Do they stay or do they go?—Adherence to post-tonsillectomy recovery advice in a regional Australian centre

Introduction

Tonsillectomy and adenotonsillectomy are among the most commonly performed surgeries by Ear, Nose and Throat (ENT) surgeons. In Australia, over 35,000 tonsillectomies were performed between June 2023 and July 2024 (1). Indications include recurrent tonsillitis, peritonsillar abscess and obstructive sleep apnoea (2). Postoperative complications include bleeding, infection, and dehydration (3). Of particular concern is the risk of post-tonsillectomy bleeding (PTB) and respiratory complications (3-5).

PTB is classified as either primary (within 24 hours of surgery) or secondary (more than 24 hours postoperatively) (2). The reported incidence of primary PTB is 0.2–2.2% and secondary PTB 2.18–6.9% (3,6-10). In Australia, the reported incidence of PTB requiring return to theatre is 1.6% (11). Though rare, PTB can result in life-threatening haemorrhage and respiratory compromise (12,13).

The risk of PTB poses unique challenges in regional settings, where healthcare access is limited by geographical distance and variability in access to ENT and emergency services (14). In Australia, many ENT surgeons are reluctant to perform tonsillectomy on patients who reside more than one hour from a hospital with ENT capability unless the patient agrees to remain in proximity to specialist care for 10–14 days postoperatively (14). However, financial pressures, employment obligations, and family responsibilities can limit patients’ ability to adhere to this advice and undergo surgery. Alternatively, some may choose to undergo surgery but return home prematurely. This increases the risk of delayed recognition and management of PTB, potentially necessitating costly retrievals to ENT-equipped hospitals.

Toowoomba Hospital (TH) is a regional hospital in Queensland, Australia, located 130 kilometres from the closest tertiary hospital in Brisbane. TH services a catchment of over 88,000 km2 across southwestern Queensland and northern New South Wales, with some patients travelling several hundred kilometres to access care. The postoperative care instructions at TH typically addresses analgesia, diet, and indications for urgent medical review. For patients from regional or remote areas, additional guidance includes recommendations to remain near facilities with ENT services during the recovery period to mitigate the risks associated with delayed management of complications such as PTB. Patients under 18 years of age are advised to remain within 45 minutes of an ENT-equipped facility for 10 days following tonsillectomy. Adult patients are advised to remain within 45 minutes of a physician-staffed, 24-hour emergency department for 10 days following tonsillectomy. These recommendations are discussed during the informed consent process, reinforced with written information, and reiterated during postoperative care. Routine follow-up phone calls are conducted day 1, 5 and 14 postoperatively for day cases, or at day 5 and 14 for patients who remain in hospital overnight following surgery. At follow up, patients are asked whether they have adhered to the proximity advice.

Neither the Royal Australasian College of Surgeons (RACS) nor the Australian Society of Otolaryngology, Head and Neck Surgeons (ASOHNS) have issued formal guidance on post-tonsillectomy proximity to care. Consequently, recommendations may vary between clinicians and institutions. Excessively stringent advice may limit access to surgery for regional patients, whereas overly lenient advice may compromise patient safety. There is little published data on adherence to proximity advice following tonsillectomy in regional Australia. This study aims to address this gap.

Methods

Study design

This prospective observational audit was conducted at TH, a regional referral centre in Queensland, Australia. The aim was to evaluate adherence to postoperative proximity advice among patients who underwent tonsillectomy or adenotonsillectomy. The study period was from 1 June 2024 to 31 December 2024. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The project was reviewed by the Darling Downs Health Human Research Ethics Committee (HREC) and determined to be a negligible-risk activity not requiring full HREC review (reference: EX/2024/QTDD/106569). The HREC indicated that individual informed consent was not required, as the study involved analysis of routinely collected clinical data obtained as part of standard care without any additional risk or burden to patients. The study is reported according to the STROBE reporting guidelines (available at https://www.theajo.com/article/view/10.21037/ajo-2026-1-0002/rc).

Study population

All patients who underwent tonsillectomy or adenotonsillectomy during the study period were included in descriptive analyses. Patients were included in the adherence analysis if they attended their postoperative telehealth review. Patients who did not attend follow-up were excluded this analysis.

