What are the follow-up instructions for a patient after a tonsillectomy?

Post-Tonsillectomy Follow-Up Instructions

Clinicians must follow up with patients and caregivers after tonsillectomy to document bleeding complications, ensure adequate pain control, and monitor for respiratory issues, with specific attention to primary bleeding (within 24 hours) and secondary bleeding (after 24 hours, typically days 5-10). 1

Pain Management Instructions

Prescribe ibuprofen, acetaminophen, or both as first-line analgesics for post-tonsillectomy pain control. 1

• Never prescribe codeine or any codeine-containing medications to children younger than 12 years due to risk of life-threatening respiratory depression from variable metabolism. 1
• Non-aspirin NSAIDs (ibuprofen, diclofenac) are safe and do not significantly increase bleeding risk, unlike aspirin which must be avoided. 2
• Counsel families that pain typically lasts 11-12 days postoperatively, with most patients requiring rescue analgesia 1-3 times daily during the first week. 3
• Emphasize the importance of anticipating, reassessing, and adequately treating pain as part of perioperative education. 1

Bleeding Surveillance Protocol

Document the presence or absence of both primary bleeding (within 24 hours) and secondary bleeding (after 24 hours) in the medical record for every patient. 1

• Primary hemorrhage occurs in 0.2-2.2% of cases and is typically related to surgical technique. 2
• Secondary hemorrhage occurs in 0.1-3% of cases, usually between days 5-10, caused by eschar sloughing as the tonsil bed heals. 2
• Educate patients and caregivers about warning signs requiring immediate medical attention: fresh bleeding, respiratory distress, severe pain, and signs of dehydration. 2
• Most bleeding episodes can be managed with local measures, but significant bleeding requires return to the operating room for surgical re-exploration and cauterization. 2
• Post-tonsillectomy hemorrhage accounts for approximately one-third of tonsillectomy-related deaths, making vigilant surveillance critical. 2

Respiratory Monitoring Requirements

Arrange overnight inpatient monitoring for children under 3 years of age OR those with severe obstructive sleep apnea (apnea-hypopnea index ≥10 events/hour, oxygen saturation nadir <80%, or both). 1, 4

• Children under 3 years have a higher respiratory complication rate (9.8%) compared to older children (4.9%). 4
• Patients with obstructive sleep apnea have respiratory complication rates of 5.8-26.8%, particularly those with craniofacial disorders. 2
• High-risk patients requiring extended monitoring include those with obesity, Down syndrome, craniofacial abnormalities, neuromuscular disorders, sickle cell disease, or mucopolysaccharidoses. 1, 2

Counseling on Persistent Symptoms

Counsel patients and caregivers that obstructive sleep-disordered breathing may persist or recur after tonsillectomy and may require further management. 1

• For recurrent throat infections, benefits of tonsillectomy do not extend beyond the first year postoperatively, and benefits are significantly lessened for children with mild disease burden. 1
• Discuss that control groups in studies show significant spontaneous reduction in infection rates over time without surgery. 1

Follow-Up Timing and Quality Metrics

A postoperative follow-up period of 10 days is sufficient to identify all but the most rare cases of post-tonsillectomy hemorrhage. 5

• The latest reported episode of secondary bleeding occurred 38 days postoperatively, though this is exceptionally rare. 5
• Determine your rate of primary and secondary post-tonsillectomy bleeding at least annually for quality improvement and comparison with national benchmarks. 1, 2
• Return to normal daily activities typically occurs after 12 days (range 2-24 days). 3

Common Pitfalls to Avoid

• Do not prescribe perioperative antibiotics as they provide no benefit in reducing bleeding or infection rates and contribute to antibiotic resistance. 1, 4
• Avoid inadequate pain counseling—families must understand that significant pain lasting 11-12 days is expected and requires proactive management. 1, 3
• Do not discharge high-risk patients (age <3 years or severe OSA) without arranging overnight inpatient monitoring. 1, 4
• Avoid prescribing aspirin postoperatively as it increases hemorrhage risk. 2