Dietary Advice

The majority of hospitals recommended returning to a normal diet in the post-operative period (88 per cent for adults, 83 per cent for children); however, 26 per cent also suggested preferentially eating hard foods (such as dry toast) and 8 per cent suggested soft foods. The reasoning behind this advice was explained in some of the leaflets: hard, dry foods were said to ‘keep the healing area where the tonsils were clean’ by ‘removing dead tissue’. Similarly, cold and soft foods were said to ‘reduce pain, increase dietary intake and reduce the risk of post-operative bleeding’.⁷ This advice was unreferenced within the information sheets.

This differing of opinion on preferential or restricted diets is reflected within the published literature. Setabutr et al. (2011) questioned 793 US otolaryngologists on the post-operative dietary advice they routinely gave; 59 per cent of respondents recommended a soft diet and 35 per cent an unrestricted diet.^{Reference Setabutr, Adil, Adil and Carr3} It is known that children will preferentially choose a soft or liquid diet in the post-tonsillectomy period when given the choice; however, further than this, most post-tonsillectomy dietary advice seems to be based on historical anecdotes.^{Reference Thomas, Moore and Reilly8,Reference Idvall, Holm and Runeson9} A systematic review of 17 studies by Millington et al. (2016) concluded that there was no statistical difference in post-operative pain or haemorrhage rates between restricted and unrestricted diets in adult populations.^{Reference Millington, Gaunt and Phillips4} Similar conclusions were drawn in a systematic review of eight studies by Bannister and Thompson (2017) in paediatric groups.^{Reference Bannister and Thompson10} However, it is important to note, as recognised by Millington et al. (2016), that most of the included studies in these reviews were generally of poor quality, with small sample sizes and inappropriately powered and non-randomised studies, meaning drawing conclusions was difficult.

Although restricted diets do not appear to confer any benefit, there is some evidence that additives to diets can reduce post-operative morbidity. A small-scale study by Sylvester et al. (2011) demonstrated statistically significant improved pain scores in children in the first four hours post-operatively when ice-lollies were provided; however, this benefit did not appear to last beyond the four-hour mark.^{Reference Sylvester, Rafferty, Bew and Knight11}

Dietary supplements

The addition of honey to the post-operative diet has been suggested as beneficial in reducing pain and analgesia use. A 2014 meta-analysis concluded that its use following tonsillectomy may have such positive effects, but it was on the basis of four small-scale heterogeneous studies only.^{Reference Hwang, Song, Jeong, Lee and Kang12} However, a more recent Cochrane review on the effects of honey on wound healing has concluded that the ‘evidence for differences in the effects of honey and its comparators is of low or very low quality and does not form a robust basis for decision making’.^{Reference Jull, Cullum, Dumville, Westby, Deshpande and Walker13}

The use of chewing gum post-operatively was widely recommended to both adults (52 per cent of hospitals) and children (40 per cent of hospitals) in the leaflets analysed. However, this recommendation appears to be largely based on historical anecdotal observations. In 1982, Maurice Schiff commented on the beneficial use of bubble gum in reducing post-operative pain: the ‘increased deglutition effort’ being said to ‘permit the milking out of lymphatics even better than chewing gum’.^{Reference Shiff14} The only published study with a positive finding was that of an observational audit in 1997 that demonstrated a moderate reduction in the number of general practitioner consultations by patients following tonsillectomy after the use of chewing gum was encouraged and added to post-operative instructions.^{Reference Jones, Temple, Morar, Roland and Rogers15} However, the observational nature and lack of any objective patient morbidity or adherence scores make it impossible to draw any meaningful conclusions from this study in isolation. The only prospective randomised, controlled trial on the use of chewing gum following tonsillectomy demonstrated that its use significantly delayed the resumption of a normal diet and significantly increased the average amount of pain experienced by patients.^{Reference Hanif and Frosh16} On the basis of this study alone, the use of chewing gum should be discouraged in the immediate post-operative period.

