Removal of tonsils (tonsillectomy) - Consequences and complications

Postoperative complications of tonsillectomy (removal of the tonsils) are divided into bleeding, infectious complications and a number of others.

Bleeding. In the vast majority of cases, with proper preoperative preparation of the patient and a well-performed surgical intervention, as well as in the absence of abnormally large vessels feeding the tonsil, the postoperative period passes without complications. However, even under these conditions, tonsillectomy patients require special attention from the medical staff on duty, primarily with regard to possible delayed bleeding. The operated patient should be warned not to swallow saliva and blood streaks, but to spit them into the towel provided to him, and he should not roughly wipe his lips, but only apply the dry surface of the towel to them, otherwise herpetic eruptions or inflammation of the mucous membrane may occur on the lips. After the operation, the patient should not sleep for at least the next 6 hours, and at night the nurse on duty should visit him 3-4 times a night and make sure there is no bleeding.

It is especially important to follow these rules for children who, due to their age, cannot follow the instructions of medical personnel and swallow blood when bleeding occurs during sleep. Filling the stomach with blood causes nausea in the child, waking him up, and he suddenly vomits blood, often in large quantities. The danger lies not only in massive blood loss, but also in aspiration of blood during sleep and asphyxia. Having lost a significant amount of blood, the child becomes pale, lethargic, covered in cold sweat; the pulse is thready, heart sounds are weakened, blood pressure is low, breathing is rapid, shallow, pupils are dilated. The child develops a pronounced feeling of thirst. Significant blood loss leads to spontaneous cessation of bleeding, but the above-mentioned signs of hemorrhage are harbingers of shock from blood loss, which, if appropriate emergency measures are not taken, can lead to death. With significant blood loss, loss of consciousness, convulsions, involuntary urination and defecation may be observed. These signs indicate an extremely serious condition. Large, especially rapid blood loss can lead to the development of acute vascular insufficiency. For a person, the loss of about 50% of blood is life-threatening, and the loss of more than 60% is absolutely fatal, unless there is urgent intervention by resuscitators. During tonsillectomy (removal of tonsils), it should be borne in mind that the patient's serious condition can occur even with significantly smaller volumes of blood loss due to the fact that surgical intervention is carried out in an extensive reflexogenic zone, injury to which can lead to a reflex spasm of the cerebral vessels, which often occurs with blood loss. In clinical practice, blood loss is assessed not only by the amount of blood lost, but also by the severity of the patient's condition. Death from blood loss occurs as a result of paralysis of the respiratory center. Emergency care for blood loss is provided by a resuscitator, and the patient is prescribed blood transfusions and blood-substituting fluids, drugs that stimulate the functions of the respiratory and vasomotor centers, and anti-shock drugs. In case of ongoing bleeding, hemostatic agents are prescribed (adroxon, antihemophilic globulin, vikasol, hemophobin, prothrombin complex, fibrinogen, etamsylate). Vitamins C, K, B12, intravenous calcium chloride, etc. are also prescribed. Among the hemostatic agents of local action, hemostatic sponges, fibrin isogenic film, adrenaline, etc. may be recommended.

In rare cases, late bleeding may occur between the 5th and 8th days after surgery during the separation of crusts from the palatine tonsil niches. As a rule, these bleedings are not dangerous and occur as a result of the patient's failure to comply with the diet.

Postoperative infectious complications occur much less frequently, but their occurrence significantly aggravates the postoperative course, and in some cases poses a danger to life. They usually occur in individuals weakened by other infections, poorly prepared for surgery, or in case of non-compliance with the postoperative work and rest regimen, as well as in case of occurrence of a superinfection unrelated to the surgery (flu, pneumonia, herpes infection, etc.). Infectious complications are divided into local-regional, occurring at a distance, and generalized.

Local-regional complications:

1. postoperative tonsillitis or acute febrile pharyngitis, manifested by inflammation and hyperemia of the posterior pharyngeal wall, soft palate, regional lymphadenitis;
2. abscess of the lateral wall of the pharynx, which usually occurs on the 3rd day after surgery; its occurrence may be caused by the introduction of infection by the needle when it passes through the infected surface of the tonsil, imperfect surgical technique, which causes injury to the lateral wall of the pharynx with penetration into muscle tissue, or incomplete removal of tonsillar tissue from the supratindalar fossa;
3. postoperative diphtheria of the pharynx, especially in cases where the operation was performed under unfavorable epidemic conditions.

In some cases, when adenotomy is performed simultaneously, purulent-inflammatory complications may occur in the ears.

Complications that arise at a distance relate mainly to the bronchopulmonary system and are caused by aspiration of blood and infected contents of the palatine tonsil (bronchopneumonia, lung abscesses, secondary pleurisy, etc.). These complications are facilitated by painful sensations in the throat and the prolonged presence of tampons in the niches of the palatine tonsils, preventing active expectoration of blood and sputum from the bronchi.

Generalized complications include rare septicemia, which occurs 4-5 hours after surgery and is manifested by septic fever and severe chills. The process begins with thrombosis of the pharyngeal venous plexus, which spreads to the jugular vein, and from there the infection enters the general bloodstream.

Sometimes after tonsillectomy (removal of the tonsils) hyperthermic syndrome, transient diabetes insipidus, agranulocytosis, acetonemia develop. There are cases of acute laryngeal edema, occurring immediately after the operation and requiring emergency tracheotomy. In other cases after tonsillectomy (removal of the tonsils) there is violent salivation, literally a gushing stream of saliva from the anterior-inferior angle of the palatine tonsil niche, which is explained by injury to the abnormally located posterior pole of the submandibular gland, which is in direct contact with the lower pole of the palatine tonsil. In these cases, atropine and belladonna are prescribed per os, which reduce salivation during the period of scarring of the damaged parenchyma of the salivary gland.

Other complications that sometimes occur after tonsillectomy (removal of the tonsils) include subatrophic pharyngitis, cicatricial disfigurement of the soft palate and palatine arches that occurs with a conservative operation (individual predisposition to the formation of keloid scars), hyperplasia of the lymphoid formations of the posterior pharyngeal wall, as well as the lingual tonsil, extending into the palatine tonsil niche. In some cases, even with a normal postoperative picture of the tonsil niches, some patients complain of paresthesia, pain in the throat, difficulty swallowing for many years after the operation, not motivated by any anatomical changes. Special studies have established that these sensations are caused by microneuromas that occur with inevitable ruptures of the nerve endings of such nerves as the glossopharyngeal, palatine and lingual. Treatment of patients suffering from the above-mentioned paresthesias, which often provoke cancerophobia, should be long-term, comprehensive, using various physiotherapeutic methods, local balsamic applications, and supervision by a psychotherapist.

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