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Introduction   

Tonsils, the lymphoid tissue masses located near the entrance of the digestive and respiratory tracts, play a crucial role in our immune system. They act as a front-line defense by forming the initial immunological response to inhaled or ingested pathogens. When patients and healthcare providers discuss tonsils, they often refer to the palatine tonsils at the back of the throat between the two palatine arches. Understanding this role is not just important, but it’s the foundation of our knowledge and practice in this area.  

Tonsillectomy is a standard surgical procedure in the United States, with over 525,000 cases performed annually in children under the age of 15. This high prevalence is not just a statistic but underscores the importance of healthcare professionals being well-versed in this area. A tonsillectomy, often performed with or without an adenoidectomy, involves completely removing the tonsil, including its capsule, by dissecting the peritonsillar space between the tonsil capsule and the muscular wall. Historically, tonsil surgery was only a partial excision for fear of removing healthy tissue and, for a while, was deemed the safest and the best method for excision. However, with the advances in medical technology, advanced lighting, the ability to control hemostasis, and anesthetic techniques made complete excision possible.  

Two of the most common reasons for tonsillectomy are sleep-disordered breathing (SDB) and recurrent throat infections. These conditions can significantly impact a patient’s health status and quality of life. As healthcare professionals, it is not just essential but crucial to understand the indications and contraindications of tonsillectomy. Being aware of the potential complications, including bleeding, velopharyngeal insufficiency, and dehydration, and providing the best care possible is part of our responsibility. Vigilance and care are paramount in this field, and being prepared for potential complications is part of that responsibility. This responsibility should make you feel committed and dedicated to your patient’s well-being.  

Anatomy and Physiology  

First, we will examine the anatomy and physiology of the tonsils and their components to understand better their diseased states and the implications for surgical excision.  

Tonsils are derivatives of the 2nd pharyngeal pouch and typically appear around the 4th or 5th month of gestation and continue to develop with the child’s growth (2). Tonsils are present at birth and tend to reach full size between six and eight years old. Tonsils and adenoid tissue are found to be the most immunologically active between four and twelve years of age and begin to atrophy shortly after ten years of age (2). 

The palatine tonsils are a component of Waldeyer’s ring of lymphoid tissue (1). Other parts included in Waldeyer’s ring are the adenoids, tubal tonsils, and lingual tonsils (1). The potential space between the capsule and muscle is called the peritonsillar space. The tonsils are located along the lateral wall of the oropharynx, in a fossa between the palatoglossus and palatopharyngeal muscles, which form the anterior and posterior arches (1). The glossopharyngeal nerve, susceptible to injury during tonsillectomy, is located within the deep muscles lateral to the tonsils. Temporary swelling around this nerve can cause taste alterations and referred earaches. The tonsils have multiple blood vessels providing vasculature to them.  

The main vessels come from branches of the external carotid artery, and they are supplied blood supply via five arteries:  

• Lingual artery 

• • Gives off the tonsillar branch  

• Facial artery 

• • Gives off a tonsillar and ascending palatal branch   

• Ascending pharyngeal 

• Internal maxillary arteries.  

• • Supplies the tonsil via the descending palatal artery 

• • Numerous anomalies from this architecture can exist 

Structure and Function  

As previously mentioned, tonsils are lymphoid tissue, and like all lymphoid tissues, they play a role in the body’s immunity and defense against infection and foreign pathogens.  When antigens are inhaled or ingested, tonsils are correctly positioned for exposure, leading to the development of lymphokines and immunoglobulins.  Tonsils are primarily composed of B-cell lymphoid tissue; therefore, one of their roles is mucosal secretory immunity. On the surface of the tonsils are specialized antigen-capture cells referred to as M cells.  M cells allow for the capture of antigens generated by micro-organisms. After recognizing an antigen, the M cells activate T and B cells in the tonsils and trigger an immune response. When B cells are stimulated, they increase in the seminal areas of the tonsils. B memory cells mature at the seminal center and are stored for repeated exposure to the same antigen. B cells also secrete IgA, an antibody that plays a vital role in the immune function of mucus. Recent studies have found that tonsils also generate T lymphocytes, but the production mechanism differs from the thymus. (2) 