General post-operative management

Following tonsillectomy, 79 per cent of hospitals suggested 2 weeks off work for adults, and 84 per cent suggested 2 weeks off school for children (Figure 2). Many of the leaflets suggested that being around others at work or at school in the post-operative period resulted in an increased risk of infection. The Getting It Right First Time analysis found that 1.1 per cent of adults and children were re-admitted to hospital post-tonsillectomy with ‘infection’^{Reference Marshall2}; however, the underlying risk factors for developing such a post-operative infection have not been well categorised in the literature. More research in this domain could be valuable, as 14 days off work or school can represent a significant drawback to undergoing tonsillectomy for patients who find it difficult to take the required time off work or off school during term-time.

Post-operative analgesia

Most hospitals recommended the use of ‘regular painkillers’ to both adults (87 per cent) and children (81 per cent). Although there is no strong evidence for any one particular regimen of medication over another in the literature, many studies report better post-operative pain control with a multi-modal analgesic approach in both adults and children.^{Reference Aldamluji, Burgess, Pogatzki-Zahn, Raeder and Beloeil17–Reference Tolska19} As required dosing of analgesia post-operatively has been associated with higher average pain scores, a regular analgesia regimen based on local policy is recommended by some.^{Reference Dorkham, Chalkiadis, von Ungern Sternberg and Davidson18} However, these conclusions are drawn from relatively small scale studies, which suffer from a lack of randomisation. A 2015 Cochrane review on as required versus fixed schedule analgesia administration post-tonsillectomy found limited evidence to draw any conclusions about the comparative efficacy of the two regimens on the basis of three randomised, controlled trials.^{Reference Erskine, Wiffen and Conlon20}

Avoiding the use of aspirin was mentioned in 51 per cent of advice leaflets for children but not in any for adults. The British National Formulary for Children states that the use of aspirin in the UK is not licensed for children under the age of 16 years with certain exceptions because of the risk of Reye's syndrome occurring in the paediatric population.²¹ Meta-analysis has demonstrated a statistically significant increased risk of developing post-tonsillectomy haemorrhage with regular post-operative use of aspirin in both paediatric and adult patients.^{Reference Krishna, Hughes and Lin22} Counselling patients who regularly take aspirin regarding this increased risk should therefore be undertaken routinely and included in post-operative information leaflets.

Mouthwash and throat sprays

Seven per cent of advice sheets for adults recommended the regular use of mouthwashes and throat sprays post-operatively. A 2013 Cochrane review of seven trials on the use of oral rinses, mouthwashes and sprays concluded that poor reporting quality, high risk of bias and inadequate data did not permit comprehensive and reliable conclusions to be made regarding their efficacy in aiding post-operative recovery.^{Reference Fedorowicz, van Zuuren, Nasser, Carter and Al Langawi23} Limited results suggested that lidocaine spray appeared to be more effective than saline spray at reducing the severity of pain until the third post-operative day, and although a small number of participants experienced a burning or stinging sensation with benzydamine spray, it was generally not sufficient enough to cause discontinuation of its usage.^{Reference Fedorowicz, van Zuuren, Nasser, Carter and Al Langawi23} Further prospective, double-blind, large-scale, randomised, controlled trials on the use of such adjuncts are required in order to draw more reliable conclusions.

General post-operative risks

The most frequently mentioned post-operative risks in the leaflets analysed were increasing post-operative pain (18 per cent), bleeding (71 per cent), infection (74 per cent), otalgia (68 per cent) and need for a repeat procedure (65 per cent; Figure 3). It is well known that many post-operative patients will attend their general practitioner surgery with fears that increasing throat pain and otalgia over the first post-operative week indicates evolving or worrisome pathology.^{Reference Cooper24} Only 21 per cent of adult leaflets and 15 per cent of paediatric leaflets made mention of increasing pain being normal during the first week, while many more mentioned the risk of otalgia (74 per cent for adults, 63 per cent for children). Many studies have documented increased pain scores between 3 and 7 days post-operatively,^{Reference Tan, Carachi and Anderson25–Reference Stewart, Ragg, Sheppard and Chalkiadis27} and otalgia is also a well-documented risk and seen in up to 69 per cent of children post-tonsillectomy.^{Reference Castellano, Gámiz, Bracero, Santiago, Soldado and Solanellas28,Reference Lee and Sharp29} Increasing awareness of these common side effects of tonsillectomy could help assuage patient and parent worries in the post-operative period and help reduce the incidence of post-operative general practitioner and hospital attendances.

