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

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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[1]. 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[2].

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[1].

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[3]
  • 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)[4][5]

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[6]
  • 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)[1][7])
    • 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[8]

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)[9]
      • 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 [10]
    • Opioids
      • Consider reducing opioid doses by 50% for children with significant OSA, accompanied by continuous monitoring including pulse oximetry and prolonged PACU observation [11]

PONV prophylaxis

  • Serotonergic antagonists
    • Ondansetron (0.1 mg/kg single dose; maximum 4 mg) with intraoperative dexamethasone[12]
      • Cochrane systematic review showed that compared to placebo, children receiving dexamethasone were half as likely to vomit in the first 24 hours[13]
  • Promethazine is associated with risk of sedation and respiratory depression in the setting of residual anesthesia and opioids [14]

Potential complications

  • High risk of postoperative pulmonary complications, especially in patients with severe OSA[15][16]
    • Postoperative respiratory complications occur in 5.8% to 26.8% of children with OSA undergoing tonsillectomy[17][18]
    • 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[19]
    • 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

References

  1. 1.0 1.1 1.2 Mitchell, Ron B.; Archer, Sanford M.; Ishman, Stacey L.; Rosenfeld, Richard M.; Coles, Sarah; Finestone, Sandra A.; Friedman, Norman R.; Giordano, Terri; Hildrew, Douglas M.; Kim, Tae W.; Lloyd, Robin M. (2019-02-01). "Clinical Practice Guideline: Tonsillectomy in Children (Update)". Otolaryngology–Head and Neck Surgery. 160 (1_suppl): S1–S42. doi:10.1177/0194599818801757. ISSN 0194-5998.
  2. "Ambulatory surgery in the United States, 2006". stacks.cdc.gov. Retrieved 2021-05-16.
  3. Van Someren, V. H.; Hibbert, J.; Stothers, J. K.; Kyme, M. C.; Morrison, G. A. (1990-06-01). "Identification of hypoxaemia in children having tonsillectomy and adenoidectomy". Clinical Otolaryngology and Allied Sciences. 15 (3): 263–271. doi:10.1111/j.1365-2273.1990.tb00784.x. ISSN 0307-7772. PMID 2394027.
  4. Hollis, L. J.; Burton, M. J.; Millar, J. M. (2000). "Perioperative local anaesthesia for reducing pain following tonsillectomy". The Cochrane Database of Systematic Reviews (2): CD001874. doi:10.1002/14651858.CD001874. ISSN 1469-493X. PMC 7025437. PMID 10796831.
  5. Bean-Lijewski, J. D. (1997-06-01). "Glossopharyngeal nerve block for pain relief after pediatric tonsillectomy: retrospective analysis and two cases of life-threatening upper airway obstruction from an interrupted trial". Anesthesia and Analgesia. 84 (6): 1232–1238. doi:10.1097/00000539-199706000-00011. ISSN 0003-2999. PMID 9174298.
  6. Wynne, D.M.; Marshall, J.N. (2002-10-01). "Risk of accidental extubation with disposable tonsillectomy instruments". British Journal of Anaesthesia. 89 (4): 659. doi:10.1093/bja/aef548. ISSN 0007-0912.
  7. Patino, M.; Sadhasivam, S.; Mahmoud, M. (2013-12-01). "Obstructive sleep apnoea in children: perioperative considerations". British Journal of Anaesthesia. 111: i83–i95. doi:10.1093/bja/aet371. ISSN 0007-0912.
