What is the management for stomatitis after tonsillectomy?

Management of Post-Tonsillectomy Stomatitis

The management of post-tonsillectomy stomatitis should focus on pain control with ibuprofen and acetaminophen, adequate hydration, and supportive care, while avoiding antibiotics unless there are signs of secondary infection.

Diagnosis and Assessment

When evaluating post-tonsillectomy stomatitis, consider:

• Timing of onset (typically within first week after surgery)
• Presence of oral ulcerations or inflammation
• Associated symptoms (pain, difficulty swallowing, fever)
• Distinguishing from normal post-operative pain vs. complication
• Ruling out more serious complications like secondary hemorrhage

First-Line Management

1. Pain Control

   • Ibuprofen and acetaminophen are strongly recommended for post-tonsillectomy pain management 1
   • These medications can be used alone or in combination
   • Dosing should be scheduled rather than as-needed to maintain pain control
   • Avoid codeine and codeine-containing medications in children under 12 years (FDA black box warning) 1, 2

2. Hydration

   • Encourage frequent small sips of cool liquids
   • Avoid acidic, spicy, or rough-textured foods that may irritate inflamed tissues
   • Monitor for signs of dehydration (decreased urination, dry mucous membranes)

3. Supportive Care

   • Cold foods/beverages may provide temporary relief
   • Soft, bland diet to minimize discomfort while eating
   • Oral rinses with warm salt water (for older children/adults)

Important Considerations

• Antibiotics are not routinely recommended for post-tonsillectomy care 1

  • The American Academy of Otolaryngology-Head and Neck Surgery strongly recommends against perioperative antibiotics 1
  • Consider antibiotics only if clear signs of secondary bacterial infection are present

• Steroid therapy

  • A single intraoperative dose of dexamethasone is recommended during tonsillectomy 1
  • This helps reduce post-operative nausea, vomiting, and pain
  • Additional steroid therapy post-operatively is not routinely recommended

Special Considerations

PFAPA Syndrome

• In cases where tonsillectomy was performed for PFAPA syndrome (Periodic Fever, Aphthous Stomatitis, Pharyngitis, and Adenitis), post-operative stomatitis may represent disease recurrence rather than a surgical complication 3, 4, 5
• Monitor for recurrent fever patterns and other PFAPA symptoms
• In rare cases of PFAPA recurrence after tonsillectomy, consider:
  • Single-dose corticosteroids during attacks
  • Consultation with rheumatology for potential colchicine therapy 5

Follow-Up Recommendations

• Routine follow-up should document presence/absence of complications including stomatitis 1
• If symptoms persist beyond 2 weeks or worsen, re-evaluation is necessary
• Consider referral back to the otolaryngologist if symptoms are severe or persistent

Common Pitfalls to Avoid

1. Prescribing unnecessary antibiotics for expected post-operative inflammation
2. Using codeine or codeine-containing medications in children under 12
3. Inadequate pain control leading to dehydration
4. Failing to distinguish between normal post-operative course and complications requiring intervention
5. Missing signs of more serious complications like secondary hemorrhage

By following these evidence-based recommendations, most cases of post-tonsillectomy stomatitis can be effectively managed with supportive care and appropriate pain control while avoiding unnecessary antibiotic use.