Tonsillectomy — A Complete Patient Guide and Consent

A tonsillectomy is the surgical removal of the two palatine tonsils — the soft oval lumps of lymphoid tissue on either side of the back of the throat. The operation is performed under general anaesthetic, takes a surgeon around ten to fifteen minutes for a routine case, and is usually a day-case procedure: most patients go home the same day. The technical part of the operation is straightforward. The challenging part is the two weeks of recovery that follow, which is why this page is so long.

If your operation is being performed for obstructive sleep apnoea or snoring, please also read the overview at Snoring & Obstructive Sleep Apnoea. If you are reading on behalf of a child or for recurrent tonsillitis, the broader background is at Tonsils & Adenoids and Paediatric ENT.

What Are Tonsils?

The tonsils most people mean when they say "my tonsils" are the palatine tonsils — the two lymphoid structures you can see on either side of the back of the throat when you open wide. They sit between two slings of muscle: the palatoglossus in front (the anterior tonsillar pillar) and the palatopharyngeus behind (the posterior tonsillar pillar). Above them, these two muscles meet at the uvula — the small dangling piece in the centre of the soft palate that many people call the "punching bag" at the back of the throat. Understanding this muscular arrangement matters later when I explain why a tonsillectomy can be so painful, and why I am cautious about the way the surrounding muscles are handled during surgery.

The palatine tonsils are not the only tonsils we have. There is a whole ring of tonsil-like tissue around the entrance of the mouth and nose, named Waldeyer's ring after the German anatomist who described it. It includes:

• The adenoids (pharyngeal tonsil) at the back of the nose — when enlarged in children, these block nasal breathing and cause glue ear.
• The lingual tonsils at the back of the tongue — when enlarged, they cause a lump-in-the-throat sensation, snoring and back-of-tongue obstruction in adults.
• The tubal tonsils near the opening of the Eustachian tube — occasionally swell and block the ears.
• The lateral pharyngeal bands — small strips of lymphoid tissue running down the side of the throat.

For most patients undergoing a tonsillectomy, only the palatine tonsils are removed. Children with nasal blockage often have an adenoidectomy at the same time (a separate operation through the mouth, without external scars).

Why Do We Have Tonsils?

Nobody knows for certain. The current best theory is that tonsils act as watchtowers — strategically placed at the entrance to the digestive and respiratory tracts, sampling the bacteria, viruses and food particles that come past, and helping the immune system learn what to prepare for. They are largest in early childhood and gradually shrink during adolescence; by adulthood most tonsils are almost invisible. Adults with persistently large tonsils are unusual and often have no idea this is rare.

The most common worry I am asked about in clinic is whether removing the tonsils will weaken the immune system. The honest answer is no — there is no good evidence that it does. Tonsils are one part of a much larger lymphoid system that includes the spleen, thymus, gut lymphoid tissue, and the rest of Waldeyer's ring. If the palatine tonsils and adenoids are removed, the rest carries on doing the work. In patients who suffer recurrent tonsillitis, removing the tonsils often appears to improve immune function, because the immune system is no longer working overtime fighting recurrent infections of a single gland.

Two recent systematic reviews (Altieri et al. 2020; Bitar et al. 2015) concluded that there is insufficient evidence to suggest that removing the palatine tonsils or adenoids harms immunity. The historical scares — polio paralysis after tonsillectomy in the 1970s, Hodgkin's lymphoma in the 1990s, asthma and respiratory disease in a much-publicised 2018 JAMA paper — have each been examined in better-designed follow-up studies and have not held up. The 2018 asthma paper, for example, mistook the direction of causation: children with asthma have more upper respiratory symptoms and so are more likely to need tonsillectomy, not the other way around.

A Short Video Guide

Before reading further, the ten-minute video below covers the practical core of what you need to know — what to expect, how to manage pain, what to eat, and the warning signs. I refer back to it throughout this page.

Who Needs a Tonsillectomy?

Deciding whether to remove tonsils is rarely black and white. The two commonest reasons are recurrent infection and obstruction; less commonly, tonsils are removed for abscess (quinsy), for diagnosis of suspected cancer, or to gain surgical access to deeper structures in the throat.

Recurrent tonsillitis — the SIGN guidelines (and why they are guidelines, not rules)

UK practice usually follows the Scottish Intercollegiate Guidelines Network (SIGN) criteria for offering a tonsillectomy for recurrent infection. The infections must each be clinically significant — meaning they cause real disruption to school, work or daily life — and meet one of the following frequencies:

• Seven or more episodes in one year, or
• Five episodes per year for two consecutive years, or
• Three episodes per year for three consecutive years.

These thresholds exist because many cases of recurrent tonsillitis settle naturally over a few years. The intent is to avoid unnecessary surgery while still operating on patients who genuinely need it. The problem is that some commissioners and clinics treat the SIGN criteria as rules. I have seen patients with six severe infections per year for five years denied a tonsillectomy because they "do not meet the threshold". This is bad medicine. The guidelines are designed to support individual judgment, not replace it.

Between 1991 and 2011 the UK tonsillectomy rate dropped by 44%. In the same period:

• Hospital admissions for severe tonsillitis rose by 310%.
• Quinsy admissions rose by 31%.
• Life-threatening deep neck abscess admissions rose by 39%.
• Tonsillectomy patients spent 14% more time in hospital beds despite fewer operations.

