Tonsillectomies and children

A tonsillectomy is an operation to remove the tonsils. These are two pads of immune tissue at the back of the throat. The operation is performed through the mouth, so it does not usually leave a visible scar.

Children may have a tonsillectomy because enlarged tonsils obstruct breathing during sleep or because they have repeated, significant tonsil infections. Removing the tonsils does not prevent every future sore throat.

The adenoids, which are similar tissue behind the nose, may be removed during the same operation. This combined procedure is called an adenotonsillectomy.

A surgeon may remove the tonsils completely. Another technique, called intracapsular tonsillectomy, leaves a thin layer of tonsil tissue behind. This may reduce pain and bleeding, but the remaining tissue can grow and occasionally requires further treatment.

One common reason is obstructive sleep-disordered breathing. Enlarged tonsils can narrow a child's airway during sleep, causing loud snoring, pauses in breathing, restless sleep or daytime problems. Obstructive sleep apnoea is the more serious form, in which breathing repeatedly becomes reduced or stops briefly.

A sleep study may be recommended when the diagnosis is uncertain or when a child's medical history could increase the risks of surgery. A sleep study measures breathing, oxygen levels and other body functions overnight.

Tonsillectomy may also be considered for repeated, documented tonsil infections. The decision is based on how often infections occur, how severe they are and how much they disrupt school, sleep and family life. Surgery is more likely to be helpful when infections have been frequent over several years or have caused complications such as an abscess beside a tonsil.

Less commonly, surgery may be needed to examine an unusually enlarged or abnormal-looking tonsil.

A tonsillectomy is not the right choice for every child who snores or has sore throats. Many children with occasional infections improve without surgery. Snoring can also have causes other than enlarged tonsils.

The healthcare team will balance the likely benefit against the pain, bleeding risk and recovery time. They may recommend monitoring instead if infections are not frequent or well documented.

Surgery may be delayed when a child:

• Has a fever, chest infection or other acute illness near the operation date
• Has not followed the required fasting instructions
• Has an untreated bleeding problem
• Is taking a medicine that increases bleeding and needs an individual plan
• Has a health condition that must be stabilised before general anaesthesia

Children with severe obstructive sleep apnoea, certain heart or lung conditions, bleeding disorders, craniofacial differences or other complex needs may still benefit from surgery. However, they may need extra testing, specialist planning or overnight monitoring.

The treating facility's own instructions take priority. Contact the facility if anything is unclear or if your child becomes unwell before surgery.

Tell the surgical team about all medicines, vitamins, supplements and non-prescription products your child uses. Include any personal or family history of unusual bleeding, reactions to anaesthesia or sleep-related breathing problems.

Do not stop a prescribed medicine unless the treating team tells you to. Some medicines can affect bleeding, but the safest plan is specific to your child.

Your child must stop eating and drinking at the times given by the anaesthesia team. Fasting lowers the risk of stomach contents entering the lungs during anaesthesia. If the fasting instructions are not followed, the operation may need to be postponed.

Arrange for a responsible adult to take your child home and remain with them. Plan for time away from school or nursery and have the recommended fluids, foods and pain medicines available.

Your child receives general anaesthesia and is fully unconscious. The anaesthesia team monitors breathing, heart rate, blood pressure and oxygen levels throughout the operation.

The surgeon holds the mouth open with a special instrument and removes the tonsils from the surrounding throat muscle. Bleeding is controlled using pressure, heat, electrical energy or other surgical tools. There are no external cuts.

If planned, the adenoids are removed during the same anaesthetic. The exact technique may be total or intracapsular tonsillectomy.

After the operation, your child is moved to a recovery area. Staff monitor breathing, bleeding, pain and the ability to drink. Many children go home the same day. Some stay overnight because of their age, medical history, sleep apnoea severity or recovery after anaesthesia.

Throat pain is expected and often lasts 10 to 14 days. It may improve and then become more noticeable again several days after surgery. Ear, jaw or neck pain can occur because these areas share nerves with the throat. Follow the written pain-medicine schedule provided by the surgical team. Codeine should not be used for pain after tonsil or adenoid surgery in children.

Drinking is especially important. Small, frequent sips may be easier than a full cup. Your child can usually progress to normal food as tolerated, following the facility's instructions. A white or yellow coating where the tonsils were removed and temporary bad breath are normal parts of healing.

