Tonsillectomy and/or adenoidectomy

Tonsillectomy and/or adenoidectomy

Anesthesia type	General
Airway	ETT (consider oral RAE)
Lines and access	PIV
Monitors	Standard 3 or 5-lead ECG
Primary anesthetic considerations
Preoperative	Assess OSA severity if present Avoid anxiolytics if severe OSA
Intraoperative	Mask induction if no PIV Shared airway with surgeon Lower FiO2 to reduce risk of airway fire Emerge after complete hemostasis is achieved Protect airway from blood/secretions Increased incidence of laryngospasm
Postoperative	Smooth, rapid emergence (short case) High risk of postoperative respiratory complications OSA precautions PONV prophylaxis
Article quality
Editor rating	Comprehensive
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Tonsillectomy and/or adenoidectomy (often abbreviated T&A) is a surgical procedure to remove the tonsils with/without adenoids, which are lymphoid tissues encircling the posterior oropharynx. Indications for T&As include 1) recurrent throat infections, 2) obstructive sleep-disordered breathing. While infections used to be the most common indication in the past, the majority of tonsillectomies are now being performed for obstructive sleep apnea (OSA). Tonsillectomies are the second most common ambulatory surgery performed in children under 15 years old in the United States.

Preoperative management

Patient evaluation

System	Considerations
Airway
Neurologic
Cardiovascular
Pulmonary	OSA is the most common indication for T&As. Polysomnography (sleep study) is useful to assess for severity of OSA. For patients without a polysomnography, access for sleep-disordered breathing with questions about snoring and apnea; other symptoms may include excessive daytime sleepiness, inattention, poor concentration, or hyperactivity. Patients often have a history of frequent URIs which may affect the optimal timing of an elective surgery.
Gastrointestinal	Standard NPO guidelines.
Hematologic	Assess for history of bleeding tendencies or easy bruising, given the risk of postoperative hemorrhage.
Renal
Endocrine
Other

Labs and studies

• The American Academy of Otolaryngology–Head and Neck Surgery recommends referring the following children with obstructive sleep-disordered breathing for polysomnography pre-operatively if:
  1. The child is <2 years of age, or
  2. The child exhibits any of the following: obesity, Down syndrome, craniofacial abnormalities, neuromuscular disorders, sickle cell disease, or mucopolysaccharidoses.

Operating room setup

• Consider a cuffed oral RAE ETT or wire reinforced ETT
• Accordion

Patient preparation and premedication

• Consider distraction methods (toys, videos, tablet computers, games, parental presence if deemed appropriate) as opposed to anxiolytics in children with severe OSA
• If giving preoperative anxiolytics, consider continuous pulse oximetry monitoring for children with OSA
• Consider preoperative albuterol treatment for patients with recent URI <2 weeks ago or moderate-severe OSA

Regional and neuraxial techniques

• Local anesthesia is controversial and not preferred (risk of significant complications associated with local infiltration)

Intraoperative management

Monitoring and access

• Standard ASA monitors
• 5-lead EKG if needed
• PIV, often will have to be done post-induction in children

Induction and airway management

• Mask induction if no PIV
• Intubation with cuffed ETT - consider oral RAE or wire-reinforced ETT
  • If in-between sizes for oral RAE, consider larger size given the risk of extubating with neck extension during surgery
  • If normal ETT, tape midline
• Deep intubation vs paralysis
  • T&As are generally short procedures (30 min - 1 hour)
  • Consider using a low dose of NDMB or succinylcholine if opting to paralyze for intubation to allow for reversal at the end of the case

Positioning

• Supine with neck extended
• Table is usually turned 90 degrees

Maintenance and surgical considerations

• Maintain anesthetic depth with sevoflurane
• Lower FiO2 to lowest possible to reduce risk of airway fire (preferably below 30%)
• Consider higher volume hydration (if tolerated) to prevent PONV
• Consider dexamethasone 0.5 mg/kg IV to prevent airway edema

Emergence

• Administer PONV prophylaxis
  • Single-dose IV dexamethasone at the beginning of the case
  • Strongly consider a second agent for PONV prophylaxis, such as ondansetron
• Emerge only after the surgeon has achieved hemostasis
• Have surgical team consider placing an OG tube for gastric decompression at case conclusion
• Thoroughly suction the oropharynx prior to emergence to remove blood and secretions, as children who undergo tonsillectomy are at increased risk of laryngospasm and airway reactivity
• Extubate awake for patients with severe OSA

Postoperative management

Disposition

• Consider arranging for inpatient postoperative monitoring for:
  • Age < 3 years
  • Severe OSA (AHI ≥10 obstructive events/hour, oxygen saturation nadir <80%, or both))
  • Coagulation disorder
  • Inability to provide close observation post discharge (eg. families with extended travel time or social issues)  
  • Comorbid serious systemic disorders
• Consider arranging for PICU postoperative monitoring for:
  • Very severe OSA (AHI >30), for associated desaturation events, and for those with comorbidities with a known difficult airway or a syndrome with craniofacial abnormalities (e.g. Down Syndrome, Treacher Collins, Crouzon, Goldenhar, Pierre Robin, CHARGE) potentially predisposing them to postoperative airway obstruction

Pain management

• Procedure itself is quite painful
• Multimodal pain control is strongly preferred, given that children with OSA are more susceptible to the respiratory depressant effects of opioids
  • Nonopioids
    • IV dexamethasone (usually 0.1 to 0.5 mg/kg IV, usual maximum of 10 mg)
    • IV acetaminophen (usually 15mg/kg for patients above age 2, 10mg/kg for children below 2 years old)
    • Dexmedetomidine (single loading-dose of 0.3-0.5 mcg/kg)
    • Consider low-dose ketamine as an opioid-sparing agent in patients with severe OSA; however, it may also increase postoperative agitation and secretions
    • IV NSAIDs are controversial because of the risk of tonsillar bleeding and remain highly surgeon dependent despite emerging evidence that shows similar bleeding rates with ketorolac use in children
  • Opioids
    • Consider reducing opioid doses by 50% for children with significant OSA, accompanied by continuous monitoring including pulse oximetry and prolonged PACU observation

PONV prophylaxis

• Serotonergic antagonists
  • Ondansetron (0.1 mg/kg single dose; maximum 4 mg) with intraoperative dexamethasone
    • Cochrane systematic review showed that compared to placebo, children receiving dexamethasone were half as likely to vomit in the first 24 hours
• Promethazine is associated with risk of sedation and respiratory depression in the setting of residual anesthesia and opioids

Potential complications

• High risk of postoperative pulmonary complications, especially in patients with severe OSA
  • Postoperative respiratory complications occur in 5.8% to 26.8% of children with OSA undergoing tonsillectomy
  • Common causes include negative pressure pulmonary edema and acute airway obstruction
• Risk of postoperative hemorrhage and its associated adverse events, including hypoxemia (most common adverse event), bradycardia, hypotension, and difficult intubation
  • Considerations for control of hemorrhage "take-back" cases
    • Surgical emergency
    • Presume the patient has a full stomach of blood: RSI with careful, yet diligent gastric decompression at the case end
    • May require aggressive resuscitation for hypovolemia
    • Potentially difficult airway due to blood in oropharynx and swollen post-surgical tissue beds
      • Styleted ETT
      • Have additional providers for help
      • Have additional suction ready

Procedure variants

	Variant 1	Variant 2
Unique considerations
Position
Surgical time
EBL
Postoperative disposition
Pain management
Potential complications