Postoperative Care
Please find below useful information on postoperative care for common ENT operations.
Tonsillectomy and adenotonsillectomy post-operative care
Following tonsillectomy when you examine your own or your child's throat you will notice a white slough on either side of the throat where the tonsils used to be. This is normal and is a normal healing wound. This appearance will persist for a couple of weeks. The uvula (the small dangling tissue at the back of the throat) may appear bruised and/or swollen. This will settle. After a week or so the area may appear a little yellow with some redness around the edges and may indeed be a little smelly. This is nothing to worry about.
Earache is a common following tonsillectomy and is due to referred pain from the throat to the ears. Throat pain will often get worse the first 3 to 4 days after tonsillectomy. It may be moderately severe anything up to ten days after the surgery especially in an adult but then will settle day by day.
In the past patients were routinely placed on an antibiotic following removal of the tonsils for five days. Typically this is Keflex antibiotic prescribed either as a liquid or children or as a capsule for adults. Some patients may still be prescribed this however the latest research indicates that antibiotics are not usually necessary after removal of the tonsils and / or adenoids and therefore usually are not prescribed.
It is advisable that for at least a week following tonsillectomy a child sleeps in the same room as their parent. Pain relief is based on the use of paracetamol, Nurofen and endone type medications.
For children, I recommend regular Panadol every six hours (be careful not to overdose!) plus Nurofen for breakthrough pain. In the past, Nurofen was not recommended after a tonsillectomy operation but more recent research indicates that it is safe to give. If a child is still having pain not adequately managed by Panadol and Nurofen let me know as under these circumstances the narcotic oxycodone can be given. It is very strong and can cause nausea or vomiting. Most children do not need it.
Codeine containing medications such as Painstop or Panadeine is no longer recommended. I usually give a prescription for endone for adults and older teenagers. This is a powerful narcotic. Side effects can include nausea and vomiting or constipation. I tend to prefer endone instead of Panadeine Forte as the absorption of the codeine in Panadeine Forte can be variable from patient to patient.
I would still recommend in adults that they take regular Panadol with breakthrough Nurofen and only use the endone if they continue to have significant pain. It is important to read the instructions for dosage on all these medications such that you do not overdose yourself or your child on paracetamol or narcotics. Paracetamol overdosage is very serious and can cause lethal liver failure. Non-steroidal anti-inflammatory medications such as aspirin are to be avoided following tonsillectomy and/or adenoidectomy surgery as they can upset platelet function and cause bleeding. The latest research, however, suggests that Nurofen does not increase the risk of bleeding and therefore this can be used in the postoperative period alongside panadol and narcotics. Occasionally the use of warm (not hot ) honey in the back of the throat can have a soothing effect following removal of the tonsils.
A soft diet is recommended after tonsillectomy for two weeks. This would include soft soggy cereals such as soggy Weet-Bix, scrambled eggs, ice cream, yoghurt, soft fruits, soft pasta and soft sandwiches. Fluids are encouraged. Do not take hard sharp or salty foods such as dry toast or dry chips and avoid foods that take too much chewing such as firm meat.
Lukewarm drinks are permitted but not hot drinks. If all your child tolerates for several days after removal of the tonsils is ice cream, water and yoghurts then that is fine - in the early postoperative period what really matters is that they get enough fluid and enough calories. It is not essential to rinse the mouth but if you wish to do so simply use a teaspoon of salt in a cup of boiling water and cool this until it is just warm.
Rarely a child may dehydrate because they refuse to drink enough following the surgery. Often they may tolerate an icy pole and this is the first thing usually given to them after the surgery and could be tried. If you are concerned regarding a lack of fluid intake let me know as very rarely a child may need to be readmitted to hospital and placed on an intravenous drip.
The main concern following the removal of the tonsils and or adenoids is the risk of bleeding. The risk is very low with regards to adenoids. A small amount of streaky red blood in the mucus is not of any great concern but if you or your child were to spit up tablespoons of bright red blood any time up to 2 weeks or so after surgery you would need to present to your nearest accident and emergency department. Here in the shire this at Sutherland Hospital.
For adenoidectomy alone, there are no restrictions upon dietary intake. The risk of bleeding following removal of adenoids alone is very small and generally, children can be kept at home for three days and then return back to school, preschool or daycare. I do discourage vigorous activity such as sport for two weeks. Occasionally after removal of the adenoids, a child may develop a bad breath five to seven days after surgery which may persist for a few days. This is part of the normal healing response and is not of any particular concern.
