Guest: Dr. David R. White - Otolaryngology - Head and Neck Surgery (ENT)
Host: Dr. Linda Austin – Psychiatrist
Announcer: Welcome to an MUSC Health Podcast.
Dr. Linda Austin: I am Dr. Linda Austin and I am talking with Dr. David White, who is a Pediatric Otolaryngologist in the Department of Ears, Nose, and Throat here at the Medical University of South Carolina. Dr. White, I am sure that one of the procedures that a pediatric ENT doctor does a lot of are tonsillectomies, I think still done as commonly as in the olden days.
Dr. David R. White: Well, I think they are not done quite as commonly as they were in the olden days. I hear stories about people, who had their entire first-grade class loaded on to a school bus and went to the hospital and everybody got their tonsils out. We certainly don’t approach in that way anymore, but it’s still a very common procedure, one of the more common procedures in children in the United States. And usually when you talk about a tonsillectomy in kids certainly under the age of 10 or 12 years old, you also mention adenoidectomy along with it. Adenoids are like cousins of the tonsils that are in the back of the nose and so they are the tonsils that are located in the back of the nose.
Dr. Linda Austin: So just to kind of clarify the anatomy that we are talking about, if you wanted to see your own tonsils if you have not had them removed, where are they exactly?
Dr. David R. White: So, if you look in the back of your mouth of the uvula, which is a little thing that hangs down in the middle that everybody is familiar with, the tonsils are there to the sides. People are generally familiar with the tonsils. The adenoids are harder to find and looking at the adenoids usually requires either looking with a telescope through the nose, using an x-ray to look at the adenoids, or under general anesthesia we can often look at the adenoids with a mirror through the mouth.
Dr. Linda Austin: What are the most common reasons that kids get tonsillectomies or adenoidectomies?
Dr. David R. White: By far, the most common reason these days is to remove the tonsils and adenoids to the addressed problems with breathing during sleep. There is a relatively wide variety of things that fall under a larger umbrella of sleep disorder breathing, which essentially refer to problems that children have with sleeping that are caused by obstruction or partial obstruction of the airway. By far, the most common cause of obstruction of the airway in a sleeping child, who is otherwise healthy, would be large tonsils and adenoids and then the tonsils and adenoids are removed 95% to 97% of the time will get resolution of those sleep symptoms in children.
Dr. Linda Austin: How about in an adult, so is that a common procedure for snoring?
Dr. David R. White: In adults, it’s a little bit more of a complicated picture when it comes to snoring and sleep apnea. It is often part of the treatment, but many times in adults, there is a lot more that’s needed to fully treat snoring or sleep apnea, which would involve other procedures to address the palate or to address the back of the tongue or to address the nasal airway. These options are fortunately something that we don’t encounter as much in children since tonsillectomy and adenoidectomy is so successful in children.
Dr. Linda Austin: Let’s walk through the process of the tonsillectomy operation from the point of view of the patients and also from your point of view, what happens when a kid comes in for that surgery?
Dr. David R. White: So when a child comes to the operating room, first of all we have got a great program here called Scrub Club at MUSC where the children can actually get early exposure to the operating room with their parents and sort of walk through the whole process and that’s something, which here at MUSC I think is a really good option for children that are coming in for this type of procedure, but basically when the child first comes in, they would go into a holding room, which is an area where children go prior to going back to the operating room and they are with their parents and they meet the anesthesiologist and of course have we come and talk to them and make sure they don’t have any questions and once everybody is ready to go, a lot of times the anesthesiologist would give them some medication to help them feel a little bit relaxed. At that point, the parents usually give the child some kisses and the child goes back to the operating room. Once in the operating room the child breathes through a mask and some gas is given to the child, which helps them fall off to sleep, once the child is asleep and only after the child is asleep generally, an IV is started and so that is done once the child is already asleep and then an IV and a breathing tube are placed, and we take out the tonsils. The tonsils can be removed in several different ways. The technique of removing a tonsil depends on the situation, but once the tonsils are removed, we then usually turn attention to the adenoids. Adenoids are also taken out through the mouth and neither of the tonsillectomy nor the adenoidectomy leaves any sort of incision or obvious scar or anything like that on the outside of the child. Once the procedure is done, the child then wakes up in the recovery room. The total time that the child is away from the parents usually is 30 to 45 minutes. In the recovery room, once the child is able to drink well, the child is typically discharged home.
Dr. Linda Austin: So, they don’t even stay overnight?
Dr. David R. White: Generally not. Children under the age of two or three years old, we will make arrangements for them to stay in our children’s hospital overnight and over the age of three, we generally plan on turning home.
Dr. Linda Austin: And do they still get to eat all the ice-cream they want?
Dr. David R. White: Well, that’s up to their parents; from my standpoint, yes.
Dr. Linda Austin: I remember in childhood that was always the big claim that there is a one good thing about a tonsillectomy is all the ice-cream you can eat.
Dr. David R. White: Ice-cream and popsicles definitely help a lot.
Dr. Linda Austin: Any complications from this procedure?
Dr. David R. White: There are three major complications that I review with the parents and children who are going to be undergoing a procedure. The first is that it will give them a sore throat for a few days afterwards and it’s very important that the parents and children work together to make sure that the child doesn’t get dehydrated and so basically what this means is the child needs to focus on drinking plenty of clear liquids and popsicles count fortunately so that the child doesn’t get dehydrated. A small percentage of children will have trouble drinking enough liquid to stay hydrated after the operation and occasionally then would require a trip into the pediatric emergency room to have some IV fluids. Other complications include bleeding. Bleeding after a tonsillectomy occurs in about one out of fifty children, so a 2% of children if you look at all of those studies that have been done looking at large numbers of children have bleeding after the tonsillectomy. When this happens, it most frequently happens seven to ten days after the operation. What happens is that in the area where the tonsils were, there develops, what looks like a wet scab and when that starts to come off, there can be some bleeding. The child who experiences bleeding out of the mouth after a tonsillectomy should come to the emergency room. Most of the time, this requires a trip back to the operating room to control the bleeding. Finally, there is a very small risk, less than one in a thousand, speech change and specifically after an adenoidectomy with a lot of air escape through the nose and that’s something called velopharyngeal insufficiency. Most of the time, the velopharyngeal insufficiency or speech problems resolve either on their own or with speech therapy. In the small number of children where it doesn’t resolve, we have a velopharyngeal insufficiency team here at MUSC, which I am a part of and we do a series of special studies to see, which approach to treating the speech problem works best.
Dr. Linda Austin: Dr. White, thank you so much.
Dr. David R. White: Thank you.
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