A cheeseburger, please: Tonsillectomy technique speeds return to normal diet, reduces pain

Less than four hours after her tonsillectomy, Madison Boehm had a request.

A cheeseburger, please.

The 3-year-old’s mother, Lisa, was amazed. After all, it took her other child, Nick, 7, a day or two to want solid food because of soreness that lingered after his tonsillectomy.

Like the vast majority of the nearly 300,000 children who have tonsillectomies in the United States every year, Nick had both of his tonsils completely removed via a technique known as an extracapsular tonsillectomy (ET).

Madison, however, had an intracapsular tonsillectomy (IT) – a technique championed at CHOC in which 95 percent of the tonsils are removed, preserving the “capsule,” and thus protecting the muscle underneath.

The result: less risk of bleeding after surgery, vastly decreased pain after surgery, and a rapid return to normal diet.

Madison underwent an intracapsular tonsillectomy at age 3 and quickly resumed her regular diet.

Dr. Kevin Huoh, a pediatric otolaryngologist, brought the technique to CHOC when he started there in September 2013 after learning it during his fellowship at Stanford University Medical Center. So, too, did fellow pediatric otolaryngologist Dr. Nguyen Pham, who joined CHOC around the time Huoh did.

Since then, more than 1,000 children have undergone intracapsular tonsillectomies at CHOC, with the rate of tonsillar regrowth – the most cited concern for not performing ITs – remaining extremely low, Dr. Huoh says. In addition, the rate of post-tonsillectomy bleeding, the most feared post-operative complication, is pretty much zero, much lower than with traditional extracapsular tonsillectomy.

Now, in a recently published research paper in Laryngoscope, the foremost publication for otolaryngologists (also known as ENTs – for ear, nose, and throat – practitioners), Huoh predicts there will be a “paradigm shift” over the next five to seven years.

He believes ITs will become the standard surgical technique for removing tonsils in children either for snoring and sleep disordered breathing or for chronic/recurrent tonsillitis.

And CHOC, Dr. Huoh notes, was among the first pediatric hospitals in the country to adopt ITs as the standard technique.

“The reasons (most other ENTs) are not doing ITs are probably psychosocial,” Dr. Huoh says. “They’re not exposed to it. They’ve been doing tonsillectomies the same way for forever and they have a lack of exposure to this new procedure. Simply, they are set in their old ways.

“But this procedure is very, very favorable. It’s very easily learned, and it really works.”

Dr. Kevin Huoh brought the intracapsular tonsillectomy (IT) technique to CHOC in September 2013 and predicts IT will be the standard tonsillectomy technique in the U.S. in five to seven years.

Intracapsular tonsillectomies have steadily gained popularity in the United States and across the world since the procedure first was described in 2002.

But as Dr. Huoh notes in his paper, “Current Status and Future Trends: Pediatric Intracapsular Tonsillectomy in the United States,” co-written by Dr. Yarah Haidar and Dr. Brandyn Dunn, both of the UCI School of Medicine, only 20 percent of the 540 pediatric otolaryngologists who responded to a survey the three doctors sent perform intracapsular tonsillectomies.

That is certain to change in the coming years as the benefits of the technique become more widely recognized, Dr. Huoh says.

Dr. Huoh and other CHOC doctors mainly perform intracapsular tonsillectomies on children whose large tonsils cause obstructive sleep apnea.

Such was the case with Madison.

When she was 2, her parents noticed she snored a lot and woke up tired. She was sluggish and lethargic and took one or two three-hour naps per day.

“We went online and did some research, and sleep apnea popped up,” Lisa recalls.

Madison was diagnosed with having large tonsils and adenoids as well as obstructive sleep apnea, which made her a candidate for an intracapsular tonsillectomy.

Lisa says she and her husband, Cameron, researched the best hospital to take Madison to and they quickly settled on CHOC, where Dr. Pham diagnosed Madison as having large tonsils and adenoids as well as obstructive sleep apnea.

Madison had the surgery on Aug. 3, 2019.

“The doctors at CHOC were all dialed in, and I was holding her an hour after she went under,” Lisa recalls. “The recovery part is what was amazing. By the time we were home, she was totally out of the anesthesia fog and asking to eat.”

So, Lisa got Madison a cheeseburger.

She never complained about her throat – just soreness on the top of her hand from the IV.