Occasionally children may have had a coblation procedure performed on the inferior turbinates at the time of having their tonsils and/or adenoids removed. All that is required for management of this is to use a dollop of nasal cream on a cotton bud applied twice daily to each nostril rolling the bud approximately 1 cm gently inside the nostril for one week. Rarely a child may have a small amount of nosebleed following this procedure and this can be settled by simply pinching the nose shut for a minute or so.
Routinely I see patients at one month following removal of the tonsils and or adenoids and usually, this appointment has been arranged for you by my secretary prior to surgery. If a work or carers certificate is required please contact my secretary and one will be sent to you. If there are concerns between your time of discharge and the follow-up appointment please not hesitate to contact my office on 9525 3500. In the early postoperative period if there are concerns after hours you can contact the hospital where the surgery was done and the nurses on the ward can answer your questions or get in touch with me if necessary
Post-operative care following adenoidectomy
Adenoidectomy may be undertaken alone or in conjunction with tonsillectomy. If the operation is performed alone is performed as a day surgery procedure. Usually, patients are discharged approximately 4 hours postoperatively. There is very little pain associated with this operation. Any post-operative pain can be managed usually simply with Panadol or Nurofen in children.
When you look in your or your child's mouth following adenoidectomy you may notice that the uvula (the small gangly protuberance at the back of the soft palate) may appear somewhat oedematous, inflamed or ulcerated. This is not uncommon following the surgery and is not a cause for concern. It will settle over a week or so.
Patients are usually placed on a five-day course of antibiotics following surgery, typically Keflex unless there is an allergy to this medication. There is no restriction on dietary intake following adenoidectomy.
It is recommended that patients rest at home following adenoidectomy for three days. Children can then return to school but should not pursue any vigorous activity or swimming for two weeks.
The breath can become a little smelly at five to seven days postoperatively. This is not an infection and is a normal wound response. This usually settles after a few days.
Patients may often experience some nasal congestion and children may be noted to snore for a few days following adenoidectomy. This is normal and is due to normal post-operative swelling in the wound environment. It tends to settle within a week or so.
The main concern following adenoidectomy is a risk of bleeding. A small amount of blood in mucus or a very minor nosebleed is not uncommon following surgery and is not a cause for concern. More significant bleeding such as the expectoration of a tablespoonful of bright fresh blood or a brisk nosebleed that does not stop rapidly is of concern and in this instance, the patient should be taken to the nearest accident and emergency department. In the Shire, this is the Sutherland hospital or in Randwick the Prince of Wales Hospital or Sydney Children's Hospital casualty departments.
Patients should not fly in an aeroplane or travel to a remote area for three weeks following adenoidectomy.
An information brochure regarding adenoidectomy will have been provided to you prior to yours or your child's surgery. This does contain useful information regarding post-operative care.
If you do have concerns following surgery please not hesitate to contact Dr Bridger. During office hours he can be reached in his office on 9525 3500 or after hours please contact the ward at the hospital where you had surgery and the nursing staff can address your concerns or get in touch with Dr Bridger if necessary.
Post-operative care following the insertion of middle ear ventilation tubes (grommets).
Grommets are inserted as a day stay procedure and usually, you or your child will be fit to go home approximately two hours after surgery. Occasionally for 24 hours or so after the operation, you will notice a slightly bloodstained discharge from your child's ear. It is not concerning and can simply be wiped away with a cotton bud. Often patients are started on an antibiotic eardrop known as Ciloxan for about five days after surgery, usually, four drops twice daily to each ear commencing on the evening of the day of surgery.
Whether or not your child is commenced on these eardrops will depend on the amount and nature of the fluid seen in the middle ear at the time of surgery. To place the drops lie your child on their side and gently pull the ear upwards and backwards which opens up the ear canal. Drop the drops into the ear canal and then gently pumped the tragus (the small flap of cartilage in front of the ear canal) for approximately 30 seconds to pump the drops down the ear canal. Your child may comment on an abnormal taste in the mouth. This is quite normal and simply represents the drops moving down the Eustachian tube. If both ears need to be done leave your child lying on the side for a minute or so before turning them over and doing the other ear. Store the drops in your refrigerator.
Grommets are very effective in restoring hearing in children who are suffering from hearing loss due to middle ear fluid and often you may notice even before leaving the hospital that your child’s hearing has improved.