  8. Mitchell, Ron B.; Archer, Sanford M.; Ishman, Stacey L.; Rosenfeld, Richard M.; Coles, Sarah; Finestone, Sandra A.; Friedman, Norman R.; Giordano, Terri; Hildrew, Douglas M.; Kim, Tae W.; Lloyd, Robin M. (2019). "Clinical Practice Guideline: Tonsillectomy in Children (Update)". Otolaryngology–Head and Neck Surgery. 160 (1_suppl): S1–S42. doi:10.1177/0194599818801757. ISSN 0194-5998.
  9. Guler, Gulen; Akin, Aynur; Tosun, Zeynep; Ors, Sevgi; Esmaoglu, Aliye; Boyaci, Adem (2005-09-01). "Single-dose dexmedetomidine reduces agitation and provides smooth extubation after pediatric adenotonsillectomy". Paediatric Anaesthesia. 15 (9): 762–766. doi:10.1111/j.1460-9592.2004.01541.x. ISSN 1155-5645. PMID 16101707.
  10. Rabbani, Cyrus C.; Pflum, Zachary E.; Ye, Michael J.; Gettelfinger, John D.; Sadhasivam, Senthil; Matt, Bruce H.; Dahl, John P. (2020-11-01). "Intraoperative ketorolac for pediatric tonsillectomy: Effect on post-tonsillectomy hemorrhage and perioperative analgesia". International Journal of Pediatric Otorhinolaryngology. 138: 110341. doi:10.1016/j.ijporl.2020.110341. ISSN 0165-5876.
  11. Patino, M.; Sadhasivam, S.; Mahmoud, M. (2013-12-01). "Obstructive sleep apnoea in children: perioperative considerations". British Journal of Anaesthesia. 111: i83–i95. doi:10.1093/bja/aet371. ISSN 0007-0912.
  12. Bolton, C. M.; Myles, P. S.; Nolan, T.; Sterne, J. A. (2006-11-01). "Prophylaxis of postoperative vomiting in children undergoing tonsillectomy: a systematic review and meta-analysis". British Journal of Anaesthesia. 97 (5): 593–604. doi:10.1093/bja/ael256. ISSN 0007-0912. PMID 17005507.
  13. Steward, David L; Grisel, Jedidiah; Meinzen-Derr, Jareen (2011-08-10). "Steroids for improving recovery following tonsillectomy in children". Cochrane Database of Systematic Reviews. doi:10.1002/14651858.cd003997.pub2. ISSN 1465-1858.
  14. Starke, Peter R.; Weaver, Joyce; Chowdhury, Badrul A. (2005-06-23). "Boxed warning added to promethazine labeling for pediatric use". The New England Journal of Medicine. 352 (25): 2653. doi:10.1056/NEJM200506233522522. ISSN 1533-4406. PMID 15972879.
  15. Marrugo Pardo, G.; Romero Moreno, L. F.; Beltrán Erazo, P.; Villalobos Aguirre, C. (2018-11-01). "Respiratory Complications of Adenotonsillectomy for Obstructive Sleep Apnea in the Pediatric Population". Sleep Disorders. Retrieved 2021-09-13.
  16. Patino, M.; Sadhasivam, S.; Mahmoud, M. (2013-12-01). "Obstructive sleep apnoea in children: perioperative considerations". British Journal of Anaesthesia. 111: i83–i95. doi:10.1093/bja/aet371. ISSN 0007-0912.
  17. Saur, John S.; Brietzke, Scott E. (2017). "Polysomnography results versus clinical factors to predict post-operative respiratory complications following pediatric adenotonsillectomy". International Journal of Pediatric Otorhinolaryngology. 98: 136–142. doi:10.1016/j.ijporl.2017.05.004. ISSN 0165-5876.
  18. Keamy, Donald G.; Chhabra, Karan R.; Hartnick, Christopher J. (2015). "Predictors of complications following adenotonsillectomy in children with severe obstructive sleep apnea". International Journal of Pediatric Otorhinolaryngology. 79 (11): 1838–1841. doi:10.1016/j.ijporl.2015.08.021. ISSN 0165-5876.
  19. Fields, Ryan G.; Gencorelli, Frank J.; Litman, Ronald S. (2010-11-01). "Anesthetic management of the pediatric bleeding tonsil". Paediatric Anaesthesia. 20 (11): 982–986. doi:10.1111/j.1460-9592.2010.03426.x. ISSN 1460-9592. PMID 20964765.