“She completely recovered in a couple of days,” Lisa says of Madison, who enjoys dancing and gymnastics. “From that first night after surgery, she has been sleeping normally, and I feel that her personality has come out a little more.”

Lisa says she has referred her friends who have kids with tonsillar problems to CHOC pediatric otolaryngologists.

“The doctors treat their patients like they are their own kids,” she says. “I had total confidence in them. They carefully explained everything that was needed, and I could always be in touch with them. They are second to none.”

Learn more about CHOC otolaryngology.

Goodbye Popsicles and pain killers: How painless tonsillectomies are changing CHOC patients’ recoveries

After hearing her mother’s stories of the aftermath of her teenage tonsillectomy, Jenna Opp was a little worried before undergoing the procedure herself.

jenna-underwent-painless-tonsillectomy

But thanks to a different technique offered by CHOC otolaryngologists, Jenna drank a smoothie right after the procedure, and by that night, she enjoyed eggs and French toast for dinner. Only two days later she was back in school and ready for a hamburger.

“I was expecting a lot more pain and not being able to talk and all those typical things,” the 18-year-old says. “But I was totally fine. I could eat and drink. I talked to my mom while I was still in the recovery room.”

jenna-painless-tonsillectomy-preop
Jenna, before her painless tonsillectomy

Jenna underwent a procedure called an intracapsular tonsillectomy, wherein CHOC otolaryngologist Dr. Nguyen Pham deftly shaved away at her tonsil, leaving a small portion behind.

In contrast, a traditional total tonsillectomy removes the entire organ, increasing bleeding risk and exposing muscle behind the tonsil, which increases pain.

In addition to decreasing the risk of post-operative bleeds, which can be fatal, the intracapsular tonsillectomy technique has shown to dramatically lower hospital readmission rates due to pain and dehydration.

Further, patients like Jenna do not require opioid pain medication and are returning sooner to school and a regular diet, Dr. Pham says.

“They offered to do it the old way or the new way,” Jenna says. “They told me the new procedure is way less painful and only takes a couple days for recovery. I was like,  ‘I’m sold on that’ and it was awesome.”

Frequently asked questions about intracapsular or painless tonsillectomies

Do the tonsils regrow?

The regrowth rate of intracapsular tonsillectomy at CHOC is 0.5 to 1%.

Does an intracapsular tonsillectomy take longer than a traditional tonsillectomy?

No. The procedure takes the same amount of time – 30 to 45 minutes.

Has this procedure been practiced in other places?

Intracapsular tonsillectomy is growing in popularity in the United States. Elsewhere in the world, such as in Sweden and France this procedure is already the preferred method of tonsil removal.

Will a patient need pain medication after this procedure?

Usually children will require only over-the-counter pain medication for a few days after surgery. Some children do not require any pain medication.

How old does a child have to be for intracapsular tonsillectomy?

There are no age restrictions for this procedure.

Learn more about tonsillectomies at CHOC.

Kids and Tonsils

Tonsils_300WHEN SHOULD TONSILS BE REMOVED?
Tonsils are removed much less frequently than in the past, but removal may be necessary under specific circumstances. “There are two predominant reasons for removing tonsils and/or adenoids in children,” says Dr. Ahuja, CHOC Specialists Division Chief of Otolaryngology. “The primary reason is obstruction, or difficulty breathing, sleep-disordered breathing or sleep apnea. The second reason is recurring infection. Tonsils may need to be removed if a child has seven tonsillar infections in one year, or five infections each year for two years, or three infections each year for three or more years, with the infections being accompanied by one or more of the following features: a fever of 1010F or above, a strep throat infection confirmed on a swab from the throat, white coating on the tonsils, large lymph nodes in the or mouth sores.” Surgical removal of the tonsils is called a tonsillectomy. Surgery should be considered only when necessary, but in appropriate situations, it can make a substantial difference in the quality of life.

SIGNS OF TROUBLE
There are many signs that the tonsils are causing a child enough trouble to warrant removing them, says Dr. Ahuja. A child who has trouble breathing, breathes often through the mouth, snores heavily, sleeps poorly, wakes up tired and fussy, exhibits behavior problems like hyperactivity or aggressive behavior, or is significantly underweight because he is having a hard time eating and breathing at the same time may be a candidate for a tonsillectomy, often with adenoidectomy, says Dr. Ahuja.

