#464: Why Tonsillectomies Keep Nurses on Their Toes

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A very common surgical procedure in the pediatric patient population is the tonsillectomy and adenoidectomy – often referred to as T&A. This procedure involves the removal of the palatine tonsils and the adenoids. Though this is a common procedure, it is definitely not to be taken lightly as it directly involves the airway and can lead to obstruction and/or post-op hemorrhage.

Before we dive into the nursing care of a patient recovering from T&A, let’s do a quick review: 

• The palatine tonsils sit on either side of the oropharynx at the back of the throat
• The adenoids (also referred to as pharyngeal tonsils) are located in the nasopharynx, behind the nose
• These tissues are part of the lymphatic system and tend to get enlarged in early childhood as the immune system is highly active during this time

The T&A procedure is performed for a variety of reasons, including recurrent tonsillitis, obstructive sleep apnea, chronic nasal obstruction, and recurrent ear or sinus infections. It is performed under general anesthesia as an outpatient procedure, though younger children (under 3 years) and those at risk for respiratory difficulty typically stay overnight. The tissues are removed through the oral cavity and the procedure overall takes about 30 to 60 minutes.

Complications of tonsillectomy and adenoidectomy

• Swelling and closure of the airway 
• Laryngospasm, which can lead to complete airway closure
• Hemorrhage – higher risk with children over six years of age
• Dehydration
• Permanent voice changes
• Infection – more prevalent in children with recurrent otitis media or tonsillitis

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L: How does the patient LOOK?

A pediatric patient undergoing a T&A will most likely have a history of recurrent tonsillitis, recurrent otitis media, chronic sinus infections, or OSA (snoring, daytime sleepiness, disrupted sleep). After the procedure, one thing you’ll notice is the absence of any external incisions – both tissues are removed through the oral cavity. 

Other elements of a typical post-op patient include: 

• Sore throat
• Refusal to eat or drink (due to pain)
• Ear pain (this is referred pain and is a common post-op symptom)
• White/gray-ish scabs that develop 24-48 hours after surgery

A: How do you ASSESS the patient?

Thorough nursing assessment is a critical component of caring for these patients so you can spot and treat complications early.

Top priority 👉 Airway and breathing

• Monitor the child’s work of breathing, it should be unlabored.
• Keep an eye on SpO2 and consider using ETCO2 as it can catch hypoxia more quickly than pulse oximetry.
• Assess lung sounds, noting that snoring is associated with partial airway obstruction. Stridor, on the other hand, indicates more significant airway obstruction, which can occur due to edema or laryngospasm.

Monitor for bleeding

Since the surgery doesn’t involve external incisions, bleeding can occur internally, which could be difficult to spot initially. In addition to visible blood oozing from the mouth or nose, other signs of bleeding include: 

• Frequent swallowing
• Frequent throat clearing
• Pallor, tachycardia, hypotension (late signs)

In addition, ingested blood causes GI upset and the child may complain of nausea. If vomiting occurs, it could be blood-tinged or have a coffee-ground appearance. 

Other key assessments

• Evaluate pain level using the appropriate pain scale
  • FLACC – Observation-based scale for children older than 1 year who are not able to self-report.
  • Wong-Baker Faces scale – For children over 3 years of age who are able to self report by choosing the face that matches how they feel.
  • Numeric scale – For children over 8 years who are able to self-report.
• Monitor hydration status by keeping an eye on mucous membranes, tears and urine output
• Assess sedation level as the patient recovers or when opioids are used.

T: What TESTS are utilized with this procedure? 

Most patients undergoing a T&A don’t require specialized testing, though pre-operative testing for OSA may be utilized in children with sleep disorders. Other tests you may see include coagulation studies and Hgb/Hct when bleeding is suspected as well as WBC when infection is suspected.

T: What TREATMENTS are provided? 

Key treatments for a patient after T&A surgery include: 

• Pain management – Common options include acetaminophen, ibuprofen, and opioids. Note that opioids should be used sparingly and with caution, especially in children with OSA.
• Hydration – Encourage fluids as the child may not want to drink due to throat pain. Offer popsicles and ice chips to provide hydration and comfort. 
• Nutrition – Once the child has shown the ability to tolerate fluids, soft foods can be introduced. Good options include yogurt, apple sauce, pudding, mashed potatoes and pasta.
• Bleeding prevention – Aim to keep the child calm and discourage coughing, throat clearing, and vigorous activity. Bleeding can occur any time post-op and the risk is most critical in the first 24-hours.

E: What EDUCATION is provided after T&A surgery?

