Tonsillectomy and adenoidectomy: indications, technique and complications
- Procedure
The tonsils, the adenoids or both are removed through the mouth under general anaesthesia, mostly for sleep apnoea or repeated tonsillitis.
See it in 3D: Palatine tonsils · Glossopharyngeal nerve (IX) · Soft palate · Pharyngeal constrictors
What it is
Tonsillectomy removes the whole palatine tonsil with its capsule, dissecting the peritonsillar space down to the constrictor muscle. Adenoidectomy removes the adenoids from the nasopharynx with a curette, microdebrider, electrocautery or coblation. Both are done under general anaesthesia with intubation, in the Rose position (neck extended with a roll under the shoulders). Today the most common indication in children is sleep-disordered breathing, followed by recurrent tonsillitis. Tonsillotomy (intracapsular) leaves the capsule and causes less pain and bleeding. This page is an educational overview: the clinical approach is on the page on tonsils and adenoids in children.
Indications and contraindications
- Tonsillectomy: sleep-disordered breathing or apnoea with tonsillar hypertrophy; recurrent tonsillitis meeting Paradise criteria.
- Recurrent or second peritonsillar abscess; tonsillitis causing febrile seizures, recurrent rheumatic fever or glomerulonephritis.
- Excisional biopsy for an enlarging asymmetric tonsil (lymphoma, carcinoma); diphtheria carrier not responding to antibiotics.
- Adenoidectomy: nasal obstruction with mouth breathing and snoring, persistent otitis media with effusion (with tubes in older children), recurrent adenoiditis or sinusitis.
- Contraindications: acute infection (wait for it to resolve), uncorrected bleeding disorder, significant anaemia, uncontrolled systemic disease.
- Relative contraindication to adenoidectomy: cleft palate or submucous cleft; caution in Down syndrome because of atlantoaxial instability.
How it is done
- Before: document episodes or apnoea (polysomnography if indicated), ask about family bleeding and medicines; coagulation tests if suspected.
- General anaesthesia with intubation; Rose position and a mouth gag that keeps the airway protected.
- Dissection tonsillectomy: the tonsil is grasped, the anterior pillar incised and the capsule dissected off the muscular bed from top to bottom.
- The lower pole is separated with a snare or scissors; haemostasis with pressure, ties or bipolar cautery.
- Other techniques: diathermy, coblation, laser; intracapsular tonsillotomy leaves the capsule and causes less pain.
- Adenoidectomy: the palate is felt (submucous cleft) and the adenoids are removed with curette, microdebrider or coblation; haemostasis with packing.
- The pharynx is suctioned and checked for bleeding before extubation; the child wakes on the side.
- Most go home the same day; young children or those with severe apnoea are observed longer.
Bleeding after tonsillectomy
| Type | When | Usual cause | What the general doctor does |
|---|---|---|---|
| Primary (reactionary) | First 24 hours, mostly the first hours | Uncontrolled vessel or blood pressure recovering after anaesthesia | Keep the patient in hospital; call the surgeon |
| Secondary | After 24 hours, typically days 5 to 10 | Infection of the bed and separation of the slough | Emergency referral, intravenous access, blood count and blood reserved |
Complications
- Primary haemorrhage (first 24 hours, from technique or an uncontrolled vessel) and secondary (days 5 to 10, from bed infection as the slough separates).
- Sore throat and referred earache; dehydration from refusing to swallow.
- Airway problems on waking: laryngospasm, uvular oedema, post-obstructive pulmonary oedema in severe apnoea.
- Velopharyngeal insufficiency (nasal voice, nasal regurgitation of fluids), especially after adenoidectomy.
- Injury to teeth, lips or tongue from the mouth gag; aspiration of blood.
- Rare: nasopharyngeal stenosis, infectious atlantoaxial subluxation (Grisel syndrome), internal carotid injury.
Next step / Initial management
- Before referral: document each episode of pharyngitis (fever, exudate, nodes, streptococcal test) and apnoea symptoms; treat streptococcal pharyngitis with amoxicillin or penicillin.
- After surgery: scheduled analgesia with paracetamol and ibuprofen as the surgeon advises; avoid codeine in children; encourage fluids and a soft diet.
- Explain to the family that a whitish tonsil bed is normal in the first days and that the earache is referred.
- Refer as an emergency, immediately, to ENT any bleeding after tonsillectomy, even if it has stopped (it may herald a larger one).
- Refer urgently, the same day, if there is dehydration from inability to swallow, persistent high fever, painful torticollis (Grisel) or breathing difficulty.
Test yourself
Think of the answer, then tap the question to see it.
A 6-year-old has had 7 documented episodes of tonsillitis in the last year. Which criterion is met and what is offered?
The Paradise criterion (7 or more episodes in one year) is met: tonsillectomy can be offered after discussing risks and benefits with the family.
On the seventh day after tonsillectomy, a child spits blood. What is this bleed called and what is its usual cause?
Secondary haemorrhage: it occurs after 24 hours, typically days 5 to 10, from infection of the bed as the slough separates; it needs emergency referral.
After tonsillectomy, an adult reports earache with normal otoscopy. Why does it happen?
It is referred otalgia via the glossopharyngeal nerve, which supplies the tonsil bed and, through its tympanic branch (Jacobson's nerve), the middle ear.
A bifid uvula is found before adenoidectomy. Why does it matter?
It suggests a submucous cleft palate; removing the adenoids can cause velopharyngeal insufficiency with nasal voice and regurgitation, so it is contraindicated or done partially.
Elsewhere in DurgiPedia
Connections
See it in 3D4
The structures of Durgical's 3D anatomy where it is found.
Microorganisms1
In Pharmacology5
Educational content; it does not replace a medical assessment and is not a clinical instruction. For a real case, follow current guidelines and specialist advice.
Sources: Tonsillectomy (StatPearls) (StatPearls Publishing, NCBI Bookshelf, 2026); Adenoidectomy (Archived) (StatPearls) (StatPearls Publishing, NCBI Bookshelf, 2023); Tonsillectomy (MedlinePlus, U.S. National Library of Medicine, 2025); Adenoid removal (MedlinePlus, U.S. National Library of Medicine, 2024).
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Representative model, for educational purposes only.