Tonsillectomy in Pokhara: When to Remove Tonsils and What to Expect
Tonsillectomy is one of the most commonly performed surgical procedures worldwide and among the most frequent ENT operations at A&B International Hospital. Despite its frequency, patients and families often have significant uncertainty about when surgery is actually warranted — as opposed to continued medical management — and what the post-operative period involves. This article provides a factual, clinical guide to that decision and to the operative and recovery process.
What Do Tonsils Do and Why Would They Be Removed?
Tonsils are lymphoid tissue located at the back of the throat, forming part of Waldeyer’s ring — a ring of lymphatic tissue that contributes to the immune response of the upper airway. In early childhood, they play a role in immune education. By adolescence and adulthood, their immunological contribution is minimal, and their removal does not impair systemic immune function.
The two main indications for tonsillectomy are recurrent acute tonsillitis (the infection-based indication) and obstructive tonsillar hypertrophy (the size-based indication, including obstructive sleep apnea from enlarged tonsils blocking the airway during sleep). Peritonsillar abscess that has recurred or is associated with recurrent tonsillitis is a third indication.
When Is Tonsillectomy Indicated for Recurrent Tonsillitis?
The most widely used clinical guideline defines recurrent acute tonsillitis warranting tonsillectomy as seven or more documented episodes in one year, five or more per year for two consecutive years, or three or more per year for three consecutive years. Each episode must be significant — documented throat infection with fever, cervical lymphadenopathy, exudate on the tonsils, or positive throat culture for group A streptococcus.
This threshold exists because the natural history of recurrent tonsillitis tends toward improvement over time in children, and because tonsillectomy carries real surgical risks. Patients who meet the threshold have sufficient evidence of recurrent infection that the benefits of surgery outweigh the risks.
Patients who do not strictly meet the criteria but who have had fewer but severely disabling episodes — requiring hospitalisation, causing significant school or work absence — can still be considered for surgery on an individual basis.
In the Nepali context, documented episodes are often under-counted because patients manage mild to moderate infections at home without presenting to hospital. A clinical history that suggests the frequency and severity of attacks, supported by any available records, is used to guide the decision.
What Are the Problems Caused by Enlarged Tonsils?
Tonsillar hypertrophy — enlargement of the tonsils — can cause chronic nasal obstruction, snoring, and obstructive sleep apnea (OSA) even in the absence of recurrent infection. OSA is characterised by repeated episodes of partial or complete airway obstruction during sleep, causing oxygen desaturation, disrupted sleep architecture, and daytime sleepiness.
In children, untreated OSA is associated with behavioural problems, learning difficulties, growth problems, and in severe cases, cor pulmonale (right heart failure from chronic oxygen desaturation). This makes tonsillar hypertrophy with OSA a significant paediatric health problem, and tonsillectomy (often combined with adenoidectomy — removal of the adenoids located higher in the nasopharynx) the treatment of choice.
In adults, OSA from tonsillar hypertrophy is treated with tonsillectomy as well, though in adults, OSA more commonly involves additional factors (obesity, structural anatomy) and may not be fully resolved by tonsillectomy alone.
What Is the Surgical Procedure for Tonsillectomy?
Tonsillectomy is performed under general anaesthesia. Two main surgical techniques are used: diathermy (electrocautery) and cold steel dissection. Cold steel involves sharp dissection of the tonsil from its bed followed by bipolar diathermy for haemostasis. Diathermy techniques use electrical energy for simultaneous cutting and haemostasis.
The choice of technique has some relevance to post-operative pain and bleeding risk. Cold steel dissection may produce slightly more immediate haemorrhage controlled intraoperatively; diathermy techniques may produce more post-operative pain from tissue damage. In practice, both techniques produce comparable outcomes in experienced hands.
Coblation (radiofrequency ablation) is a lower-temperature technique increasingly used in paediatric tonsillectomy that may reduce post-operative pain and haemorrhage risk, though the evidence is still developing.
Surgery takes approximately 20–30 minutes. Most patients are discharged the same day or after one night of observation.
What Is the Risk of Post-Operative Bleeding and How Is It Managed?
Post-tonsillectomy haemorrhage is the most serious complication, occurring in approximately 2–5% of patients. It is classified as primary (within 24 hours of surgery, typically in the operating theatre setting) or secondary (5–10 days post-operatively, when the tonsillar slough — the scab — separates).
Secondary haemorrhage is the clinically critical risk. Patients and families should understand that days 5–10 post-surgery represent the highest-risk period. Any bleeding from the mouth after tonsillectomy requires immediate return to hospital — it is never safe to manage at home. Small amounts of blood can precede severe haemorrhage.
Patients are advised to maintain adequate hydration (dehydration makes the tonsillar surface crack), avoid aspirin-containing analgesics (which impair platelet function), and avoid physical exertion during the first two weeks.
What Is the Diet and Recovery After Tonsillectomy?
Post-operatively, patients eat cold soft foods — ice cream, yoghurt, cold soup, cold water, ice lollies. Cold reduces pain and vasoconstricts the tonsillar bed. Hard, sharp foods (crisps, crackers, toast) are avoided because they can traumatise the tonsillar fossa and precipitate bleeding.
Regular paracetamol is prescribed for pain. Non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen are generally avoided in children due to bleeding concerns, though some guidelines permit short-term use in adults.
Children typically return to school in 1–2 weeks. Adults return to desk work at 1–2 weeks and physically demanding work at 2–3 weeks. Full recovery of the tonsillar fossa takes 3–4 weeks.
White patches at the tonsillar site are normal healing tissue (fibrin), not infection. Patients should not attempt to clean or disturb these patches.
The expected functional improvement following tonsillectomy for recurrent tonsillitis is a significant reduction in throat infections and associated antibiotic use. For OSA, a significant reduction in snoring and apnea events typically occurs within weeks.
A&B International Hospital
Pokhara-02, Bindhyaabasini Way to Sarangkot
Phone: +977 061-412512
Website: abinthospital.com
If you or your child has had frequent throat infections or has been told they snore heavily or stop breathing during sleep, an ENT assessment at A&B International Hospital will determine whether tonsillectomy is appropriate. ECHS polycards accepted.
