Op to trim your child’s tonsils to help them sleep
A NEW technique can cut the risk of complications from tonsil surgery. Joanne Trup’s two-year-old son, Ethan, had the operation last September, as she tells LUCY ELKINS. The family lives in North-West London.
WHeN ethan was one, we were on a family holiday to Spain and sleeping in closer proximity than normal and I became aware that he was briefly stopping breathing when he slept.
He would do two loud snores then sound as if he was holding his breath for a few seconds. It gave me a real fright.
Back home, I became more and more aware of it — it was happening every night. It was scary, but not unfamiliar as his sister Isabella, now six, had a similar problem two years earlier.
Her paediatrician told me she had obstructive sleep apnoea, where the throat narrows during sleep, causing breathing problems. This was due to big tonsils blocking her airway, so she had them removed when she was three.
I suspected ethan had the same problem as he was also having difficulty getting a whole mouthful of food down. It was as if there was an obstruction. He would have frequent sore throats and would gulp a lot, as if swallowing was uncomfortable.
The paediatrician had warned me that obstructive sleep apnoea can lead to children getting less and poorer quality sleep. I’d noticed ethan was crying more than normal. We’d also been warned this could lead to developmental issues, such as learning difficulties.
So after a few weeks I took him to see michelle Wyatt, the surgeon who’d treated Isabella two years earlier, using our private medical insurance. She said that it sounded as if ethan also had obstructive sleep apnoea.
After examining him, she said that he had very large tonsils and recommended surgery to remove them. However, she said she wouldn’t do a traditional tonsillectomy, where they cut away the whole tonsil (which Isabella had), as this is a major operation and is not commonly performed on children under three.
SHe
said there was a new technique with far fewer risks. Rather than cutting away the tonsils in entirety, they would be ‘debulked’, or made smaller.
ethan had the operation in September. He was out within an hour, as Isabella had been, but bounced back much more quickly.
Isabella had been on painkillers for two weeks and for three or four days was utterly knocked out. She was lethargic, complained of stinging in her throat and was off her food for a few days.
ethan, on the other hand, was eating and drinking as normal within two to three hours of having surgery. He didn’t even have a sore throat. I was advised to keep him off nursery for a week, but he was ready to go back before then.
Now he’s fine. He no longer snores or stops breathing, and the swallowing issues and sore throats have gone.
THE SURGEON
MICHELLE WYATT is a consultant paediatric ear, nose and throat surgeon at Great Ormond Street Hospital and The Portland Hospital, london. eveRy year, around 40,000 operations are performed to remove tonsils — two lumps of tissue that sit at the back of the mouth, one on each side.
There are two main reasons for removing them. The first is recurrent tonsillitis, which is causing a child to need lots of time off school or multiple courses of antibiotics.
The other reason is if the tonsils are so big (naturally or as a result of infection) that they are obstructing breathing at night — known as obstructive sleep apnoea. This is what ethan had.
During sleep, there is a natural loss of muscle tone in the tongue and throat, which means that the tonsils sag across the airway.
This can stop the person breathing temporarily, causing their oxygen levels to drop and their brain to wake them up in order to start breathing again.
We operate because obstruc- tive sleep apnoea in children has been linked to medical problems such as putting excess strain on the heart and related lung problems.
And research increasingly suggests that this condition maybe also be linked to developmental problems. Adults get sleep apnoea, too, but it’s more significant for a child because their developing brain is at risk from the drop in oxygen it briefly causes.
Tonsils are made of lymphoid tissue, which makes proteins, called immunoglobin, that fight infections. Fortunately, there are other tissues around the body that also make these proteins, so having your tonsils out does not detrimentally affect general health.
Until recently, the only option for removing tonsils was a traditional tonsillectomy.
The tonsil tissue is contained inside a fibrous white capsule. With a tonsillectomy, we cut away this capsule from the muscle bed at the back of the throat using small forceps. We then tie off the blood vessels with stitches or cauterise them (seal them by applying heat).
Removing them this way means you are left with exposed muscle and nerves, which can be very painful and may require a couple of weeks off school.
There is also a risk of bleeding, which can occur up to ten days after the operation. This can be especially significant for a very young child, who has a smaller volume of blood to begin with. In rare cases, it can be life-threatening.
Five in every 100 patients will experience delayed bleeding, and one in 100 will need further surgery to stop it. This is quite a risky operation — there could be bleeding in the stomach, which could enter the lungs and cause problems with the breathing and anaesthetic.
With the newer technique, rather than remove the tonsils completely, the surgeon leaves a tiny portion of them in place.
This means there is no painful exposed muscle and, as no larger blood vessels are cut, the risk of heavy bleeding is practically zero.
The operation is performed on adults, but has only recently been taken up for treating children.
It is carried out under general anaesthetic. As with a standard tonsillectomy, we approach the tonsils through the mouth; then we nibble away at them to reduce their size.
I use a wand-like instrument called a coblator, which has an electric current passing through the end.
When you apply the wand to the tissues, it melts them away. It’s not burning, because it’s done at a low temperature (40-65c). There is no need for stitches.
This operation is perfect for large tonsils that are an obstruction to breathing. There was some debate about how good it is for those who need their tonsils removed as a result of repeated infections.
Some argue that by leaving a tiny amount of the tonsil, there’s the chance of residual tonsillitis. However, nowadays we remove as much as 98 per cent of the tonsils, so it’s unlikely infection will recur.
FURTHeRmoRe,
the infections tend to occur in tiny pits on the tonsils called crypts, but these are removed.
The procedure does carry a risk of bleeding, but it’s much less significant than with the other techniques. There’s also a risk of infection and a very small chance of regrowth of the tonsil tissue.
A U.S. study published in Laryngoscope confirmed that it reduces post-operative hospital admissions for emergency treatment. I’m impressed with the results and recovery rate. ‘THIS is a useful alterative to the existing technique and overall it is considered an improvement,’ says Nicholas Roland, consultant eNT surgeon at Aintree University Hospital.
‘It’s more comfortable for the patient and the risk of bleeding during the operation is lower.
‘But there is still a risk of primary bleeding (just after the operation).
‘And it doesn’t make much difference to the risk of secondary bleeding as a result of infection.’
THE operation costs £4,200 privately and a similar sum to the NHS.
ANY DRAWBACKS?