Rigid application of the SIGN criteria has not saved money or improved outcomes — it has just shifted the problem. If you fall narrowly outside the threshold but tonsillitis is plainly dominating your life, ask for a specialist opinion.

Chronic tonsillitis (one long infection rather than many short ones)

Some patients have chronic low-grade tonsillitis — they feel unwell, have a constant sore throat, and never have a clear week. They may not have seven discrete episodes in a year, yet their quality of life is severely affected. In these cases, surgery is sometimes performed despite active infection, accepting the higher bleeding risk because the alternative is no improvement. This is a shared decision that should be made with the surgeon after a careful discussion of the trade-offs.

Obstructive tonsils — snoring and sleep apnoea

Doctors generally have a lower threshold for removing tonsils when they are causing obstruction of the airway, particularly in children. A child with large tonsils, loud snoring, witnessed apnoeas, restless sleep, daytime irritability, behavioural problems or school under-performance often benefits dramatically from tonsillectomy with adenoidectomy. Sleep studies are not always required in children, but are useful in borderline cases and essential for adults.

Adult OSA is more complex. Tonsillectomy may be one part of a wider treatment plan that includes CPAP, weight management, soft-palate or tongue-base surgery, and sometimes hypoglossal nerve stimulator implants. Drug-induced sleep endoscopy (DISE) is often used to confirm that the tonsils are an important obstruction site before recommending surgery.

Both infected and obstructive

Some patients have both: large tonsils that obstruct the airway and repeatedly become infected. The usual approach is to settle the infection first with antibiotics and steroids, then operate. Where the obstruction is critical and won't settle, occasionally we operate despite the active infection — accepting the higher bleeding risk because waiting longer is more dangerous still.

Less common but important indications

Quinsy (peritonsillar abscess). A collection of pus between the tonsil and the throat wall. Patients have severe one-sided throat pain, trismus (inability to open the mouth fully), a "hot potato" voice and a deviated uvula. Most quinsies are drained under local anaesthetic with immediate relief; tonsillectomy is generally not required after a single quinsy unless recurrent.

Deep neck abscesses. A tonsil infection that has spread through the fascial planes of the neck — potentially life-threatening because it can extend into the chest (mediastinitis), affect the carotid sheath or cause stroke. These patients often need urgent surgical drainage including tonsillectomy.

Rheumatic fever and post-streptococcal glomerulonephritis. Historical complications of untreated streptococcal tonsillitis, now rare in the UK because of widely available antibiotics. They remain important reminders of why severe tonsillitis is not trivial.

Febrile convulsions. A child whose febrile seizures are repeatedly triggered by tonsillitis may need an earlier tonsillectomy than SIGN thresholds suggest. Strict adherence to numerical criteria would leave the child at avoidable risk.

Sickle cell disease. Tonsillitis can trigger painful sickle crises. Sickle cell patients are often offered a tonsillectomy after only two clinically significant infections rather than waiting for the standard threshold.

Tonsil cancer. A unilaterally enlarged tonsil, an ulcerated tonsil, or a tonsil associated with persistent unexplained neck lymph node enlargement should be investigated urgently. Tonsillectomy is often part of the diagnostic process: the tissue is sent to a pathologist to confirm the diagnosis and guide further treatment. Tonsil cancer has three main causes — smoking and alcohol (older patients, poorer prognosis), HPV (younger adults, better prognosis), and lymphoma (any age, treated separately).

Tonsil stones with socially disabling halitosis. Tonsil stones are not trapped food — they are bacterial debris that hardens in tonsillar crypts. Most cases do not require surgery, but a small group of patients with deeply fissured tonsils, persistent stones and significant bad breath find their lives transformed by tonsillectomy. Each case is judged individually.

Surgical access. Some operations — soft-palate procedures for snoring, Eagle syndrome, glossopharyngeal nerve surgery — require removal of the tonsils first to expose the deeper structures.

Alternatives to Surgery

Watchful waiting

Particularly in children approaching puberty, the tonsils may shrink naturally and the problem may resolve on its own. Keeping a written diary of infections — date, severity, time off school or work, treatment given — is the single best way to see whether the trend is improving or worsening. If the last six months are clearly better than the six before, another six months of watchful waiting is usually reasonable.

Antibiotics

Antibiotics treat the bacterial component of an acute episode but do not prevent future episodes. Long-term prophylactic antibiotics were tried decades ago and abandoned — they did not reduce recurrence and they bred antibiotic-resistant infections. A short course of penicillin V (or an alternative for those allergic) in the run-up to surgery is sometimes used to reduce bacterial load when operating on a patient with chronic tonsillitis.

Steroids

Short courses of oral steroid (dexamethasone or prednisolone) can be very useful for severe acute tonsillitis, reducing swelling and improving pain. A short course is also given routinely during a tonsillectomy itself, where the evidence is clear that it reduces pain, swelling and post-operative nausea. Long-term steroids are not used for tonsillitis. Topical steroid nasal sprays can reduce adenoid size by a small but sometimes clinically useful amount in children — they do not work for palatine tonsils.

Oral hygiene

Saltwater gargles, careful clearance of tonsil stones, and good oral hygiene make many patients feel better, though the evidence that they change disease outcomes is limited. They are cheap, harmless, and worth trying.

