Anesthesia Management of Adenotonsillectomy
Anesthesia Management of Adenotonsillectomy
Anesthesia Management of Adenotonsillectomy
10.5005/jp-journals-10003-1181
Anesthesia Management of Adenotonsillectomy
REVIEW ARTICLE
1
Assistant Professor, 2Additional Professor
1,2
Department of Anesthesiology, BYL Nair Hospital, Mumbai
Maharashtra, India
Corresponding Author: Deepa Suvarna, Assistant Professor
Department of Anesthesiology, BYL Nair Hospital, Mumbai
Maharashtra, India, Phone: 02228942046, e-mail: doctordeepas@
yahoo.co.in
Fig. 1: The tonsils
TONSILLECTOMY
Tonsils are removed by dissection. Either local or general
anesthesia can be employed. The mouth is kept open and
the tongue depressed with a Davis’ gag (The original
Davis’ gag was invented by Dr Davis, of Boston, Mass.
Henry Edmund Gaskin Boyle, 1875 to 1941, anesthetist, Fig. 2: Glossopharyngeal nerve block
St Bartholomew’s Hospital, London, improved it). The
tonsil is seized with vulsellum forceps. An incision is bupivacaine 0.5% with epinephrine. The distal 1.5 cm is
made through the mucous membrane, and the capsule of bent to 90°. An assistant retracts the tonsil laterally with
the tonsil is exposed. The tonsil is removed by dissection, the suction apparatus and the tongue is retracted with
starting at the upper (palatal) pole. When the pedicle a tongue depressor. The tip of the needle is directed
is defined, it is severed by a wire snare. Bleeding can laterally behind the posterior arch so that it lies deep to
be accurately stopped by ligating any bleeding vessels, the tonsil bed. The point of entry is anywhere behind the
arteries or veins. posterior arch. The 90° angle allows for safe contact with
the retropharyngeal mucosa. The needle tip will pierce
ADENOIDECTOMY the retropharyngeal mucosa laterally and can be safely
directed behind the tonsil blindly. After aspiration to
Adenoids are removed with a guarded curette pressed
avoid intravascular injection, 3 ml local anesthetic are
against the roof of the nasopharynx and then carried
injected in an adult. For a small child the dose is 1 to 2 ml.
backward and downward with a firm sweeping
Combined with general anesthesia, glossopharyngeal
movement.
nerve block improves operative conditions and provides
LOCAL NERVE BLOCKS excellent postoperative analgesia. Adult patients report
pain-free periods of more than 6 hours postoperatively.
The use of local anesthetic for tonsillectomy is not
Although children still often cry on awakening their
new. Many approaches have been described like the
recovery from anesthesia appears to be much smoother.
peritonsillar infiltration or injection at the base of the
tongue. PREOPERATIVE ASSESSMENT
The patient is positioned in a sitting or semi sitting
position. Two to three milliliter of 1 or 2% xylocaine is A thorough history taking is important. Note for history
infiltrated in upper pole near the anterior and posterior of recurrent respiratory infection and use of antibiotics,
pillar junction submucosally and along anterior pillars antihistaminics or other medications (may be blood
ballooning the infiltrated region another 2 ml is infiltrated thinners). In patients with obstructive sleep apnea
in the lower pole. The 1 to 2 ml injected beneath the syndrome (OSAS) long-standing hypoxia and hypercarbia
tonsillar capsule using the dental syringe by holding leads to increased airway resistance which in turn causes
and reflecting the anterior pillar with long (Hughes) pens pulmonary vasoconstriction. Thus, these patients can
intending to block the sensory supply of Lesser palatine have a higher pulmonary pressure which causes a right
nerve and glossopharyngeal nerve. sided heart failure (cor pulmonale). Facial features and
The glossopharyngeal nerve supplies most of the size of tonsils noted to judge the difficulty of intubation.
sensation responsible for pain transmission following Presence of wheezing or rales on auscultation of the
tonsillectomy or uvulopalatopharyngoplasty. It can chest may be sign of lower respiratory tract infection.
also be blocked using an intraoral approach with a Any teeth missing must be noted preoperatively. Teeth
single point injection where the nerve lies just deep to can be dislodged while performing laryngoscopy by the
the tonsil bed (Fig. 2). A standard 21 gauge, 4 cm needle anesthesiologist or the application of mouth gag by the
is attached to a Luer locked 3 ml syringe containing surgeon.
18
AIJOC
Flexible laryngeal mask airways (LMA) can be also Considerations for Post-tonsillectomy Bleed
used for tonsillectomies. They are advantageous as they
Bleeding tonsils are one of the most difficult problems
decrease the incidence of postoperative stridor and to be tackled even for an experienced anesthesiologist.
laryngospasm. Gentle assisted ventilation is both safe and It is evident from literature that most post-tonsillectomy
effective while using LMAs if peak inspiratory pressures bleeding occurred within the first 6 hours after surgery.
kept below 20 cm of water. Tonsillar enlargement could Secondary bleeding usually occurs from 24 hours
make placement of LMA difficult6 for which maneuvers to 5 to 10 days after surgery due to sloughing of the
like head extension, lateral insertion of LMA, anterior eschar. Many a times these children may be extremely
displacement of the tongue, pressure on the tip of the LMA hypovolemic and display tachycardia and pallor. It is
using the index finger or the use of laryngoscope may difficult to estimate the amount of blood swallowed by
be used. The opinions vary when it comes to extubating the patient hence this patient to be treated as full stomach.
