Stuart N. Thomas, MD

Central Park Ear, Nose & Throat

 

  1. HYDRATION, HYDRATION, HYDRATION

The most important concept after surgery is aggressive hydration. It is of utmost importance that over the first 10-14 days, the patient drink plenty of fluids—more than one would normally—to avoid dehydration. We believe that this lessens the risk of bleeding and potentially lessens the fever as well. Most certainly, the patient will feel better if well hydrated.

The ideal liquid is Pedialyte, but an acceptable alternative is dilute Gatorade (diluted 1:1 with water). Sugary drinks or those with caffeine are not good alternatives. Orange juice is very acidic and will likely sting. But in the end, the best liquid is the one the patient will drink in sufficient amount!

For children, you should record the amount of everything they drink in a 24 hour period. If the patient drinks nothing or only has a few sips over a 12 hour period, you need to contact our office (or the Doctor on-call, if the office is closed) to discuss. We will ask how much the child has had to drink in the last 12-24 hours and may want to know how many times the child has urinated and even what color the urine is. These details help us decide if there is a significant risk of dehydration. If we believe the patient is dehydrated, you will be instructed to proceed to either a Pediatric ER (Cook Children’s Hospital, if in Tarrant County) or Medical Center of Arlington ER (for adults) for assessment and possible intravenous fluid replacement.

For children, the amount of fluid varies by the weight. The following table gives rough guidelines for how much a child of a given weight should be drinking. This does not take into account the additional issues of fever or a fluid deficit from several days of not drinking enough. The key here is to make the amount listed the MINIMUM amount your child drinks—more is definitely better!

 

Weight in Kg Weight in Pounds Fluid intake in 24hr (ml) Fluid intake in 24hr (oz)
15 33 1250 42
20 44 1500 50
25 55 1600 54
30 66 1700 57
35 77 1800 60
40 88 1900 63
45 99 2000 68
50 110 2100 71
55 121 2200 74
60 132 2300 78

 

 

  1. FEVER

Fever is quite common in the first few days after surgery—more so for smaller children.   Fevers as high as 104° is sometimes seen in smaller children. Generally, how high the fever goes is not a major issue for concern as long as the child is drinking well and remaining hydrated. It is important to remember that the amounts of liquid listed above do NOT account for fever. Amounts should be increased significantly if the child is running significant fever.

The duration of the fever can, rarely be an issue of concern. If the patient is still running temperatures of 101.0° or above 7 days after the surgery, you should contact our office for guidance.

No fever-reducing medications should be given. Tylenol is a bad idea because the prescription narcotic pain medication has Tylenol in it. Giving the patient additional Tylenol puts them at risk of potentially life-threatening liver toxicity. And we feel that Ibuprofen (Motrin, Advil, etc) should not be used because of the potential increase in risk of bleeding.

For comfort, bathing the patient in tepid water or giving them an alcohol rub-down may ease the discomfort of the fever.

  1. DIET

Eating after Tonsillectomy hurts for the first 7-10 days. And it is not terribly important as long as the patient is drinking plenty of liquids. The patient can eat any food they desire postop—without regard to consistency. In other words, solid foods are OK if the patient wants them, but they may hurt more when swallowed than soft foods. In general, soft foods that are not too hot or cold will feel the best.

  1. PAIN AND ITS CONTROL
  1. Throat pain

This is the expected normal pain after Tonsillectomy. It can be quite severe and can last for well over a week. Complete resolution of pain may take close to 3 weeks.

  1. Ear pain

Ear pain is “referred pain” in the sense that it is caused not by any problem with the ears per se, but rather is caused by a sensory nerve that innervates both the side of the throat and the ear canal, making it seem like the ear is hurting. Not uncommonly, this pain will start several days after surgery, involve one or both ears and be the last pain to finally resolve. It is frequently noted to be the worst pain.

  1. Neck pain

After Adenoidectomy, neck pain can sometimes occur due to irritation of the ligaments along the front of the cervical spine that reside immediately deep to the location of the adenoids. These ligaments can become inflamed after the surgery and cause pain on neck motion.   This is rarely an issue of concern, but if the neck pain becomes so bad as to cause the patient to splint the neck (ie—hold it rigidly in place and not move it) or complain exclusively of severe neck pain, our office should be contacted. After asking some further questions, we may ask to evaluate the patient further.