A recent meta-analysis of nine studies of taste dysfunction following tonsillectomy found that it is a relatively common side effect, estimated to affect 10–20 per cent of patients; however, it is rarely enduring.^{Reference Kim, Lee, Yun and Bae30} Altered tongue sensation is also frequently seen and can be longer lasting, reported by up to 82 per cent of patients at 3 months post-operatively in one study.^{Reference Smithard, Cullen, Thirlwall and Aldren31} These risks were mentioned in 60 per cent of leaflets for adults but only in 2 per cent of the leaflets for children; while these are important risks to mention pre-operatively, post-operative written advice reassuring the patient that these symptoms will pass with time should also be considered.

Dysphonia post-tonsillectomy is also relatively common and can be significant; however, it generally resolves over time. In a retrospective study of 1258 patients by Brkic et al. (2020),^{Reference Brkic, Liu, Campion, Leonhard, Altumbabic and Korlatovic32} patients undergoing adenotonsillectomy, tonsillectomy or adenoidectomy were found to have significant post-operative voice disturbance up to the seventh day, but rates decreased significantly after the first month. This was only mentioned in 21 per cent of leaflets for adults and 2 per cent of leaflets for children. Reassurance that these symptoms will improve could help prevent social and work-related frustrations around these symptoms and should therefore be included in post-operative advice sheets.

Bleeding

Post-operative bleeding represents the most concerning common complication of tonsillectomy. Much research has gone into stratifying the risk of bleeding with different surgical techniques, yet advice around the significance of any bleeding given to patients in the post-operative period appears to vary. The majority of hospitals recommended that any post-operative bleeding should necessitate medical attention (71 per cent adults and children). However, a smaller percentage of hospitals stated that ‘bleeding up to a spoonful is normal’ (12 per cent) or that only ‘continued bleeding’ should prompt medical attention (17 per cent). In a large, multicentre prospective study of 4594 patients, Sarny et al. (2011) calculated that 12 per cent of patients experienced a ‘minor bleed’ (requiring conservative or medical management only) post-tonsillectomy, with 5 per cent experiencing a major bleed (requiring surgical intervention, a blood transfusion or resulting in death).^{Reference Sarny, Ossimitz, Habermann and Stammberger33} These ‘minor’ bleeds can often be a precursor to a more major bleed, a so called ‘herald’ bleed. Indeed, in the same study, 10 per cent of patients who experienced a minor bleed later went on to have a major bleeding episode (an increase in the risk of a major bleed by a factor of 2 above the overall risk). Forty-one per cent of these second major episodes of bleeding occurred the day after the minor bleed.^{Reference Sarny, Ossimitz, Habermann and Stammberger33} As such, it seems prudent to recommend to a patient that any episode of bleeding should necessitate medical attention given the risk of subsequent larger bleeds and the potential need for medical therapy to prevent this.

Post-operative risks not mentioned

In light of the landmark Montgomery versus Lanarkshire case of March 2015,³⁴ it has become a legal requirement to include details of ‘material risks’ in the surgical consenting process in order to attain fully informed consent from patients. Material risks should be tailored to the individual patient and as such it may be important to remember and discuss rare and uncommon, but associated, risks that were not frequently mentioned in advice sheets. Such risks include temporomandibular joint dislocation and dysfunction secondary to the surgical technique,^{Reference Khami, Tan, Glicksman and Husein35} velopharygeal insufficiency^{Reference Maini, Osborne, Fadl, Spyridakou, Ogunyemi and Hill36} and rotatory subluxation of the atlantoaxial joint, also known as Grisel's syndrome, which can lead to neck deformity and serious neurological complications.^{Reference Al-driweesh, Altheyab, Alenezi, Alanazy and Aldrees37}