WHAT ARE TONSILS AND ADENOIDS ANYWAY?
The tonsils are part of the body’s immune system. Specifically, they are two oval-shaped masses of tissue in the back of the throat that trap germs that could enter the body’s airway and cause an infection. Tonsils also produce antibodies to fight infection. Sometimes, they get infected and swollen, and lead to a condition common in kids called tonsillitis. The adenoids are small pads of lymphoid tissue like tonsils, located in the upper portion of the throat, behind the nose. They serve a similar purpose as the tonsils. “The majority of the time if we are removing the tonsils for obstruction or blockage, we remove the tonsils and adenoids,” says Dr. Ahuja.

FAST FACTS

  • Age range of children most commonly affected by tonsillitis: 3 -7
  • Number of tonsillectomy procedures performed annually in children younger than 15 in the U.S.: 530,000+
  • Percent of healthy children who have tonsils and adenoids removed due to obstruction who will show a marked improvement. The success rate falls for obese children, or children with certain birth disorders: 80

    View the full feature on Kids and Tonsils

    Dr. Gurpreet Ahuja
    Dr. Gurpreet Ahuja
    CHOC Otolaryngology
    (Ear, Nose and Throat)

    PHYSICIAN FOCUS: DR. GURPREET AHUJA

    Dr. Ahuja is the CHOC Specialists’ Division Chief of Otolaryngology, and past president of the medical staff at CHOC. He is a Clinical Professor of Otolaryngology at the University of California, Irvine, and Director of Pediatric Otolaryngology training for UCI’s residency program in Otolaryngology. He completed his residency in Otolaryngology/Head and Neck Surgery at the Manhattan Eye, Ear, and Throat Hospital in New York, followed by a fellowship in Pediatric Otolaryngology at the Children’s National Medical Center in Washington, D.C. Dr. Ahuja specializes in pediatric airway reconstruction, pediatric sinus surgery, childhood hearing loss and congenital head and neck disorders. Dr. Ahuja is actively involved in the Orange County community, serving on the Board of Directors of the OC Human Relations Council.

    Dr. Ahuja’s philosophy of care: “My philosophy is to treat every child as I would have my own child treated. It’s
    very important for me to engage the parents in the care of their child and to have them on board with what I am
    recommending so we have a consistent approach to treatment. I always make it a point to follow the standard of care with up-to-date information about the child’s medical condition. I also consider it important to educate the parents about the child’s condition.”

    EDUCATION:
    All India Institute of Medical Sciences, New Delhi, India

    BOARD CERTIFICATIONS:
    Otolaryngology

    More about Dr. Ahuja | CHOC Pediatric Specialties Otolaryngology

    This article was featured in the Orange County Register on April 14, 2014, and was written by Amy Bentley.

Tips for Tonsillectomy Recovery

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More than 530,000 tonsillectomies are performed each year in children ages 15 and younger, but the common procedure does require some recovery time.

Children will typically have a sore throat for a week to 10 days following surgery, and they usually feel well enough to resume their normal activities after two weeks, says Dr. Gurpreet Ahuja, an ear, neck and throat specialist and the CHOC Children’s Specialists Division Chief of Otolaryngology.

Children who are otherwise healthy and not obese or underweight typically leave the hospital the same day as their surgery, and most children can return to school a week later, he says.

Dr. Ahuja noted there is a small risk for bleeding after surgery, so children recovering from a tonsillectomy should stay close to home as a precaution. If excessive bleeding occurs, parents should contact their surgeon or physician immediately or take the child to the nearest emergency department.

Here are some tips for parents of children recovering from surgery to remove the tonsils and adenoids:

  • Ensure your child is drinking lots of water and fluids. Proper hydration is important to help prevent fever, bleeding or infections.
  •  To soothe the throat, have the child drink lots of chilled fluids like water and Gatorade, and eat soft, cold foods after surgery such as Popsicles, smoothies and ice cream.
  •  Have the child eat soft foods that are easy to swallow, such as pasta, rice, noodles, bananas and yogurt.
  • For pain management, patients ages 10 and younger can take over-the-counter pain medications such as ibuprofen and acetaminophen. Children older than 10 tend to have a little more pain and discomfort and may need a prescription pain medication. Contact your physician to ask about prescriptions for pain if needed, and also if you have any questions or concerns about your child’s recovery.

Learn more about otolaryngology at CHOC Children’s.