Incidence of Tonsillectomy  

Tonsillectomy is the most common ambulatory surgical procedure for children in the United States. Roughly 300,000 tonsillectomies are performed on children under 15 every year. Studies have shown that the number of tonsillectomies has increased, with sleep-disordered breathing (SDB) being the primary reason for surgery. (4) 

Indications  

As previously mentioned, two of the most common indications for having a tonsillectomy are sleep-disordered breathing (SDB) and recurrent tonsillitis. Children with enlarged tonsils may have problems breathing at night; tonsils can trap excess bacteria, leading to frequent or painful sore throats. In their cases, tonsils have become more harmful than protective and must be removed. (6) 

SDB (1) 

• General term for breathing difficulties during sleep  

• Recurrent partial or complete upper airway obstruction during sleep resulting in disruption of normal ventilation and sleep patterns 

• Caused by large tonsils and adenoids  

• Higher risk in children who are overweight or obese, with muscle weakness, or some genetic issues or disease that affects nerves  

• Diagnosis   

• • History and physical  

• Symptoms 

• • Hyperactivity  

• • Daytime tiredness  

• • Aggression  

• Signs  

• • Heroic snoring  

• • Witnessed apnea 

• • Restless sleeping  

• • Growth restriction  

• • Poor school performance  

• • Nocturnal enuresis  

• Higher rates of antibiotic use, hospital visits, and increase in healthcare usage due to upper respiratory infections  

Recurrent tonsillitis (1) 

• Bacterial  

• When antibiotics are not effective  

• More than seven episodes in the prior year or more than five episodes annually in two years  

• Documentation of each infection should include sore throat and one or more of the following: 

• • Temperature > 38.3 degrees Celsius  

• • Cervical adenopathy 

• • Tonsillar exudates 

• • Positive GABHS  

Other reasons for a tonsillectomy include (1, 2, 6): 

• Hemorrhagic tonsillitis  

• Recurrent or chronic pharyngotonsillitis  

• Tonsilloliths (tonsil stones) 

• • When large  

• • Cause halitosis, otalgia, and foreign body sensation 

• Adenotonsillar disease  

• • Recurrent tonsillitis and adenoiditis 

• • This can result in hypertrophy, thereby playing a role in sleep apnea 

• Peritonsillar abscess (quinsy)  

• • Recurrent peritonsillar abscess  

• Streptococcal carriage 

• Tonsillar asymmetry (rule out malignancy) 

• Malignancy  

• • Squamous cell carcinoma  

• • Lymphoma  

A tonsillectomy may be considered if (7): 

• Infections occur more than seven times in a year or more than five times a year over two years 

•  Increased absence from school  

• Trouble breathing and does not sleep well due to enlarged tonsils blocking the airway 

• Abscess or growth on tonsils 

• Frequent and bothersome tonsil stones 

• Modifying factors may indicate earlier surgical intervention (6): 

• • Antibiotic allergy/intolerance  

• • PFAPA (periodic fever, aphthous stomatitis, pharyngitis, and adenitis) 

• • Peritonsillar abscess 

Benefits include:  

• Better sleep quality  

• Fewer infections  

• Improved quality of life  

Risks  

Tonsillectomy is a surgical procedure that includes some risks, like any other procedure. After surgery, a child may have (6): 

• Throat pain that lasts up to two weeks 

• Vomiting or a feeling like they must vomit 

• Thirst or dryness, especially if they are vomiting (dehydration) 

• Bleeding in their mouth (from the tonsils) 

• Temperature greater than 101°F 

Complications 

Due to it being a surgical procedure, adverse events include possible hospitalization, risks of anesthesia, prolonged throat pain, and increased financial costs (6). To date, there are no absolute contraindications for a tonsillectomy.  

Complications of a tonsillectomy are more common than any other childhood surgical procedure: 2.7% of children are readmitted within 30 days, and 12.4% present to emergency departments, often because of bleeding. Deaths occur occasionally. Tonsillectomy may have long-term effects on the frequency of respiratory, infectious, and allergic conditions (5). 