Data collection

Data were obtained during routine follow-up assessments conducted within the study period. The variables collected included patient demographics (age, sex, residential location, and distance from TH), procedure performed and self-reported adherence to postoperative proximity advice.

Patients were categorized as ‘local’ (<45 minutes) or ‘distant’ (>45 minutes) based on GPS travel time from their residential town or suburb to TH using Google Maps under standard conditions. This cutoff was used to align with institutional postoperative proximity recommendations at TH.

During routine follow-up assessments, patients were asked whether they remained within the recommended proximity for the suggested duration during their recovery. Adherence was defined as patient or caregiver self-report of remaining within the recommended proximity for the advised duration. Patients or caregivers who reported not following this advice were classified as non-adherent. Patients who did not attend follow-up were excluded from adherence analysis but were included in descriptive analyses of geographic distribution.

Data analysis

Descriptive statistics were used to summarise patient demographics and adherence outcomes. Categorical variables were reported as frequencies and percentages, while continuous variables were reported as median and interquartile range (IQR). Data analysis was performed using Microsoft Excel.

Results

A total of 347 tonsillectomy-related procedures were performed during the study period. The age of patients ranged from 2 to 79 years, with a median age of 8 years (IQR: 5–14 years). The majority of patients undergoing tonsillectomy were under 18 years of age (82.4%). Of the total cohort, 199 patients (57.3%) resided locally (within 45 minutes of the hospital), while the remaining 148 (42.7%) were classified as distant. The geographic distribution of all patients by travel time to the hospital is shown in Figure 1.

Figure 1 Travel time from patient residence to Toowoomba Hospital for patients undergoing tonsillectomy during the study period. Most patients resided within 45 minutes of the hospital; however, a substantial proportion lived >1.5 hours from specialist care.

Adenotonsillectomy was the most frequently performed procedure (n=179, 51.6%), followed by tonsillectomy alone and adenotonsillectomy with grommet insertion. Other procedures were less common. The full distribution, stratified by patient location, is presented in Table 1.

The failure-to-attend (FTA) rate for postoperative telehealth follow-up in the distant cohort was 51/148 (34.5%), leaving 97/148 patients (65.5%) with available follow-up data. Among these, 79/97 [81.4%, 95% confidence interval (CI): 73.7–89.1%] reported adherence to proximity advice, while 18/97 (18.6%, 95% CI: 10.8–26.2%) reported non-adherence. When considered across the entire distant cohort, this corresponds to a crude adherence proportion of 79/148 (53.4%), representing a conservative estimate assuming non-adherence among those without follow-up.

Among patients with follow-up, adherence appeared higher in paediatric patients (65/77, 84.4%, 95% CI: 79.3–93.5%) than in adults (14/20, 70.0%, 95% CI: 60.9–79.1%). These proportions correspond to 65/121 and 14/27 of the total distant cohort, respectively. This analysis was exploratory and not powered for formal statistical comparison.

Discussion

This study investigated the geographic distribution of patients undergoing tonsillectomy at a regional Australian hospital, with the aim of assessing adherence to postoperative proximity advice. The risk of PTB is well established, and access to timely care is a critical factor in managing potential complications (2-13,15). This is particularly important in regional settings, where patients often live at significant distances from ENT services or emergency departments.

In our cohort, over 40% of patients resided more than 45 minutes from ENT services, including nearly 30% who lived more than 1.5 hours away. The FTA rate to postoperative telehealth reviews in this cohort was 34.5%. The FTA rate in specialist outpatient clinics in other studies is variable, with up to 37% of patients failing to attend at least one appointment (16,17). Although not assessed here, common FTA reasons reported elsewhere include forgetfulness, technical issues, and competing commitments (17,18). Of those who attended follow up, 81.4% of patients reported adherence to proximity advice, while 18.6% did not. Non-adherence is likely multifactorial, reflecting financial barriers, work or caregiving responsibilities, and limited social support. Given the high FTA rate, true adherence is potentially lower than observed.

Non-adherence is particularly concerning in paediatric patients, who comprise most tonsillectomy cases and may be more vulnerable to delayed recognition of PTB. Although rare, PTB can be life-threatening and requires immediate recognition and management (19). Retrieval of patients from remote areas is also costly, with aeromedical transfer exceeding AUD $5,000 per flight hour (20). This underscores the importance of ensuring patients are adequately counselled on risks and supported to adhere with recommendations.

