Tonsillectomy and Adenoidectomy

Airway: Requires either a south RAE, reinforced ETT, or flexible LMA.
Access: 22G-18G, depending on age.
Pain: Moderate; usually worst at day 5-7.
Position: Supine, head elevated with neck extended.
Time: 30-60min.
Blood loss: Usually minimal; ~4ml/kg in children. May be difficult to estimate if blood enters stomach.
Special: Antibiotic chemoprophylaxis are usually not required.

This covers anaesthesia for elective tonsillectomy. Anaesthetic management of the bleeding tonsil is covered elsewhere.

Removal of tonsils and adenoids. Performed for either:

Considerations

  • Indication for surgery
    Primary pathology may affect choice of premedication, opioids, and choice of discharge destination.
  • A
    • Risk of difficult mask ventilation and intubation
    • Discussion with surgeon about preferred airway
  • B
    • Presence and severity of OSA will affect
      • Secondary effects
        • CO2 retention
        • Failure to thrive
        • Cor pulmonale
      • Sensitivity to opioids and sedatives
        Generally avoid premedication in paediatric cohort.
      • Post-operative destination
      • Awake vs. deep extubation
    • Risk factors for post-operative apnoea
      • Age ⩽3
      • Moderate-severe OSA
      • Overnight nadir SpO2 ⩽90%
      • Ex-premature
      • Under/overweight
      • Syndromic
      • Recent RTI/asthma
      • Intraoperative desaturation
  • G
    • PONV prevention
      Suggest 0.5mg/kg of dexamethasone.
  • H
    • Coagulopathy

Preparation

  • Standard ANZCA monitoring in adults

Induction

  • Gas induction
    Common in children.

  • IV induction may be safer in severe OSA

  • Airway obstruction is common
    Often require CPAP to alleviate.

  • Intubation

    • Careful laryngoscopy to avoid bleeding from enlarged tonsils and adenoids

  • Laryngeal mask
    Reduced incidence of post-extubation complications.

Intraoperative

Maintenance with:

  • Propofol/remifentanil
    Smooth haemodynamics and emergence.
  • Deep volatile

Analgesia Strategies

Goal is to provide adequate analgesia and avoid post-operative apnoeas

A recipe:

  • Dexamethasone 0.2mg/kg
    Reduces pain, bleeding, PONV, and time to first oral intake.
  • Paracetamol 15mg/kg
  • Parecoxib 1mg/kg
  • Opioid
    • Children
      Fentanyl 1-2mcg/kg.
    • Adults
      Have more pain, and pain will depend on surgical technique.
      • Cold steel
        Less pain; fentanyl or smaller doses of morphine.
      • Bipolar diathermy
        Less pain.
      • Unipolar diathermy
        Significant pain. Morphine or oxycodone, often >10mg.

Surgical Stages

  • Positioning
  • Insertion of mouth gag
    • May compress ETT if not using a reinforced tube
    • Highly stimulating
    • May dislodge ETT
  • Adenoidectomy
    If performed, will be removed with a curette.
  • Packing of nasopharynx
  • Tonsillectomy
    • Superior pole drawn medially
    • Dissected from the tonsillar pillar and removed
  • Haemostasis

Postoperative

Emergence is critical:

  • Remove throat pack
    If used. Suction stomach if not used.
  • Careful suctioning
    Under vision.
  • Consider deep extubation
    • Most suitable in small children
    • Place left lateral, head-down
      Leave until fully awake.
  • Avoid coughing

Risk factors for post-operative airway events:

  • Age < 3 years
  • Severe OSA
  • Ex-premature
  • Under-overweight
  • Syndromic
  • Significant cardio/respiratory disease
  • Intercurrent RTI
  • Intraoperative event:
    • Desaturation
    • Use of CPAP
    • Delayed emergence

Post-operative care:

  • Day stay unless:
    • ⩽2 years old
      More likely to have severe airway obstruction postoperatively.
    • Severe OSA
    • Other comorbidities
  • Analgesia
    • Paracetamol QID
    • Celecoxib BD for 5/7
    • PRN opioid whilst in hospital
      Not on discharge.

References

  1. Coté CJ, Posner KL, Domino KB. Death or neurologic injury after tonsillectomy in children with a focus on obstructive sleep apnea: houston, we have a problem! Anesth Analg. 2014 Jun;118(6):1276-83.