  1. How to use the pain medication

You have been prescribed Hycet™ (or its generic equivalent), a mixture of Hydrocodone (potent narcotic analgesic) and Acetaminophen (Tylenol™), in an alcohol elixir (meaning that this will sting when swallowed by the post-tonsillectomy patient). It is a Class 2 narcotic and thus cannot be phoned-in, faxed-in or e-scribed to a pharmacy by Federal regulation. The dosage is given as range (from low to high amount expressed in milliliters) that is primarily determined/limited by the acetaminophen component and is based on the patient’s weight. It is extremely dangerous to give the patient a higher dosage than the bottle prescribes or to dose it more frequently than prescribed, due to the potential liver toxicity of the acetaminophen. We recommend scheduled dosing of the medication for the first 7 days postop. This means giving the patient the higher of the dosage range every 6 hours, around the clock for the first 7 days. (For example, if the bottle says “take 4-8ml every 6 hours as needed for pain”, you should give the patient 8ml of the Hycet™ every 6 hours, around the clock).

There was a recent study that raised concerns about a small group of patients that are called “rapid metabolizers” that seem to develop dangerously severe sedation (sleepiness) with Codeine, a different narcotic, when given in a scheduled fashion after Tonsillectomy. The FDA has recommended that that drug not be “scheduled.” No such recommendation exists for Hydrocodone, but prudence suggests that if the patient is extremely sleepy/sedated by the narcotic, the current dose should be skipped and we should be contacted immediately. I have personally had no patients in the last 20 years that have exhibited this effect.

The last issue in regards to pain control is what to do if the Hycet™ is just not controlling your pain. We have several alternatives in that situation, depending on the age of the patient. Please contact us to discuss this.

 

  1. NAUSEA AND VOMITING

Given modern anesthesia techniques, this is thankfully an uncommon occurrence, although we do still see it in the first 24 hours occasionally and even more rarely as a side effect of the pain medication.   In the event of nausea, please contact our office—we will discuss and probably prescribe Ondansetron (Zofran™) which will normally control the symptoms.

 

  1. BLEEDING

Bleeding is the most common complication seen after Tonsillectomy, with roughly somewhere between 3-5% of patients experiencing it to some degree postoperatively. It is also frequently the most terrifying complication, with blood coming from the mouth and occasionally the nose as well. Bleeding from the mouth tends to appear much more severe than it really is because of the admixed saliva and the frequent coughing and gagging that accompanies the bleeding.   The good news is that most cases resolve without the need for any surgical or ER therapy. In a few cases, if the bleeding doesn’t stop promptly, the patient must be returned to the OR for control of the bleeding under anesthesia. This occurs in only about 1-2% of all case. But bleeding is NEVER normal, and if the patient has ANY bleeding, you should contact our office immediately.

If this happens, what we instruct you to do will depend on the age and size of the patient—the smaller and younger the patient, the more likely we will be to have you bring them to the ER for evaluation.

 

  1. OTHER
  1. Constipation

This is very common postoperatively because of the narcotic pain medication. Over the counter stool softeners are a good idea for the first week or two to help control this.

  1. Bad breath

Everyone that has either Tonsillectomy or Adenoidectomy will experience this (and so will their family). It is due to the growth or oral bacteria in the healing tonsil wounds in the back of the throat and is harmless and completely normal. It always resolves within 2-3 weeks postop.

  1. White patches in back of throat

If you inspect the back of the patient’s throat within the first 7-14 days, you will see strange white looking “scabs” where the tonsils used to be. This is a mixture of fibrin (normal in healing wounds) and the bacteria mentioned above. It is completely normal and is no cause for concern.

  1. ACTIVITY

We believe there is a correlation between vigorous physical activity and the risk of postoperative bleeding after Tonsillectomy.   As such, we strongly recommend no such activity for the first 2-3 weeks postop.

  1. HOW TO CONTACT US

If you are experiencing any of the issues noted above that are highlighted in red (or any other questions or concerns for that matter), please contact us by calling our Main office number (817-261-9191). If the call is during office hours and you need immediate assistance, you may dial “0” and tell the operator what is happening. They will have one of our Nurses or Medical Assistants call you back quickly.

If the problem is less acute, we ask that you choose the phone option to “leave a message for the nurse” and record your question. We do our best to answer these the same day they are left.

If the problem occurs after hours, please select the phone menu option to be transferred to the Answering Service and tell them what you need. They will contact the Doctor on Call, who will call you back promptly. One of the Physicians in Central Park ENT is always on call and is available to help you. We kindly request that you try to limit calls late at night to true emergencies.