problems.
4. Infection. This is actually a very uncommon complication of surgery, but it is often incorrectly diagnosed by other doctors. This is because the tonsils heal with a white scab, which gives the throat the appearance of a severe bacterial infection. This white scab is normal! Also, fever in the first 24 hours after surgery is extremely common and is NOT a sign of infection. Fever after the first 24 hours may be a sign of infection, but it is more commonly associated with dehydration (see above).
5. Pain. Almost all children will have some pain following surgery. Children vary enormously. Some children will be very happy and active 2 to 3 days after surgery, while other children will be very "poky" even 10 days after surgery. Sore throat and ear pain are the most common complaints. Suggestions for reducing postoperative pain are given below (Postoperative Care).
6. Voice change. Children with large tonsils and adenoids tend to have a muffled voice. You and other family members are accustomed to this voice. You may be somewhat surprised or disturbed by the change in your child’s voice after surgery.
7. Swallowing and speaking problems. When people swallow or speak, the soft palate moves backward to touch the back of the throat. Among other things, this prevents liquids from coming out of the nose when we swallow. For a variety of reasons, children with very large adenoids sometimes have soft palate problems after surgery. This can lead to nasal regurgitation of fluids and unpleasant voice changes. These problems are almost always temporary, but may take weeks to resolve. Severe and troubling forms of this complication are fortunately rare, occurring only in about 1 in 1500 patients (8). Rarely, these problems may be permanent, and surgery on the soft palate would be needed to correct this situation.
8. Lack of snoring. After T&A, your child’s snoring should be much quieter, and it may disappear altogether. This may not sound like a problem. Nevertheless, parents frequently get used to a child’s snoring and come to depend upon it as a sort of baby monitor. Parents often report that they have to check their child several times a night "to make sure he’s still breathing". You will eventually get used to a quieter household.
Postoperative Care
1. What are my priorities in caring for my child at home?
A. Be alert for postoperative bleeding. Remember that this may occur as late as 10 days after surgery (and, rarely, even past ten days). If you notice ANY bright red blood or dark blood clots in your child’s spit or vomit, notify Dr. Hoffman or an emergency room physician immediately!
B. Avoid dehydration! (See Question 2.) Your child needs to drink, drink, drink; hydration is VERY important. Dehydrated children feel sicker, have more pain, and may require hospitalization if their dehydration worsens.
C. Avoid starvation. Water and sugar-free soft drinks have no calorie content. Make sure your child drinks fluids that are sweet (juices, non-diet soft drinks) or nutritious (warm broth).
D. Malnutrition is not as common a problem as dehydration and starvation. Your child can do fairly well during her/his recovery period eating what we would usually consider an atrocious diet (juice, soda, ice cream, jello, pudding and so forth.) Nevertheless, if your child is not having problems eating liquids or soft foods, you may certainly try to encourage him/her to eat foods that are nutritious (see section below, What can my child eat?)
2. How can I make sure that my child stays well hydrated?
Encourage your child to drink liquids. Be firm and persuasive. Avoid acidic juices (lemonade, orange juice, pineapple juice etc.) as these may sting. Apple juice and grape juice are usually well tolerated. Popsicles, ice cream, sorbet, and noncaffeinated soft drinks are also well tolerated. Allow soft drinks to go flat before drinking them, as the bubbles can be irritating, especially soon after surgery.
Particularly in the first few days after surgery, examine your child’s urine. It should be pale yellow, NOT dark yellow or brown. Dark urine is an indication that he/she is not drinking enough liquids.
3. Will my child need to take any medications after surgery?
Your child will go home with two medications, an antibiotic and a pain medicine. Please follow the instructions on these prescriptions very carefully.
We recommend that you give your child the pain medication that has been prescribed. In the first 2 to 3 days, give this medication on a regular basis; do not wait until she/he is crying in pain. Gradually decrease the amount and the frequency; you may also substitute a weaker pain medicine (children’s tylenol, NOT motrin). Do not exceed the maximum dose described on the prescription. To help reduce pain, you can also try using sore throat sprays such as chloraseptic or numbing lozenges.
4. What can my child eat?
I used to warn parents away from any foods with points: pretzels, popcorn, tortilla chips, and so forth. Nowadays, I tell parents to let their kids eat whatever they want, but I also supply this caution: "Start soft; when he tries something new, make sure he tries only a small mouthful. His eyes and his stomach may say YES, but his throat may tell him NO." Far kinder if this happens with a small mouthful than a large one.
5. What physical activity is permitted, and when can my child go back to school?
Normal play activity is allowed. During the first 10 to 14 days after surgery, do not allow your child to engage in strenuous activity. Once your child no longer needs pain medication, eats and drinks without difficulty, and can engage in normal play without tiring prematurely, he is ready to go back to school.
Vacations are acceptable, with some reservations. Your child may not feel much like traveling during the first 10 days after surgery. Also, because of the risk of delayed postoperative bleeding, you should not travel anywhere during the first 2 weeks such that you would be more than 30 minutes from an emergency room (air travel, for example, is a bad idea.)
1. Obstructive sleep apnea in infants and young children. S.L.D. Ward and C.L. Marcus. Journal of Clinical Neurophysiology, 1996, 13(3):198-207.
2. Use of nasal continuous positive airway pressure as treatment for childhood obstructive sleep apnea. C.L. Marcus, S.L.D. et al. Journal of Pediatrics, 1995, 127:88-94.
3. Respiratory compromise after adenotonsillectomy in children with obstructive sleep apnea. S.A. McColley et al. Archives of Otolaryngology-Head and Neck Surgery, 1992, 118:940-943.
4. Outcome and complications following surgery for obstructive adenotonsillar hypertrophy in children with neuromuscular disorders. K. Grundfast et al. Ear, Nose and Throat Journal, 1990, 69:756-760.
5. Selected risk factors in pediatric adenotonsillectomy. M.E. Gerber et al. Archives of Otolaryngology-Head and Neck Surgery, 1996, 122:811-814.
6. Predictive factors for respiratory complications after tonsillectomy and adenoidectomy in children. M.J. Biavati et al. Archives of Otolaryngology-Head and Neck Surgery, 1997, 123:517-521.
7. Postoperative complications after tonsillectomy and adenoidectomy in children with Down's Syndrome. N.A. Goldstein et al. Archives of Otolaryngology-Head and Neck Surgery, 1998, 124:171-176.
8. Complications of tonsillectomy and adenoidectomy. D.A. Randall and M.E. Hoffer. Otolaryngology-Head and Neck Surgery, 1998, 118(1):61-68.
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