If your child is experiencing pain following grommet insertion usually Panadol is all that is required to treat it. It is permissible to use Nurofen as an alternative. A child can return to daycare, preschool or school on the day after surgery. They can play sport but should not go swimming for a week after surgery.
While the grommets are in it is important to protect the ears from water. When bathing your child keep their head out of the water. To wash their hair smear some vaseline over a small cotton ball and gently use this to plug the ear. Then you can tip water over their head to wash their hair. As an additional protective measure or in the case of children who will not tolerate anything in the ears a hair wash visor can be used which is obtainable from larger baby stores. This looks like a tennis visor and will protect the child ears when washing their hair. If you think that water has gone in your child's ear then simply gently pull the ear up and back and use your hairdryer from approximately 50 cm away for a minute or so to blowdry the ear.
Children are allowed to swim (including jumping in the pool and going underwater) after grommets have been in place for one week but they do have to protect the ears from water while grommets are in. Two layers of protection are required. Firstly an earplug and secondly a swimming cap or swimming headband. Bluetac can be used or silicon earplugs purchased at the chemist but better options are either a pro-plug or a custom-moulded earplug both of which are available from my Miranda practice. You would need to ring the office and make an appointment to see our audiologist Jane such that these can be fitted. Likewise, children's swimming headbands are available.
Apart from this, there are no restrictions on child activities with grommets in place. Grommets will help if your child needs to go in an aeroplane as they will perform the pressure equalising for the ear. Contact sports are permitted three days after grommet insertion.
It is possible to develop an ear infection while grommets are in place. In this instance, the child may develop an earache and/or a discharge from the ear. If this happens to contact the Miranda office and I or one of my colleagues (if I am not in the office that day) will endeavour to see your child that day such that the ear can be cleaned and appropriate antibiotic eardrops and possibly oral antibiotics will be commenced. In general with antibiotic eardrops, ear infections with grommets tend to settle quite rapidly.
Your first post-operative appointment following grommet insertion will be at one month after surgery and subsequent appointments will be at four-monthly intervals until the grommets have left the eardrums. The average time for this to occur is approximately 12 months. If the grommets have discharged from the eardrums then occasionally you may see a grommet in the outer part of the ear canal. It is usually a small black tube and if seen in the outer ear could be gently plucked away with a pair of tweezers. You may indeed notice a grommet on your child's pillow. It is not concerning if the grommet comes out and indeed the natural history is that the eardrum will discharge the grommet.
You will have been provided in the college of surgeons information brochure regarding treatment with grommets. This does have useful information regarding post-operative care. Your child will undergo a hearing assessment following grommet insertion. This may be arranged early after grommets have been inserted but often will not be performed until after the grommet has left the eardrum if your child is progressing well with their speech (and in older children their reading) development
Care of the nose following septoplasty and /or turbinoplasty surgery
Following septoplasty and/or turbinoplasty surgery it is normal to spend one night in the hospital and be placed on intravenous antibiotics for that night following the surgery. Usually, dressing is placed in either side of the nose and therefore the nose will feel blocked for that first post-operative night. This can be somewhat uncomfortable and cause the mouth to feel dry, the eyes to water and pain or discomfort in the nose and forehead. Medication will be provided in the hospital to alleviate any pain. The dressing will be removed the following morning. It is often a little painful to remove the dressing but it only takes a few seconds for the dressing to come out of the nose. Once the dressing has been removed if is common for the nose to bleed for up to 10 minutes or so. This usually settles quite rapidly. Any pain associated with nasal obstruction due to the use of the dressing will usually be settled quite quickly once the dressing has been removed.
Patients are usually discharged from the hospital an hour or so after the removal of the nasal dressing to ensure that there is no further bleeding. It is recommended that patient's rest at home for up to 10 days following this type of nasal surgery before returning to work. Some patients if they are feeling well and are involved in a sedentary occupation may be able to return to work as early as five days after surgery. It is common to have a slightly sore throat for a few days following surgery due to the use of an endotracheal tube at the time of the operation by the anesthesiologist. If a work certificate is required simply contact my office and one will be forwarded to you.