Since most T&A procedures are conducted in the outpatient setting, education for caregivers is a significant component of patient care. Vital things to include in your teaching plan are:

• In the first two weeks after surgery, the child will be more susceptible to infection. They should avoid crowded environments or being around individuals who are sick. The child will be advised to stay home from school/daycare for 1 to 2 weeks.
• Voice changes are normal after surgery, but if the child is hesitant to speak or speaks at a low volume for more than a few weeks after surgery, contact the physician.
• Avoid strenuous activity for 2 to 3 weeks after surgery.
• The child may feel nauseous in the first 24-hours, which can be due to ingesting blood (even a small, expected amount). If the child vomits, it may be slightly blood-tinged. 
• A sore throat is expected for several days after the procedure and typically is most severe on days 5 through 7. Treat with medications as prescribed as well as cold fluids, ice chips, or popsicles. 
• An earache or jaw pain is common after surgery. 
• Snoring and mouth breathing are common after surgery due to swelling. The child’s breathing should return to normal within 10-14 days.
• A low-grade fever up to 101.5° F is typical after surgery and can be treated with acetaminophen or ibuprofen. 
• Bad breath is normal after surgery and can linger for up to 2 weeks.
• White patches in the throat are scabs from the surgery and should disappear in about 2 weeks.
• Encourage hydration.
  • 0-2 years: 16 oz of fluid/day
  • 2-4 years: 24 oz of fluid/day
  • 4 and older: 32 oz of fluid/day
• Some physicians recommend avoiding straws, others say it’s ok. Heed your individual surgeon’s advice.
• Stick to soft foods for two weeks. Good options include pasta, mashed potatoes, pudding, scrambled eggs, pancakes, ice cream, etc… Avoid crunchy, spicy, or citrus foods.

It’s also important the caregiver knows when to seek urgent medical care or contact their physician. In addition, ensure the caregiver understands that the child should stay within 30-45 minutes of an emergency room for the first two weeks after surgery. Other important things to teach include:

• Seek medical care if the child has signs of infection such as a fever above 101.5° F, significantly bad breath or yellow mucus.
• Contact the physician for any signs of bleeding, including spitting up blood clots or coffee-ground emesis.
• If the child is actively bleeding from the mouth, seek medical care immediately. This is most likely to occur as the scabs fall off, typically between the 6th and 10th post-op day but can also occur if the scabs fall off too early. Note that vigorous coughing and throat clearing can also lead to bleeding.
• Seek medical care immediately if the child has difficulty breathing or is unable to swallow (indicated by drooling). 
• Contact the physician if the child is nauseous or unable to keep fluids/food down beyond the first 24 hours.
• Notify the physician if the child is not drinking enough or there are signs of dehydration (decreased urine output, dry mucous membranes, crying without tears).

Tonsillectomy and adenoidectomy may be one of the most common pediatric surgeries, but as nurses, we know it’s anything but routine. Airway vigilance, bleeding assessment, pain control, and caregiver education all play a critical role in keeping these patients safe.

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References:

Albin, A. (2014, October 15). Post-tonsillectomy complications more likely in children from lower-income families. UCLA. https://newsroom.ucla.edu/releases/post-tonsillectomy-complications-more-likely-in-children-from-lower-income-families

Boston Children’s Hospital. (2024, March). Home Care Instructions after a  Tonsillectomy and Adenoidectomy. Boston Children’s Hospital. https://www.childrenshospital.org/sites/default/files/2024-03/tonsillectomy-adenoidectomy-family-education-sheet.pdf

Cincinnati Children’s. (2024, June). Tonsillectomy. Cincinnati Children’s. https://www.cincinnatichildrens.org/health/t/tonsillectomy

Cleveland Clinic. (2026, January). Adenoidectomy. Cleveland Clinic. https://my.clevelandclinic.org/health/treatments/15447-adenoidectomy-adenoid-removal

Damam, S., Meshram, R. J., Taksande, A., Lohiya, S., Khurana, A., Patel, A., Khandelwal, R., Nath, R., Javvaji, C. K., & Kakkat, S. (2024). Navigating Pediatric Capnography: A Comprehensive Review of Scope and Limitations. Cureus, 16(1), e53289. https://doi.org/10.7759/cureus.53289

Della Vecchia, L., Passali, F. M., & Coden, E. (2020). Complications of adenotonsillectomy in pediatric age. Acta Bio Medica : Atenei Parmensis, 91(Suppl 1), 48–53. https://doi.org/10.23750/abm.v91i1-S.9256

Langhan, M. L., Li, F.-Y., & Lichtor, J. L. (2017). The impact of capnography monitoring among children and adolescents in the postanesthesia care unit: A randomized controlled trial. Pediatric Anesthesia, 27(4), 385–393. https://doi.org/10.1111/pan.13077

Meegalla, N., & Downs, B. W. (2025). Anatomy, Head and Neck, Palatine Tonsil (Faucial Tonsils). In StatPearls. StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK538296/

Thomas, S. (2015, October 1). POSTOPERATIVE CARE OF THE TONSILLECTOMY & ADENOIDECTOMY PATIENT. Central Park Ear, Nose and Throat. https://centralparkent.net/2015/10/01/postoperative-care-of-the-tonsillectomy-adenoidectomy-patient/