MBChB, (Otago), FRACS (Otolaryngology, Head & Neck Surgery)
Ear, Nose and Throat Surgery Head, Neck and Thyroid Surgery Facial Plastic Surgery Snoring surgery www.drleaper.co.nz Post-operative instructions for children’s tonsillectomy or adenoidectomy General information: Tonsillectomy is the removal of the tonsils. Tonsils are a collection of lymph tissue at the back of the throat. They can become infected repeatedly (tonsillitis) and they can also become swollen and cause airway obstruction. There are many other areas containing lymph tissue that do not cause similar problems. There is no evidence that the removal of the tonsils has any adverse effect on the immune system or makes infection more likely. The adenoids are a collection of lymph tissue at the back of the nose. The adenoids may block the nose, cause sinusitis and also block the Eustachian tubes that run to the ears resulting in ear infection. A tonsillectomy and adenoidectomy is performed under general anaesthesia. It takes around 20-30 minutes for the actual surgery. Local anaesthetic is injected around the tonsils, which are then gently dissected free. Blood vessels are sealed off and the back of the throat carefully checked to make sure it is clear. The patient is then transferred to the recovery room. The tonsillectomy leaves an area about the size of a 50-cent piece that has to heal over the course of approximately 10 days. This area moves whenever the child swallows or talks causing pain. After a few days, nerve endings start to grow back. These nerve sprouts can be very tender until they are covered and healing is complete. An adenoidectomy does not tend to be very painful as the area at the back of the nose does not move and has fewer pain fibres. Children generally require regular pain relief following tonsillectomy. As an estimate it takes one day per year of life for the pain to settle. In older children and teenagers the pain tends to be more severe and can last up to 2 weeks. At about 5 days, the pain may change; it often becomes worse and may be associated with earache. We think this may be the nerve endings in the throat starting to grow back. It does not mean anything is wrong and this can be part of the normal course after a tonsillectomy. It is not unusual to feel down at this point as it is nearly a week from the surgery and the pain should be getting better not worse. I believe the key to getting through this point is to take the pain relief regularly and try to drink and eat as much as normal. Swallowing may actually help with the pain and stop the throat going into spasm. Diet: A child can eat or drink as normal. Some foods may cause more pain than others and this normally depends on the acidity of the food and the texture. Chips and toast may be easy to swallow, whereas tomatoes or kiwifruit (which are quite acidic) can be more painful. Trying different foods is probably the best way to see if it can be swallowed.
Pain Relief: Paracetamol I usually recommend a dose of 15mg per kg every 4 to 6 hours. This will be written on the directions from the pharmacy. Oxynorm This is a relatively new medication to be used in children and I find it very useful. The dose is based on the child’s weight and is usually 0.1mg per kg 4 hourly. Oxynorm is a strong pain relief (about half way between codeine and morphine). It is a liquid that works fast and tends to be predictable in how much pain relief it provides (unlike alternatives such as codeine). Side effects can include nausea and vomiting. It can also make your child sleepy. If this is excessive then seek urgent medical attention. Amoxicillin This medication is designed to reduce any infection that may occur in the days after the surgery. I suggest starting it 2 days after surgery. Side effects can include nausea, vomiting and diarrhoea. A rash may indicate an allergy. Prednisolone This is an anti-inflammatory steroid that reduces the swelling in the throat following the surgery. It is generally well tolerated but side effects may include hyperactivity, lack of sleep and tummy pain. Ibuprofen This is a very effective pain relief although it may be linked to a higher rate of bleeding. I prefer for this to be used as a backup if other pain relief medication is not working. Post Tonsillectomy bleeding There is a small but not insignificant risk of bleeding after tonsillectomy. Approximately 1 in 50 children need to return to hospital. This may occur up to 14 days after the surgery. If your child loses any more than 2 teaspoons of blood, you should contact me and be heading to the nearest emergency department. Generally, the bleeding will stop by itself but there is a chance that a second operation is needed to stop the bleeding. The child is best to spit the blood out and remain as calm as possible. If you are unable to contact me, then call Dunedin Hospital and ask for the ENT registrar. There will always be someone on duty 24 hours a day. I treat any bleeding after a tonsillectomy very seriously and will almost always admit the child to hospital for observation even if the bleeding had settled. Vomiting It is not unusual for a child to vomit following a tonsillectomy. We think this is a combination of the anaesthetic combined with a little swallowed blood. We routinely give anti-sickness medication during the procedure. Generally one or two vomits do not require any treatment. If the vomiting continues or is associated with a lot of nausea then the nurse may give you some more anti-sickness medication. After discharge, nausea is generally due to one or more of the medications. Any medication can make you feel sick. I generally advise trying to stop the
amoxicillin and the Oxynorm and see if things settle. It is important to maintain enough oral fluid intake during this time. Very occasionally a child will need to be readmitted to hospital due to vomiting.
Available online at www.sciencedirect.comCognitive and Behavioral Practice 17 (2010) 290–300Current Treatment Practices for Children and Adults With Trichotillomania:Christopher A. Flessner, Bradley/Hasbro Child Research Center/Warren Alpert School of Medicine at Brown UniversityFred Penzel, Western Suffolk Psychological Services, Huntington, NYTrichotillomania Learning Center–Scienti
Fallbesprechungen zum Grundkurs Öffentliches Recht II (Teil 2) Fall 5 – Lösung – Die Klage des H hätte Aussicht auf Erfolg, wenn sie vor dem (rechtsweg-)zuständigen Gericht er- hoben werden würde sowie zulässig und begründet wäre. Aufbauhinweis: Hier wird ein dreistufiger Aufbau i.R.d. Klage vertreten. Ein zweistufiger Aufbau, der zwischen Sachur- teilsvoraussetzungen und Be