Experience Summary

In this 360-degree video, observe the pre-procedure discussion between an ENT surgeon, a paediatric patient and his mother prior to the child’s tonsillectomy.

Clinical Context

A tonsillectomy is the surgical removal of the palatine tonsils; often this is done together with adenoidectomy (adenotonsillectomy) in paediatric patients. The procedure is among the most common childhood surgeries and is considered when the tonsils cause significant problems that are not adequately controlled by medical therapy.

Indications:

• Recurrent tonsillitis / sore throats: frequent episodes of bacterial tonsillitis (e.g., meeting criteria such as the “Paradise” criteria: for example seven or more episodes in one year, or five or more per year over two years, or three or more per year over three years).
• Sleep-disordered breathing / obstructive sleep apnoea (OSA): when tonsil and/or adenoid hypertrophy obstruct the airway, causing snoring, disturbed sleep, behavioural or growth issues.
• Severe complications: peritonsillar abscess not responsive to drainage/medical management; rare but serious issues like febrile seizures triggered by tonsillitis or tonsillar disease suggestive of malignancy (e.g. unilateral enlargement).

These interventions are weighed against the risks, as tonsillectomy has potential complications: bleeding (intra- and post-operatively), anaesthetic risk, pain, swallowing difficulties, dehydration, etc. Moreover, many guidelines emphasise that not all children with sore throats or tonsillitis are good candidates; quality of life, severity, frequency, response to medical therapy, and comorbidities must be considered.

Key Counselling Points

When discussing tonsillectomy with a child’s carers (and when age-appropriate, with the child), these steps help ensure informed decision making:

1. Explain what the tonsils are and what they doClarify the normal role of tonsils as immune organs, the difference between viral vs bacterial infections, and why removing them may help.
2. Describe the indications in the child’s caseLay out why surgery is being considered: frequency of tonsillitis, presence of sleep apnoea, effect on growth, school attendance, behaviour, swallowing or breathing.
3. Discuss non-surgical and “wait-and-see” optionsFor milder symptoms, supportive therapy, medical management (antibiotics when needed), or observation may be alternatives. Risks and benefits of delaying surgery should be considered.
4. Outline the procedureHow the surgery is done (cold steel vs hot methods vs newer techniques), requirement for general anaesthesia, duration of surgery, hospital stay (day case vs overnight) especially for children with comorbidities or those who are young or low weight.
5. Explain risks and complicationsIntraoperative risks (anaesthesia, bleeding), postoperative pain, risk of secondary bleeding, dehydration, infection, possible persistence or recurrence of symptoms (sleep apnoea may persist), taste changes or voice change, etc. Discuss risk mitigation (e.g. hydration, pain control, monitoring).
6. Discuss recovery and aftercareWhat to expect in the days following surgery: throat pain, eating & drinking, analgesia, when to return to normal activity, school; what warning signs to watch for (bleeding, breathing difficulty, dehydration, fever).
7. Shared decision makingEngage the family and child (if possible) in weighing pros and cons, considering their preferences (e.g. aversion to surgery vs burden of recurrent disease), quality of life impacts. Ensure they understand absolute vs relative benefit.
8. Documentation and consentProvide written information, leaflets; ensure assent/consent are properly obtained; check understanding; allow time for questions.
   

Learning Outcomes

1. Understand the key points in pre-tonsillectomy counselling.
2. Understand the safety netting and post-procedure advice required in tonsillectomy.
3. Understand the indication for tonsillectomy in paediatric patients.

External Resources

• British Association for Paediatric Otorhinolaryngology - Day Case Paediatric Adenotonsillectomy Consensus Guideline