Minor procedures

Carbon dioxide laser tonsillotomy and radiofrequency tonsil reduction (Celon) can shrink tonsils without complete removal, often under local anaesthetic. They cause far less post-operative pain, but the tonsils may regrow and the procedure may need to be repeated.

Risks & Complications

Every operation carries risks. The most important ones for tonsillectomy fall into five groups: bleeding, infection, pain, injury to nearby structures, and anaesthetic risks. I cover each in turn.

1. Bleeding

This is the single most important complication to understand. Bleeding after tonsillectomy is divided by timing into three patterns, each with a different cause and a different implication.

Intraoperative bleeding

Bleeding during the operation itself. The amount depends on the surgical technique used and the surgeon's skill. Modern techniques — bipolar dissection, coblation, the harmonic scalpel — produce very little intraoperative bleeding. Traditional cold-steel dissection produces more but causes less surrounding tissue damage. Intraoperative bleeding is largely outside the patient's control and is dealt with at the time.

Primary haemorrhage (first 24 hours)

Bleeding that occurs within the first 24 hours of surgery — most often around 4 to 6 hours after the operation. The mechanism is usually that blood vessels which constricted during surgery have now relaxed and started to bleed. Primary haemorrhage is particularly dangerous because the patient is still drowsy from anaesthetic and may swallow blood without realising. The first sign is sometimes vomiting of dark, coffee-ground material — partially digested swallowed blood. Anyone who notices fresh red blood from the mouth in the first 24 hours should alert the nursing staff immediately. Vigilant ward nursing, particularly experienced paediatric nursing, prevents most primary haemorrhages from becoming serious.

For children, primary bleeding is particularly worrying because their total blood volume is small — even a modest bleed can be a significant percentage of their circulating blood. If one of my own children had a tonsillectomy, I would have them sleep on their stomach with their mouth pointing down onto the pillow immediately after the operation so that any bleeding would be obvious rather than swallowed.

Secondary haemorrhage (24 hours to 14 days)

The most concerning form of bleeding because it usually happens after discharge, when the patient is at home and may be far from a hospital with on-call ENT services. Up to 4% of patients experience a secondary haemorrhage that requires medical intervention. Most occur between days 4 and 10, when the soft white slough on the healing tonsil bed begins to lift away from the underlying tissue.

Approximately one in three patients notice some small amount of blood in saliva at some point during recovery. This is usually a few streaks, lasts a few minutes, and is not a significant bleed. What you are watching for is:

• Continuous fresh red blood from the back of the throat.
• Bleeding that lasts more than 10 minutes.
• Vomiting of blood, or coffee-ground material.
• Dizziness, weakness or feeling faint.

Any of these — go to the nearest A&E immediately. Do not drive yourself if there is any chance of feeling faint.

2. Infection

The healing tonsil beds are open wounds inside a mouth full of bacteria. Some bacterial colonisation is normal. Established infection presents around days 4 to 10 with worsening (rather than improving) pain, foul breath, fever, increasing difficulty swallowing, and sometimes asymmetry — one side becoming clearly worse than the other. Infection is the principal driver of secondary bleeding, because bacterial colonisation of the tonsil bed erodes into the underlying small blood vessels. Suspected infection should be assessed urgently. Some surgeons (including me) prescribe a short course of oral antibiotics if infection is suspected; intravenous antibiotics may be needed in hospital for established infection.

3. Pain and discomfort

Adult tonsillectomy is one of the most painful routine ENT operations. There are two reasons it hurts:

Exposed nerve endings. The tonsils themselves have very few pain fibres, but the muscle underneath does. Once the tonsils are removed, those nerves are exposed for the two weeks it takes the throat lining to heal over the tonsil bed.

Muscle spasm. The muscles at the back of the throat (palatoglossus and palatopharyngeus) are highly sensitive to inflammation. Like a cramp in the foot, they hurt much more if you keep them still — and the only reliable way to settle them is to keep them moving. Patients who try to "rest" the throat by avoiding swallowing find the pain getting steadily worse. Patients who keep using the muscles — eating, drinking, chewing gum — find the muscle spasm component of the pain settles. This is counter-intuitive but it is the single most useful piece of advice in this whole guide.

I cover the practical pain strategy in detail in the Pain Management section below.

4. Injury to nearby structures

The tongue

The mouth-gag used to open the mouth and hold the tongue out of the way (the Boyle Davis gag) compresses the nerves and blood vessels running along the sides of the tongue. The longer the operation, the more pressure builds up. The result is occasional taste disturbance (around 9–13% of patients in the first few weeks; less than 1% have a long-term problem), short-lived tongue numbness or weakness, or a bruise at the tip of the tongue from being pressed against the teeth. Most of these settle within two to three weeks. To minimise the risk, I aim to complete a routine tonsillectomy in around seven minutes and watch the colour of the tongue throughout — if it goes dusky blue, the gag is releasing the pressure on the blood vessels instantly.

Teeth

The Boyle Davis gag rests against the upper front teeth. Patients with crowns, caps, veneers, bridges or loose front teeth are at slightly higher risk of damage. Please tell your surgeon and anaesthetist before the day of the operation if you have any cosmetic dental work, dentures, or wobbly teeth. In children around age six, deciduous teeth that are already very loose are sometimes removed during the operation rather than risk them dislodging into the airway. Damage to dental work, if it occurs, may need private repair as NHS dental cover is limited.

