Anesthesia for Tonsillectomy

Tonsillectomy and adenoidectomy is a common procedure in pediatric anesthesia, and occasionally in adult anesthesia. It is unfortunately also associated with an increased risk of morbidity and mortality due to both patient population and surgical complications. Anesthetic technique can significantly affect outcomes, and there is still ongoing debate regarding many aspects of anesthetic management for these cases.

The American Academy of Otolaryngology-Head and Neck Surgery defines absolute indications for adenotonsillectomy as upper airway obstruction, dysphagia, sleep disorders (including obstructive sleep apnea [OSA]), peri tonsillar abscess recalcitrant to medical management, febrile seizures due to tonsillitis and need for tonsillar biopsy. OSA is increasing in prevalence as an indication for the procedure, and children may present very differently from adults: failure to thrive, behavior disturbances and poor school performance as opposed to the classic adult symptomatology. Disease severity is often not predicted by symptomatology. This patient population is at risk for postoperative apnea, which in children could lead to cardiac arrest. Some anesthesiologists advocate for limiting long-acting opiates such as hydromorphone in these patients, however adequate postoperative pain control is necessary to avoid postoperative nausea and vomiting (PONV) – a problematic complication in this surgical population given the increased risk of tonsillar bleeding with retching. Many practitioners will use multimodal analgesia of short and long acting opiates, acetaminophen, and NSAIDs. Toradol has been found to have an increased incidence of bleeding in a Cochrane analysis, but there is insufficient data to conclude other NSAIDs carry the same association. Local anesthesia infiltration under general anesthesia is employed in some centers to decrease narcotic usage, blocking the lesser palatine and glossopharyngeal nerves. This technique also tends to result in smoother extubations.

In addition to adequate postoperative pain control, administration of dexamethasone and ondansetron is relatively standard for the prevention of PONV. Studies have been conducted to investigate whether liberal IV hydration decreases PONV, and found that a bolus of 10-30ml/kg/hr in older children did result in significantly less nausea and vomiting.

The gold standard for airway management is an endotracheal tube (ETT), usually an oral RAE or reinforced ETT. Most prefer an oral ETT taped down the midline. However reinforced laryngeal mask airways (LMA) have been described in the literature for these procedures. LMAs carry a greater risk of laryngospasm and aspiration, but some argue they can allow for a smoother emergence and avoidance of neuromuscular blockade. If used, LMAs should be employed only by practitioners experienced with their use in adenotonsillectomy.

Controversy still exists whether to extubate these patients deep or awake. Some advocate that awake extubations are safest given decreased incidence of laryngospasm, aspiration, and post-extubation apnea. However deep extubations offer smoother emergence and decreased emergence delirium. Studies have not shown a significant difference in complications between the two. Dexmedetomidine has been employed in decreasing emergence delirium and providing a smoother postoperative recovery.

Finally, early recognition and prompt management of post-tonsillectomy bleeding is paramount in ensuring safe postoperative care of these patients. Hydration, large bore IV access, ensuring availability of suctioning, rapid sequence induction, and availability of blood products are cornerstones of management.

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