Limitations

This study has several limitations. First, it was an observational study conducted at a single regional centre, which may limit the applicability of findings to other settings with different patient demographics or access to care. Second, adherence to postoperative proximity advice was assessed based on patient or caregiver self-report, which is subject to recall and social desirability bias. Patients may overreport adherence to align with perceived expectations, potentially leading to overestimation of adherence rates. Objective verification of location adherence [e.g., using global positioning system (GPS) tracking or accommodation records] was not feasible and potentially unethical. In addition, follow-up was incomplete, with a high FTA rate that may have introduced selection bias by preferentially capturing more engaged or health-literate patients. Patients who did not attend follow-up may have different adherence behaviours, and true adherence may therefore be lower than observed. Therefore, true adherence is likely substantially lower and may approximate worst-case estimates closer to 50% if non-attenders are assumed non-adherent.

This study did not assess clinical outcomes such as PTB, readmission, or complication rates. As such, the direct clinical impact of non-adherence cannot be determined from this study.

Implications and future directions

The geographic distribution of patients undergoing tonsillectomy at TH underscores the practical challenges of delivering safe surgical care in regional settings. A significant proportion of patients reside beyond the advised recovery radius, potentially increasing the risk of delayed recognition and management of postoperative complications. Thishighlights the importance of clear, consistent preoperative counselling regarding proximity to emergency care, particularly for patients living more than 45 minutes from an ENT-equipped facility.

Patients from regional and remote areas incur additional direct and indirect costs to access the same care as those residing closer to referral hospitals, often with little to no financial assistance. These costs may contribute to the nearly 20% non-adherence rate found in this study.

These findings have implications at both the clinician and health system level. At the clinician level, practical strategies may include clear and consistent preoperative counselling regarding postoperative proximity, provision of written instructions on discharge and reinforcement during follow-up. At the system level, structural barriers to adherence should also be addressed, including improving access to telehealth follow-up, subsidized accommodation and developing consistent, evidence-based guidelines to support equitable care for patients in regional and remote settings.

Further research is warranted to explore barriers to adherence and to evaluate the effectiveness of targeted interventions, including accommodation support, improved discharge communication, and enhanced follow-up protocols. Multi-centre or prospective studies could provide a more comprehensive understanding of adherence patterns and outcomes across diverse regional contexts. Standardized, evidence-based guidance from RACS or ASOHNS may also reduce variability in practice and ensure safer, more equitable access to tonsillectomy for regional Australians.

Conclusions

A substantial proportion of patients undergoing tonsillectomy at a regional Australian centre reside beyond the recommended proximity to emergency ENT care during the postoperative period. While self-reported adherence was high amongst those attending follow-up, the high FTA rate limits the strength of conclusions. These findings highlight the need for improved patient engagement, discharge planning, and system-level strategies to support safe postoperative recovery in geographically dispersed populations.

Acknowledgments

ChatGPT 4.0 was used to edit the manuscript for language, structure and readability. The authors thank Megan Green and Michael Markham for the administrative support.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://www.theajo.com/article/view/10.21037/ajo-2026-1-0002/rc

Data Sharing Statement: Available at https://www.theajo.com/article/view/10.21037/ajo-2026-1-0002/dss

Peer Review File: Available at https://www.theajo.com/article/view/10.21037/ajo-2026-1-0002/prf

Funding: None.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://www.theajo.com/article/view/10.21037/ajo-2026-1-0002/coif). Dr. D.M. serves as a Board Member of the Queensland Branch of the Australian Society of Otolaryngology Head and Neck Surgery and as Treasurer of the Australia and New Zealand Rhinologic Society (ANZRS). He has received consulting fees from and serves on an advisory board for Medtronic, which manufactures the Bizact device used in some procedures included in this study. Medtronic had no role in the study design, data collection, analysis, manuscript preparation, or decision to publish. The other author has no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The project was reviewed by the Darling Downs Health Human Research Ethics Committee (HREC) and determined to be a negligible-risk activity not requiring full HREC review (Reference: EX/2024/QTDD/106569). The HREC indicated that individual informed consent was not required, as the study involved analysis of routinely collected clinical data obtained as part of standard care without any additional risk or burden to patients.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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