Glossopharyngeal nerve

The glossopharyngeal nerve runs deep to the tonsil bed and can occasionally be irritated by "hot" cautery techniques used to control bleeding. Sustained injury is very rare in routine tonsillectomy and much more likely in tonsil cancer surgery where deeper dissection is required.

Voice

The vocal cords are well away from the operative field. Most voice change after tonsillectomy is short-lived and due to mild trauma from the breathing tube, not from the operation itself. Some professional opera singers have reported subtle changes to the upper vocal range — discuss this at consent if you sing professionally. Patients with very large tonsils sometimes notice their voice becomes clearer after surgery, because the tonsils were dampening particular frequencies.

Jaw joint (temporomandibular joint)

Keeping the mouth open for the duration of the operation can strain the jaw joint. Patients with pre-existing TMJ problems may have a temporary worsening of symptoms. Most settle with anti-inflammatories and rest within a week or two. Patients with significant TMJ disease should mention it at the consent appointment.

5. Other complications

Globus sensation (lump-in-the-throat)

The feeling of a lump or apple in the throat that lingers for two to three weeks (sometimes longer) is partly due to uvular swelling after the operation, and partly due to acid reflux worsened by the anti-inflammatories used for pain. For this reason, I usually prescribe a proton-pump inhibitor (omeprazole or lansoprazole) alongside the diclofenac or ibuprofen — for the duration of those drugs and for a few days afterwards. Esomeprazole 20mg twice daily is my usual choice as it appears to have fewer side effects than the alternatives.

Fatigue and tiredness

The body enters a catabolic state after major surgery, using energy and protein to repair tissue. Most patients notice some fatigue for two to three months. Professional athletes occasionally notice a small drop in peak performance for a couple of months. Higher-protein diet, good sleep, and gradually increasing exercise all help.

6. Anaesthetic risks

As with any operation under general anaesthetic, there are standard risks: nausea and vomiting after surgery, sore throat from the breathing tube, allergic reactions, and rare serious complications including malignant hyperthermia and anaphylaxis. The Royal College of Anaesthetists publishes excellent patient infographics on anaesthetic risk by age group, which the anaesthetist will discuss at your pre-operative appointment.

Pain Management — The Single Most Important Skill

If you read only one section of this page, read this one. Patients who manage their pain well find the operation tolerable; patients who fall behind on their painkillers find it miserable, need extra time off, are more likely to develop dehydration and infection, and are more likely to bleed.

Understand why it hurts before it hurts

The first painkiller is not paracetamol, ibuprofen or codeine — it is understanding. Patients who know in advance that pain peaks between days 3 and 7, that the muscle-spasm component of the pain responds to chewing rather than rest, and that the long-acting painkiller given at surgery wears off around day 2, are far better placed to deal with the experience. Pain perception is heavily influenced by fear and surprise. Removing the fear and surprise removes a real portion of the pain.

Take painkillers on a schedule, not on demand

Paracetamol, ibuprofen and codeine work synergistically and should be taken even when you do not feel in pain. The single commonest mistake patients make is skipping a dose because they feel comfortable; the pain then breaks through and becomes very difficult to bring back under control. Set alarms. Wake up at night. Stay ahead of the pain.

Stagger the doses across 24 hours

Rather than taking everything at 06:00, 12:00, 18:00 and 24:00, alternate them so something is always working:

• 06:00 — Paracetamol 1 g
• 09:00 — Ibuprofen 400 mg (or diclofenac 50 mg if prescribed)
• 12:00 — Paracetamol 1 g
• 15:00 — Ibuprofen 400 mg
• 18:00 — Paracetamol 1 g
• 21:00 — Ibuprofen 400 mg
• 24:00 — Paracetamol 1 g
• 03:00 — Ibuprofen 400 mg

That gives you something every three hours. Add codeine 30–60 mg every four to six hours if prescribed. Add a proton-pump inhibitor (esomeprazole 20 mg twice daily) for the duration of the ibuprofen/diclofenac and a few days afterwards to protect the stomach.

Use the throat spray (Difflam / benzydamine)

Difflam spray numbs the back of the throat for a few minutes. Use it before each meal — the first bite of food is the most painful, and the spray takes the edge off. It can be repeated every 90 minutes.

Add a steroid course (in adults)

For adult patients I usually prescribe dexamethasone 2 mg twice daily for four to seven days after surgery. Steroids do not have a direct pain-relieving action but they reduce swelling and seem to add to the effect of the other painkillers.

The "day 3 surprise"

The long-acting painkiller given during the operation can last up to two days. Many patients feel surprisingly comfortable on day 1 and day 2, and are bewildered when the pain seems to suddenly increase on day 3. This is not the operation going wrong — it is the long-acting painkiller wearing off. Stay on the schedule. The pain will begin to improve again from around day 8.

Why Eating Normally Matters More Than You Think

The advice has changed completely in the last twenty years and many patients are still surprised. Older guidance was soft food only — ice cream, jelly, smooth soup. The evidence shows the opposite. Patients eating a normal slightly abrasive diet have a secondary bleeding rate of around 1%. Patients restricted to soft food only have a secondary bleeding rate of around 4% — a four-fold increase.