Patients are usually discharged on an oral antibiotic such as keflex which is taken for five days after surgery. They have also prescribed a nasal cream called nasalate if a septoplasty operation has been done. This is used twice a day for 10 days after surgery and is available over the counter at the chemist. A dollop of cream is placed on a cotton bud and this is rolled gently approximately 1 cm inside each nostril concentrating on the middle wall of the nose. After septoplasty surgery, there are small sutures inside the nose that will dissolve. Patients are placed on a nasal saline spray such as FESS saline spray which is available over the counter at the chemist. Patients can use the spray as often as they like but typically six sprays three times a day each side of the nose would be an acceptable minimum.
The nose will often feel somewhat blocked for a couple of weeks after surgery. There may be some bloodstained mucus discharge and crusting. The top lip may be a little swollen for a few days and it is useful to sleep a little head up for the first week or so after surgery with the head on a couple of pillows.
In general, nose blowing should be avoided for about two weeks after surgery. Likewise, heavy activity such as heavy lifting or exercise should also be avoided for two weeks. In general, a post-operative appointment is made for 2 to 3 weeks after surgery. At the time of his appointment the nose will be inspected and if necessary cleaned. It is usually possible to commence blowing the nose thereafter. Patients should not fly in an aeroplane or travel to a remote area where they do not have access to hospital facilities for at least three weeks after surgery.
The main concern in complication following surgery is that of bleeding which may occur anything up to two weeks after surgery and can be exacerbated by heavy activity. Paracetamol and codeine-based analgesia is recommended (eg Panadol or Panadeine or Digesic for patients with a codeine allergy or intolerance) after this sort of surgery and non-steroidal anti-inflammatory medications such as Aspirin and Nurofen should be avoided as these can precipitate bleeding. If a nose bleed occurs the patient should sit up and place a bag of frozen peas over the bridge of their nose to cool the area. The patient can press gently with tissues under their nose which can again arrest bleeding. If this does not settle the bleeding after 15 minutes or so then a nasal decongestant spray such as drixine should be used with one spray in each side of the nose. If this arrests the bleeding in the patient should again avoid strenuous activity and use the drixine every eight hours for three days with one spray in each side of the nose. If bleeding persists despite these measures or is profuse the patient should present to the Sutherland hospital accident and emergency department if they are in the shire or to their local hospital accident and emergency department. The doctors there and get in touch with Doctor Bridger.The Royal Australian College of surgeons information brochure on septoplasty and surgery to reduce enlarged turbinates will have been given to you before surgery and provide additional useful information on post-operative care.
Care of the nose following functional endoscopic sinus surgery (FESS)
When you wake up after having your sinus operation you may notice that your nose is blocked on one side or both depending on whether it has been necessary to place a dressing in your nose. If it has been necessary to place a small metal frontal trephine cannula through the skin of your eyebrow into your frontal sinus then there may be one or two small cannulae still present in your eyebrows and these will remain overnight. They will be periodically used to irrigate saline into your sinuses and the nurses will perform this with a small syringe. This is done to prevent blood clot forming in the sinuses which may subsequently form scar tissue.
You'll be checked regularly by the nursing staff in recovery and on the ward.
It will be examined as a real patient can develop bleeding into the eye socket after sinus surgery which can have a catastrophic effect on vision if not treated promptly. It is to be stressed that this is very rare. Usually, you will remain in the hospital for one night after surgery. You will be seen by Doctor Bridger the next day and any dressing in the nose will be removed as will any cannulae in the eyebrow. Removing a nasal dressing is usually a little painful but only for a very brief period. It is common for the nose to bleed for 10 minutes or so after having a nasal dressing removed.
Typically patients will spend an hour or so in hospital after having their dressing removed to ensure that there is no ongoing bleeding and then they are fit to return home. Usually, patients will be placed on an oral antibiotic such as Keflex for five days after surgery and may also be placed on an oral corticosteroid tablet such as prednisone again for five days. Patients will need to irrigate their nose regularly with a saline solution which is available over the counter at the chemist. This may be either FLO Nasal Rinse, Neilmed sinus rinse or FESS Postoperative hypertonic irrigation wash (depending on what is stocked by your chemist). All of these are equally effective and are made up of a sachet containing the irrigation crystals and a douche bottle which the crystals are placed into with boiled and then cooled water and this is then irrigated into either side of the nose three times per day commencing on the day the patient returns home. Once the saltwater solution has been instilled into the nose it will flow out again and maybe somewhat bloody or contain some discharge. This is not concerning. There can be some pain following this type of surgery but this can usually be controlled with Panadol or panadeine. Patients should refrain from using nonsteroidal anti-inflammatory medications as these can precipitate bleeding. If a patient has had frontal trephine cannulae placed then the small wounds in the eyebrows will heal very quickly. They often gape a little in the first 24 hours after surgery then shrink down. Patients are usually placed on chloromycetin ointment to be used twice daily on these wounds for one week. It is permitted to get these wounds wet in the shower after returning home from surgery.