Significant complications related to a tonsillectomy are bleeding during and after the procedure (6). Bleeding is one of the most common and feared complications following a tonsillectomy. Therefore, individuals undergoing a tonsillectomy procedure should have any risk factors evaluated prior, such as bleeding disorders or a family history of malignant hyperthermia (1). In previous reports, bleeding within 24 hours of surgery can range from 0.2%-2.2%, and bleeding after 24 hours can vary from 0.1%-3% (6). Bleeding after a tonsillectomy can result in readmission to the hospital or further surgery to control the bleeding (6). The frequency of bleeding is said to be 50% higher at night, occurring between the hours of 10 pm-1 am and 6 am-9 am (1). This increase in bleeding during these hours is said to be caused by changes in circadian rhythm, vibratory effects of snoring on the oropharynx, or drying of the oropharyngeal mucosa from mouth breathing (1).  

Operative complications include trauma to the teeth, larynx, pharyngeal wall, or soft palate (6). Additional complications can consist of difficult intubation, laryngospasm, laryngeal edema, aspiration, respiratory compromise, endotracheal tube ignition, and cardiac arrest (6). Injury to nearby structures, including carotid artery, tongue swelling, altered taste, lip burn, eye injury, and fracture of the mandibular condyle, are reported complications (6).  

Postoperative complications include (6): 

• Nausea and vomiting occur in up to 70% of patients who did not receive prophylactic anti-emetics (1) 

• • This leads to increased readmission rates  

• • Increased need for IV hydration  

• • Increased need for pain medications 

• • Decrease patient satisfaction scores 

• Pain (1) 

• • Leading cause of morbidity  

• • This leads to diminished oral intake, dehydration, dysphagia, & weight loss 

• Dehydration 

• Referred otalgia 

• Post-obstructive pulmonary edema 

• Velopharyngeal insufficiency (1) 

• • Symptoms include: 

• • • Hypernasal speech 

• • • Food regurgitation through nasal passage during feeding 

• Nasopharyngeal stenosis  

Rare occurrences of subcutaneous emphysema or pneumothorax may spontaneously resolve silently; however, they can be severe and fatal complications that can damage the body’s respiratory and circulatory functions (8).  

In rare circumstances, gas accumulation in subcutaneous emphysema can cause upper respiratory tract obstruction and spread to the thoracic cavity, leading to pneumothorax or mediastinal emphysema, which can cause obstructive shock (8). Regardless of the cause, subcutaneous emphysema of the head and neck is usually fatal.  

Complications following a tonsillectomy can be classified into three main categories (2):  

• Acute  

• • Airway obstruction due to edema 

• • Bleeding 

• • Post-obstructive pulmonary edema 

• Subacute  

• • Postoperative hemorrhage 

• • Dehydration 

• • Weight loss 

• Delayed or chronic  

• • Velopharyngeal insufficiency  

• • Nasopharyngeal stenosis  

Nursing Management  

A patient’s pain following the operation is one of the biggest challenges and problems to overcome postoperatively. Post-operative pain is an unpleasant emotional experience and is a mechanism of self-protection. Often, patients are hesitant to eat or drink due to pain, which in turn will affect their nutritional intake, which will affect their recovery and increase their probability of complications. It will also prolong their hospitalization time and increase hospital costs. (9) 

Pain from a tonsillectomy can be aggravated by drinking and eating and can often take up to 15 days to fully recover. Pain can affect a patient’s mood, sleep, and diet, increase their chance of dehydration, bleeding, and infection, and delay their recovery. Comprehensive nursing care incorporating psychological care, dietary intervention, and health education will help the patient recover. Comprehensive nursing care can significantly reduce post-operative pain, shorten the duration of pain, shorten the duration of treatment, and improve nursing satisfaction in patients recovering from a tonsillectomy.  

Conclusion

In summary, because tonsillectomies are one of the most common surgical procedures performed, healthcare providers need to be aware of the procedure’s indications and possible complications. Healthcare providers must be aware of the potential complications because complications are perilous and can progress extremely fast. Comprehensive nursing interventions applied to tonsillectomy can significantly reduce patients’ postoperative wound pain, shorten hospital stay, reduce postoperative bleeding, and decrease the incidence of postoperative complications 

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