Two mechanisms are at work:

• Mechanical cleaning. Slightly abrasive food (toast, pizza crust, chicken nuggets, raw carrot) gently scrapes the soft white slough off the healing tonsil beds. That slough is a substrate for bacteria; removing it daily reduces the risk of the deep infection that drives secondary bleeding.
• Muscle movement. Chewing keeps the throat muscles moving and reduces the painful spasm component of post-operative pain.

Practical advice:

• Eat real meals from day 1. Toast, pizza, burgers, chicken nuggets, sandwiches, raw vegetables. Avoid restricting yourself to smoothies and soup.
• You can still have soft food. Ice cream and jelly are fine — just not as the entirety of your diet.
• Crisps are less useful than they look. They go mushy in the mouth and the salt or vinegar is irritating.
• Drink generously. Dehydration is a real risk. Cold drinks usually feel more comfortable than warm. Avoid orange juice and acidic fizzy drinks for the first week.
• Chew gum throughout the day. It keeps the muscles moving and stimulates saliva.

A Day-by-Day Recovery Timeline

Day 0 — Day of operation

You will be in hospital for several hours. Most patients eat something on the ward before going home. Pain is usually well controlled thanks to the long-acting painkiller given during surgery. Some patients feel sick from the anaesthetic; anti-sickness medication is routinely given. A sensation of throat swelling is normal.

Days 1–2

The long-acting painkiller is still partly active. Many patients feel surprisingly well, which is misleading. Start your regular painkiller schedule immediately on returning home and stick to it.

Days 3–7 — the most difficult phase

Pain peaks. The tonsil beds develop their characteristic white coating. The globus sensation is often most prominent. Stay on the painkiller schedule, keep eating normal food, and contact the surgical team if pain becomes uncontrolled or you cannot swallow fluids. This is also the period when secondary bleeding is most likely.

Days 8–14

Pain begins to improve. The white slough lifts away in patches, exposing the healing pink tissue beneath. Small streaks of blood in saliva are common at this stage — alarming but usually self-limiting. Any fresh red bleeding remains a reason for urgent assessment.

Weeks 3–4

The throat is largely healed. Most patients are back to normal eating, work and most exercise. Some lingering globus sensation, mild taste change or throat tightness is normal and resolves over the next few weeks.

Beyond a month

Most people consider themselves fully recovered. The benefits — reduced infections, improved sleep, fewer days off — become evident over the following months as the absence of recurring problems becomes the new normal.

Before the Operation

Stop smoking and vaping — three months before

Nicotine in any form impairs blood supply to healing tissues, increases the risk of infection and bleeding, and delays recovery. The cell biology takes weeks to recover — a single cigarette is enough to affect the cells lining the nose and throat for up to three months. Stop at least three months before, and ideally do not restart afterwards. If you cannot stop for three months, even one month is better than nothing. Nicotine replacement gum or lozenges can be used short-term but should not be relied on long-term.

Medications

Anticoagulants and antiplatelets. Aspirin, clopidogrel, warfarin, apixaban, rivaroxaban, dabigatran. Some can be stopped safely for a few days; others require specialist input from your cardiologist or haematologist before stopping. Do not stop these drugs yourself without checking — the risk of stroke, pulmonary embolism, or stent thrombosis from stopping can be higher than the bleeding risk of the operation. The surgical team will give you specific instructions.

Potassium-sparing diuretics (amiloride, spironolactone, eplerenone, triamterene) are usually held for 24 hours before the operation to avoid problems with high potassium during anaesthesia. Restart the day after the operation unless told otherwise.

ACE inhibitors and angiotensin-II receptor antagonists (lisinopril, ramipril, enalapril, losartan, candesartan, valsartan, etc.) are usually held for 24 hours before the operation because they can cause sudden drops in blood pressure with anaesthetic drugs. Restart the day after the operation unless told otherwise.

Regular medications not listed above should be taken as normal on the morning of surgery, with a small sip of water two hours before the operation.

Herbal supplements

Tell the surgical team about every supplement you take. Some are surprisingly relevant to bleeding risk or to anaesthetic. As a rough guide, the following should be stopped a month before and a month after surgery: CBD oil, garlic supplements, ginkgo, ginseng, vitamin E, algae, arnica, bilberry, chamomile, chitosan, cinnamon, clove, cranberry, dan shen, feverfew, goji berry, grapefruit, green tea, meadowsweet, notoginseng, wintergreen. Kava, St John's wort, valerian, ashwagandha and passionflower can interact with anaesthetic drugs; echinacea may stress the liver; ephedra can cause dangerous heart rhythm changes during surgery.

Eating and drinking before the operation

Eat normally in the days before. A balanced diet helps healing afterwards — there is no benefit in extreme dieting. On the day, the standard rule is nothing to eat or drink for six hours before the operation. Some hospitals allow small sips of water until two hours before; others say nothing at all. The wording "clear fluids" is sometimes misinterpreted — squash, fizzy drinks, even alcohol have all turned up in operating theatres on the day of surgery and led to cancellations. The safest rule is no food after midnight the night before and just enough water to swallow your morning medications.

If you struggle with fasting, drink generously in the week before surgery so you arrive well-hydrated. Some patients find it useful to gradually shift their eating routine — skipping breakfast for a few weeks before — to acclimatise to fasting.