these patients. Some authors believe in deep extubation A large bore intravenous line must be immediately
as it will prevent postextubation laryngospasm. established and blood to be sent for cross match. Blood
This author recommends awake extubation once the transfusion may be needed most of the times. Maintain
protective reflexes have returned after thorough oral and volume status with adequate fluid and blood transfusion
nasopharngeal suctioning. before induction of anesthesia. Definitive airway has to
be established once the patient is back in the OR. Well
Adrenaline and ENT Anesthesia functioning large bore suction tubes (disposable Yankur
suction tips) are necessary to evacuate clots from the
Arrhythmia by injection of adrenaline in a patient receiv-
oropharynx. After preoxygenation, atropine (0.02 mg/
ing inhalational anesthetic is a major and well known
kg) administered. Induction agent is guided by the
drug interaction. Modern inhalational anesthetics are
patient’s hemodynamic status. Care must be taken to
less prone to arrhythmias. Guidelines for the use of
prevent airway obstruction and regurgitation by applying
adrenaline are as follows:7,8
cricoids pressure. Ketamine 1 to 2 mg/kg or etomidate
• Maximal concentration of adrenaline solutions should
0.2 to 0.4 mg/kg can be used as induction agents. In some
be 1:100000 to 1:200000 (10.0–5.0 µg/kg)
conditions if necessary awake intubation may be done.
• The dose in adults should not exceed more than 10 ml
Once the bleeding is controlled oral or nasogastric tube
(100 µg) of 1:100000 given over 10 minutes
is placed to empty the clots from the stomach prior to
• The dose in adults should not exceed 30 ml of 1:100000
extubation. Patient is allowed to regain full consciousness
of adrenaline solution given during any 60 minutes before extubation.
period
• Avoid hypoxia and hypercapnia. Acute Postoperative Pulmonary Edema
Presence of pink frothy fluid in the endotracheal tube
Clinical Pearls
of an intubated patient or decreased oxygen saturation
• Hypercapnia facilitates dysrhythmias with increased respiratory rate, wheezing and dyspnea
• Pediatric patients seem to be somewhat less sensitive in extubated patient are all tell tale signs of negative
to this effect, but caution should still be used. pressure pulmonary edema. The rapid relief of airway
• Hypertension seems to provoke the dysrhythmias. obstruction→decreased airway pressure→increase
Several alternative vasoconstrictors like phenylephrine venous return→increase in pulmonary hydrostatic
and ephedrine can be used by mutual consultation with pressure→hyperemia→pulmonary edema. Moderate
the surgeon. These drugs are less arrhythmogenic. continuous positive airway pressure (CPAP) allows
circulatory adaptation time. Treatment is generally
POSTANESTHESIA COMPLICATION supportive with maintaining a patent airway, oxygenation
and diuretics. Positive end-expiratory pressure (PEEP)
Postoperative Nausea Vomiting may be required in some cases. Patients resolve within
Postoperative emesis may occur due to pharyngeal 24 hours.
mucosal irritation and swallowed bloody secretion from
surgery. Antiemetics like metoclopramide or ondansetron OUTPATIENT TONSILLECTOMY
may be given. Dexamethasone helps in reducing swelling Outpatient tonsillectomies have been always contro-
and avoiding postoperative nausea vomiting (PONV). versial. The major concerns for nonadvocates have
Dehydration secondary to reduced intake and PONV been unrecognized delayed blood loss, nausea/vomit-
should be aggressively treated with intravenous fluids.9 ing and dehydration. Advances in anesthetic agents
20
AIJOC
have enabled us to conduct outpatient tonsillectomies. 3. Berkowitz RG, Zaltzal GH. Tonsillectomy in children under
Successful ambulatory anesthesia includes correct patient 3 years of age. Arch Otolaryngol Head Neck Surg 1990;
selection and meticulous preoperative evaluation. An 116:685.
4. Ferrari L. Anaesthesia for paediatric ENT procedures.
assessment prior to day of surgery prevents last minute
Danamiller Memorial education foundation. Progr Anaesth
cancellations and gives us enough time to optimize the
2001;15:15.
patients. Patients with history of bleeding disorders or 5. Deutsch E. Tonsillectomy and adenectomy changing
deranged coagulation profile, patient on blood thinning indications. Pediatr Clin North Am 1996;43:1319.
medications, children < 3 years of age are not suitable 6. Mason D, Bingham R. The laryngeal mask airway in children.
for ambulatory tonsillectomies.10 In day care surgery Anaesth 1990;45:760.
the responsibility of postoperative care lies with patient 7. Katz RL, Katz JG. Surgical infiltration of pressor drugs and
and his relatives hence clear instructions must be written their interaction with volatile anesthetics. Br J Anaesth
1976;38:712.
down. Amnestic agents (midazolam) must be carefully
8. Brown BR Jr. Anesthesia for ear, nose, throat and maxillofa-
administered in these patients as it could lead to patient
cial procedures. In: Prys-Roberts C, Brown BR Jr, editors. Int
forgetting his postoperative instructions. Patient may Pract Anaesth. Vol 2 1st edition 1996, Butterworth Heinemann
therefore be discharged only with a responsible accom- 112(1-9).
panying person. 9. Landman IS, Werkhaven JA, Motoyama EK. Anaesthesia for
pediatric otorhinolaryngologic surgery. In: Motoyama EK,
REFERENCES Davis PJ, editors. Anaesthesia for Infants and children. 7th ed.
1. Brodsky L. Modern assessment of tonsils and adenoids. 2006:789-823.
Pediatr Clin North Am 1989;36:1551. 10. Ferrari LR, Gotta AW. Anaesthesia for otolaryngologic
2. Davies DD. Re-anaesthetizing cases of tonsillectomy surgery. In: Barash PG, editor: Clinical anaesthesia sixth
and adenoidectomy because of persistent postoperative edition 2009 by Lippincott Williams and Wilkins. p. 1305-
hemorrhage. Br J Anaesth 1964;36:244-250. 1320.