It is usually recommended that patients rest at home for three days after sinus surgery. Most patients can then return to work provided that work does not involve heavy physical labour. Usually, three post-operative appointments are booked at weekly intervals after surgery. Patients should refrain from blowing their nose from the time of discharge from hospital until seeing Doctor Bridger at the first post-operative appointment. At the time of that appointment, the nose will be inspected and cleaned. Usually patients are given three appointments at weekly intervals after surgery.
Patients should avoid heavy exercise, sport and physical activity for two weeks after surgery and should avoid travelling in an aeroplane or to a remote area away from hospitals for three weeks again because of risk of bleeding. Patients should avoid taking any non-steroidal medications for two weeks after surgery.
The nose will usually feel congested and blocked for a few weeks after sinus surgery. When the nose is blown old and fresh blood clot may come out. This is normal. The major concern after sinus surgery at home is bleeding. Often a small nosebleed can be settled with a spray of nasal decongestant such as drixine however more significant bleeding does necessitate that the patient visits the emergency room of the nearest major hospital. For patients in the shire, this would be at Sutherland Hospital and for those in the eastern suburbs at the Prince of Wales Hospital in Randwick. Also if a patient has a significant unremitting pain in the face or forehead which is not able to be controlled with panadeine or equivalent analgesic medication then this should be reported to Doctor Bridger. During normal hours queries and concerns regarding your post-operative management can be addressed by contacting Doctor Bridger's office on 9525 3500.
Often patients will have had surgery to the nasal septum and/or the inferior turbinates at the same time as having endoscopic sinus surgery. An information brochure on the post-operative care of the nose for this operation will also be provided to them. Patients will also have received a college of surgeons information brochure on endoscopic sinus surgery. It also contains useful information on post-operative care.
Care of the ear following exostosis surgery
Doctor Bridger will discuss your operation to remove your exostoses at the time of consultation before surgery. Using modern equipment it is usually possible to accomplish this operation with a small incision just above the ear canal. If this is not possible a larger incision behind the ear will be made.
Patients will usually spend one night in hospital after surgery. The ear will be blocked with a dressing. There will be a small piece of cotton wool in the ear which will be changed regularly by the nursing staff. It is normal for this to be a little bloodstained when it is changed. There will be a small row of sutures just above the ear and antibiotic ointment (chloromycetin) will be placed on these. Usually, patients will be placed on an intravenous antibiotic overnight.
Patients can usually return home the day after surgery. Patients will be placed on oral antibiotics for five days (usually Keflex) and will continue using chloromycetin ointment twice a day on the small sutures just above the ear. Patients will need to change the cotton wool in their ear three or four times per day depending on how moist it is getting due to a small amount of discharge from the wound in the ear canal. Doctor Bridger will have placed three or four small squares of yellow gauze dressing in the ear canal. These are not to be removed but if one or two do fall out inadvertently do not be concerned by this and do not try to put them back again.
It is important to keep the ear dry at this time. Usually, post-operative pain is not severe and can be treated with paracetamol and codeine. Pain typically settles after a few days. Occasionally the door may be somewhat painful to 2. This likewise should begin to settle early in the post-operative period.
Usually, it is recommended that patients rest of 2 to 3 days after surgery. After this most patients can return to work but they must be aware that the dressing will remain in the ear and as much they will not be able to hear as well on this side and may have some ringing (tinnitus) in the ear until the dressing is removed.
Usually, patients will return to see Doctor Bridger at two weeks after surgery. At the time of this consultation, sutures will be removed as will the ear dressing and the ear will be cleaned. Usually, a fresh dressing is placed in the ear canal and antibiotic eardrops may be commenced. Doctor Bridger will be in usually see patients again at 1 to 2 weekly intervals for the next four weeks or so while the ear canal heals. It is important to keep the ear dry during this time will stop.
You will have been provided with a College of surgeons information brochure about exostosis surgery which does contain useful information on post-operative care. Should there be concerns about the way your ear is healing when in the post-operative period please do not hesitate to contact Doctor Bridger.