What Happens at the Hospital — A Walkthrough

Referral and pre-assessment

A GP refers you to a hospital surgeon, who assesses whether tonsillectomy is appropriate. Once you are listed, the admissions office sends an operation date — usually six to eight weeks in advance. You will then have a pre-assessment, either in clinic or by questionnaire, to check that you are fit for anaesthetic and surgery. Blood tests are sometimes required.

The day of surgery

Arrive early. Stress is the enemy of a smooth day. The nurses will check you in, re-check your details, take your blood pressure and pulse, and ask repeatedly about:

• When you last ate and drank
• Contact lenses (these must be removed)
• Loose teeth, crowns, caps, bridges
• Implants, pacemakers, metalwork
• Allergies
• Who will take you home

You will be asked the same questions multiple times by different people. This is intentional — it catches mistakes. The anaesthetist will come to see you, check your mouth opening and neck movement, and discuss the anaesthetic. The surgeon will check the consent form. You may have already signed consent at the outpatient appointment; if not, it is signed now. The consent form is not a contract — you can change your mind right up to going to sleep.

For children, a numbing cream is placed on the back of the hand under a clear plastic dressing — this takes about 45 minutes to work and allows a cannula to be placed painlessly.

The anaesthetic

You walk into the theatre or anaesthetic room. For adults, anaesthetic is usually given through a cannula in the back of the hand. For children, there are two options:

• Gas induction — a mask over the mouth and nose with anaesthetic gas. Effective but can be distressing for children and parents to watch in the first 20–30 seconds.
• Intravenous induction — the white anaesthetic drug (propofol) is injected through the cannula and the child is asleep in under 30 seconds. Usually smoother for everyone, but requires that the child accepts the cannula on the back of the hand.

One parent can come into the anaesthetic room to hold the child's hand. Decide in advance which parent it will be.

After the operation

Once you are awake in recovery, you (or one parent for a child) will be brought through. After a couple of hours in recovery and back on the ward, the team will look for four things before discharge:

• You have eaten something and not vomited
• You have passed urine
• You can walk without dizziness
• There is no bleeding from the mouth

Most patients go home four to six hours after the operation. Those with high-risk OSA may need to stay overnight for monitoring.

Aftercare in Detail

Travel

The medical advice is no air travel for at least two weeks. Travel insurance often imposes a six-week exclusion period after a tonsillectomy. Bleeding on an aeroplane is both a medical emergency and an expensive logistical problem; flights are sometimes diverted, with the patient liable for the costs if their insurance does not cover them. Check the small print before booking flights.

Driving long distance carries similar logic — stay within reach of an ENT-equipped hospital, and have a companion who can drive you to A&E if needed. Sea travel is particularly difficult to recover from a bleed on; most cruise ships have a doctor but not necessarily the equipment to manage post-tonsillectomy haemorrhage.

Eating, drinking and painkillers

Re-read the Why Eating Normally Matters and Pain Management sections. Eat real food. Stagger the painkillers. Wake up in the night if needed.

Reducing infection — gargles and tranexamic acid

If you are particularly worried about infection, a diluted hydrogen peroxide gargle can help. Dilute 6% hydrogen peroxide solution 1:6 with water and gargle 10–20 ml every hour. I also often prescribe an antiseptic gargle (Corsodyl / chlorhexidine) to reduce bacterial load. Some surgeons (including me, in selected cases) prescribe tranexamic acid in the post-operative period to reduce bleeding risk.

Exercise

Gentle walking from day 1. Avoid strenuous exercise — particularly weight-lifting, high-intensity cardio, and anything that raises blood pressure in the head and neck — for at least two weeks. The risk is rupturing a healing blood vessel and producing a secondary bleed.

Tongue exercises after healing

Once the pain has gone and you feel healed (typically after three weeks), repeatedly sticking out the tongue and moving it around helps prevent the scar tissue in the operative bed from tightening and reducing throat flexibility. Most scar tissue forms in the first three to six months. I have a YouTube video describing these exercises.

Multivitamins and zinc

Modest evidence suggests that a multivitamin containing zinc supports wound healing. The benefit is small but the risk is essentially zero. Take one for two to four weeks. Eat well, drink water, and rest.

When to Call the Hospital or Attend A&E

The following always warrant urgent assessment:

• Fresh red bleeding from the throat or mouth — more than a faint streak in saliva.
• Repeated vomiting of blood, or coffee-ground material — represents swallowed blood reaching the stomach.
• Worsening pain after day 5, rather than improving — usually a sign of infection.
• Inability to swallow saliva or take fluids — risk of dehydration; may need IV fluids.
• Fever above 38.5°C that does not settle with paracetamol.
• Signs of dehydration: very dark urine, infrequent urination, dizziness on standing, dry mouth, lethargy.
• Worsening swelling or asymmetric pain — could indicate a localised abscess.
• Faintness, dizziness, weakness — possible significant blood loss.

Call NHS 111, the hospital ENT on-call team, or attend A&E. Significant post-tonsillectomy problems are best managed early; nothing is gained by waiting.