Quiet activity is suitable at first. Avoid rough play, sports, heavy lifting and strenuous exercise for the period specified by the surgeon, because these may increase bleeding risk.

A child must not drive. A licensed teenager should not drive after anaesthesia or while taking medicine that causes sleepiness, and must follow the facility's exact restriction.

Many children need about 10 to 14 days away from school or nursery. Return should follow the surgeon's advice and take account of pain control, eating, drinking and normal energy levels.

The most important risk is bleeding. It can happen soon after surgery or during healing, often when the surgical coating begins to separate. Bleeding from the mouth or throat needs urgent assessment.

Other possible problems include:

• Dehydration because swallowing is painful
• Nausea or vomiting after anaesthesia
• Breathing problems, particularly in children with severe sleep apnoea
• Reactions to anaesthetic medicines
• Infection
• Injury to the lips, tongue or teeth
• Temporary changes in taste, voice or swallowing
• Regrowth of tissue after an intracapsular procedure

Your child's surgical and anaesthesia teams can explain how individual health conditions affect these risks.

For sleep-related breathing problems, improvement may be noticed during the first weeks. Snoring can continue temporarily because the throat is swollen. Some children have ongoing symptoms and need further assessment, especially when other factors also narrow the airway.

Children treated for repeated infections usually have fewer tonsillitis episodes, but they can still develop other throat infections. The benefit may be modest when infections were not frequent before surgery.

Removed tissue may be examined in a laboratory. If so, results usually take several days and the team will explain when and how they will be shared.

Follow-up arrangements differ by facility. Some children have a routine appointment or telephone review, while others are asked to contact the team only if recovery is not progressing as expected.

Watchful waiting is often reasonable for less frequent infections. It avoids surgery and anaesthesia, but your child may continue to have disruptive episodes. Keeping a dated record of infections, test results, fever and missed school can support later decisions.

Individual infections can be treated with fluids, pain relief and antibiotics like amoxicillin or doxycycline when a bacterial infection is diagnosed and antibiotics are appropriate. This treats the current illness but does not reliably prevent future episodes.

For sleep-related breathing problems, alternatives may include treating nasal allergies, monitoring mild symptoms or using continuous positive airway pressure, known as CPAP. CPAP keeps the airway open with air delivered through a mask. It avoids surgery but must be used during sleep and some children find the mask difficult to tolerate.

Weight-management support may improve obstructive sleep apnoea when excess weight contributes, although improvement can take time and enlarged tonsils may still obstruct the airway.

Intracapsular tonsillectomy is an alternative surgical technique. It may mean less pain and bleeding than complete removal, but it leaves a small chance of tissue regrowth or repeat surgery.

Seek emergency care for:

• Bright-red bleeding from the mouth or nose
• Vomiting blood or blood clots
• Repeated swallowing that could indicate hidden bleeding
• Difficulty breathing, blue or grey colouring, collapse or inability to wake normally

Do not let your child eat or drink while travelling for emergency assessment unless emergency staff advise otherwise.

Contact the surgical team promptly if your child cannot drink enough, urinates much less than usual, has repeated vomiting or has pain that remains poorly controlled despite following the treatment plan. Also call for a fever that reaches the threshold listed in the discharge instructions or for symptoms that are worsening rather than gradually improving.

Questions about food, activity, school return or routine healing can usually wait for the surgical team's normal office hours.

Will my child be asleep?

Yes. Tonsillectomy is performed under general anaesthesia, so your child is unconscious and does not feel the operation.

Can I drive my child home?

A responsible adult can drive. Your child cannot travel home alone or use public transport without an accompanying adult. Follow the facility's instructions about supervision after anaesthesia.

How painful is a tonsillectomy?

Moderate to severe throat pain is common, particularly when swallowing. Ear pain is also common. Regular pain relief and frequent fluids are important during the first 10 to 14 days.

When will we know if it worked?

Breathing and sleep may improve within weeks, after swelling settles. The effect on repeated infections becomes clearer over the following months. Laboratory results, when tissue is tested, usually take several days.

Can tonsils grow back?

Tonsil tissue can occasionally regrow after an intracapsular tonsillectomy because a thin layer is intentionally left behind. Significant regrowth after complete removal is uncommon.

Will removing tonsils weaken the immune system?

Tonsils are part of the immune system, but other immune tissues continue to work after removal. Tonsillectomy has not been shown to cause a clinically important loss of immune function.