Special Considerations for Children

• Children recover faster. Pain peaks earlier (often days 2–4) and resolves earlier. Most children eat normally by day 5–7.
• Pain medication is weight-based. Codeine is now avoided in children under 12 and in those operated on for sleep apnoea (because of unpredictable respiratory depression). Paracetamol and ibuprofen together cover most paediatric pain.
• Bleeding rates in children are usually lower than in adults but the consequences of significant bleeding are more serious because of smaller total blood volume.
• School attendance — most children are back at school within 10–14 days. A note is usually provided.
• For paediatric OSA, tonsillectomy with adenoidectomy is highly effective. Many children show improvements in sleep, behaviour, and school performance within weeks. See Paediatric ENT.
• Children grow after tonsillectomy. Several studies have shown improvements in height and weight in the first six months — partly from better sleep, partly from the body no longer fighting chronic infection.

Some Unexpected Benefits

Children grow

Studies of children after tonsillectomy show measurable gains in height and weight in the first six months — particularly in children whose tonsils were causing sleep-disordered breathing. Some parents need to buy new clothes within months of the operation.

Children perform better at school

The evidence is not large but is growing — and the anecdotes from parents are striking. Many describe a "different child" within weeks of the operation: better concentration, calmer behaviour, improved school performance. The underlying explanation is usually better sleep rather than any direct cognitive effect.

Better sleep — with a cautionary tale

Adults with tonsil-related sleep apnoea often discover what real sleep feels like for the first time in years. Most use this for the right things — they feel better, work better, and have more energy. A small number of high-achievers respond by reducing their sleep further, treating their newfound efficiency as more time to work. This is a mistake. Good-quality sleep is foundational. Use the gain to sleep well, not to sleep less.

Less likely to snore later in life

Large persistent tonsils through adolescence and adulthood predispose to snoring and obstructive sleep apnoea later. Addressing them earlier seems to reduce the cumulative stretching of throat tissues that contributes to OSA in middle age. Removing the tonsils is not a guarantee, but it appears to make later sleep-disordered breathing both less likely and easier to treat surgically if it does develop.

For the Curious — How the Operation Is Done

Many patients find it comforting to understand exactly what will happen — a little like calming a nervous flier by explaining the noises during take-off. This section is for those patients. If you would rather not know the operative detail, skip ahead to Different Tonsillectomy Techniques.

Step 1: Opening the mouth and securing the airway

You are anaesthetised. A breathing tube (endotracheal tube, or sometimes a laryngeal mask airway — LMA) is placed by the anaesthetist to keep you breathing safely. The surgeon then uses a Boyle Davis gag — a metal device that fits over the upper and lower teeth and gently ratchets the mouth open. A tongue depressor attached to the gag pushes the tongue and breathing tube down out of the way. The position of the gag is critical: too much pressure on the sides of the tongue compresses the nerves and causes taste disturbance; the gag must sit in the midline. I watch the tongue colour throughout — if it goes dusky blue, I release the gag to restore blood supply.

LMAs (laryngeal mask airways) sit over the voice box rather than passing through it. They are often kinder to the vocal cords and allow a faster, smoother recovery from anaesthetic. They are slightly bulkier in the operative field, so they need a little more skill from the surgeon to work around. Where appropriate, I prefer LMAs over endotracheal tubes for tonsillectomy.

Step 2: Removing the tonsils

I grasp the tonsil and pull it away from the side wall of the throat, stretching the natural plane between the tonsil and the underlying muscle (the tonsil bed). Working in this plane is like peeling an orange — the natural separation is followed rather than forced. I cauterise the small blood vessels crossing this plane before they bleed (cauterising vessels you can see is easier than chasing bleeding ones), and I aim to preserve the palatoglossus muscle in front of the tonsil. Traditional teaching cut through this muscle to improve access; I do not, both because it adds to post-operative pain and because the muscle's role in supporting the soft palate may matter for snoring in later life. There is no formal evidence for the snoring point yet, but it is biologically plausible and the operation is easily done without cutting it.

At the bottom of the tonsil — where the palatine tonsil merges with the lingual tonsil at the back of the tongue — there is a decision about how aggressively to remove tonsil tissue. I generally remove more inferior tonsil tissue than some surgeons (using cautery rather than ties at the lower pole), which makes the operation a little more useful for snoring and OSA but slightly more painful at the back of the tongue for a few days.

Step 3: Stopping the bleeding

A delicate balance: enough cauterisation to stop all current and likely-future bleeding, but not so much that the resulting dead tissue takes weeks to clear (during which infection and secondary bleeding become more likely). At the end of the operation I release the gag, ask the anaesthetist to simulate a Valsalva manoeuvre (raising the blood pressure briefly to reveal any vessel that is currently constricted but might re-open later), and cauterise any vessels that have not yet declared themselves. I then gently rub the tonsil bed with sterile gauze to dislodge any unreliable clots so they can be dealt with now rather than at 3am on the ward.

Step 4: Final touches

Sterile gauze soaked in local anaesthetic and adrenaline is laid against each tonsil bed for around 30 seconds. The local anaesthetic numbs the bed so the patient wakes up comfortable, which keeps blood pressure low and reduces the risk of early bleeding. The adrenaline constricts small vessels, both reducing immediate bleeding and prolonging the local anaesthetic's effect.

A word on operating beds

For tonsillectomy I prefer to operate on the bed the patient arrives on, rather than transfer them to an operating table. Transfers of an anaesthetised patient between beds risk pulling the breathing tube or the intravenous line. Operating on the bed is less comfortable for the surgeon (you cannot tuck your legs under the table) but safer for the patient.

Different Tonsillectomy Techniques

Extracapsular vs intracapsular

This is the most important distinction.

• Extracapsular tonsillectomy — complete removal of the tonsil with its capsule, leaving the underlying muscle untouched. The traditional approach. Used for recurrent infection, for cases where access to the throat wall is needed (sleep surgery), and where complete removal is desirable. Recovery is more painful.
• Intracapsular tonsillotomy — removes around 95% of the tonsil, leaving a thin protective layer of tonsil capsule over the underlying muscle. Recovery is faster and less painful (around four days quicker return to normal activities in published trials). However, between 0% and 27% of patients develop tonsil regrowth (UK estimate around 5%), and a small proportion need a repeat operation.

I reserve intracapsular tonsillotomy for patients whose primary problem is tonsil bulk causing obstruction — particularly children with OSA from large tonsils. I do not use it for recurrent infection (where leaving any tonsil tissue behind defeats the purpose), and I do not use it where I will later need to operate on the tonsil bed itself (sleep surgery — because residual tonsil tissue trapped under closed muscle is a recipe for deep infection). If you have had an intracapsular reduction with another surgeon and need a complete removal later — for any reason — the second operation is more painful than a primary extracapsular tonsillectomy because of scarring and obscured anatomical planes.

Cold-steel tonsillectomy with packing and ties

The historical technique: scissors or a scalpel to remove the tonsil, gauze packing to control bleeding, and surgical thread to tie off any large bleeding vessels. Largely superseded by techniques with built-in cautery, but still the foundation that most surgeons train on. Lower rate of secondary bleeding than modern hot techniques, but higher intraoperative bleeding and a longer operation.

Cold-steel tonsillectomy with bipolar diathermy

Cold-steel dissection as above, but bipolar electrocautery is used to deal with any large bleeding vessels rather than tying them. Faster than ties, equally effective, and avoids the small risk of a tie loosening later.

Bipolar tonsil dissection

The bipolar forceps are used both to cauterise and to dissect the tonsil. This is probably the most common technique in the UK today and the one with the lowest rate of primary haemorrhage. The trade-off is slightly more surrounding tissue damage from the cautery, which can increase post-operative pain.

Monopolar diathermy dissection

A single electrode spreads energy more diffusely than the bipolar arrangement. Less commonly used now because evidence suggests more post-operative pain and a higher rate of secondary bleeding than bipolar dissection.

Coblation dissection

Uses electrical energy delivered through a saline irrigation field, breaking down tissue at lower temperatures than diathermy. Often used for intracapsular tonsillotomy. Pain on day 1 may be slightly lower than other techniques; by day 7 the difference is negligible. Some published series show a slightly higher rate of secondary bleeding (around 5%) than other techniques (around 3.6%).

Thermal welding

A relatively new technique using direct heat from a thermally hot wire. Used by some surgeons in the United States, rarely in the UK. Evidence is limited.

Harmonic scalpel

An instrument that vibrates at 55,000 Hz, cutting and cauterising through ultrasonic friction. Expensive and not widely used in the UK. The NICE review found broadly comparable pain levels and slightly lower intraoperative bleeding, but higher secondary bleeding in some series.

Carbon dioxide laser

A laser beam vaporises tissue layer by layer. Used mainly for intracapsular tonsillotomy. The NICE review noted lower pain in the first 24 hours but higher pain over the subsequent two weeks (because of partial-thickness burns in surrounding tissue), slower wound healing, and a range of secondary bleeding rates (0–19%). I rarely use the laser for tonsillectomy and have seen many patients needing a second operation after laser tonsillotomy elsewhere.

Microdebrider

A rotating serrated blade with built-in suction, "nibbling" away tonsil tissue under direct vision. Used for intracapsular tonsillotomy. Limited high-quality evidence.

Celon radiofrequency ablation

A probe is inserted into the tonsil and delivers radiofrequency energy to dehydrate and shrink the tissue from within. No tonsil tissue is removed; the gland shrinks over three to six months as the damaged tissue is replaced by scar. Can be done under local anaesthetic. Very low pain, very low bleeding risk. Not suitable for recurrent infection — the tonsil is still there and can still become infected. Useful in selected patients with obstructive tonsils who cannot tolerate a general anaesthetic.

The Full Patient eBook

This page is based on Professor Veer's full patient eBook on tonsillectomy. The eBook covers every section here in more depth, with additional photographs of throats at every stage of recovery (kindly shared by previous patients). It is available free of charge to anyone considering the operation. Please contact the secretarial team and request a copy.

YouTube Videos on Tonsillectomy

• What to do after a tonsillectomy operation — the patient guide embedded above.
• A tonsillectomy operation — actual surgical footage. Not for the squeamish.
• Another tonsillectomy operation — different technique demonstrated.
• Different ways of removing tonsils — coblation, cold steel, bipolar, harmonic, Celon.
• Which tonsillectomy operation causes the most bleeding?

Frequently Asked Questions

Booking, Consent and Next Steps

If you are reading this page in preparation for a forthcoming tonsillectomy with Professor Veer, please bring any unanswered questions to your pre-operative consultation. The consent appointment is the right time to raise concerns about dental work, occupational requirements (singers, teachers, anyone whose work depends on a strong voice), specific surgical techniques you have read about, and any worries arising from this page.

If you are still considering whether to proceed, the secretarial team can arrange a consultation at 150 Harley Street or Weymouth Street Hospital, or you can book online.