Anesthesia for

Tonsillectomy/Adeniodectomy
NAQASH
LECTURER ANESTHESIA
TOSILLECTOMY AND
ADENIODECTOMY

 Tonsillectomy
Excision of lymphoid tissue form Oropharynx

 Adeniodectomy
Excision of lymphoid tissue from Nasopharynx
QUINSY
 A patient present with peritosillar abscess(quinsy)

 Normally treated with antibiotic and tonsillectomy

performed latter.

 If drainage is essential because of airway swelling.

 Pus usually aspirated with syringe and large needle

under local anesthesia

General Consideration
 Rose's Supine position
 Pad under shoulder
 Blood loss usually small, can bleed post operatively
 Practical technique
South facing RAE cuff/uncuff tube
Spontaneous ventilation/ IPPV
 Tonsillectomy and adenoidectomy procedure are
performed through mouth by using boyle-Davis gag
boyle-Davis gag
Preoperative….
 Children and young adult are usually operated

 Older adult for tonsillectomy may have malignancy

 Careful history to exclude OSA or active infection

 OSA in adult is associated with hypertension

 Bleeding disorder may sought CBC and clotting

studies are essential

Preoperative…..
 A thorough air way assessment is important

 Usually on day case anesthesia

 Topical LA on hands (mark sites of veins)

 Specific consent should be taken if suppositories

planned to be given
Premedication
 Local anesthetic gels (EMLA) should be applied to
those children for IV cannulation
 Sedative Premedication should not be given to those
with airway obstruction OR history of OSA
 An anxiolytic may be useful if there is time OR the
operation is to be performed at a predictable time.
 Antisialagogue is important (Atropine OR
Glycopyrolate
 Analgesic ( Paracetamol and other NSAID)
Perioperative management
 Standard monitoring should be applied to all patient
and provision made to assess blood loss
 Intravenous OR inhalational induction can be used.
 Patient are usually intubated with RAE tube south-
facing pre-formed (RAE,,, Ring-Adair-Elwyn)
 Some surgeon preferred nasal intubation for
tonsillectomy in adult patient.
 Check the length and patency of the Endotracheal tube
before surgery begins.
NASAL OR ORAL?
 Nasal intubation
 Disadvantages
 Epistaxis
 Adenoid injury
 Naso-pharyngeal tear
 Liable to obstruction
 Infection
 Aspiration
 Needs muscle relaxation

 Advantages
 Wider surgical field therefore preferred by some surgeons
Tonsillectomy position
Perioperative management ….
• Intubation may be difficult because of large tonsils but is usually
achieved using a non-depolarizing neuromuscular blocking
agent.
• Oral tube must be carefully secured in the midline in order to lie
correctly in boyle-Davis gag.
• With experienced senior personnel and a regular
surgical/anesthetist team the reinforced laryngeal mask airway
may be used for tonsillectomy.
• Surgeon must avoid soiling of the airway with blood
Comparing reinforced LMA & ETT
 100 pts / age 10-35 / ASA 1

LMA 50 ETT 50
surgical access 48 49
Cough Low frequency High frequency
Laryngospasam
stridor
Hemodynamic Non-significant Significant change
changes change from baseline from baseline
(at 1-5 min post
induction
Conclusion
Armored LMA is more reliable due to :
- Adequate surgical access
- Lower occurrence of BS, LS on recovery
- Fewer hemodynamic changes
Perioperative management ….
 patient are positioned with the neck extended.

 The eyes must be protected

 Instrumentation of the postnasal space during

adenoidectomy may induce bradycardia requiring

treatment with Atropine OR Glycopyrolate

 Perioperative opioids analgesic is usually required

together with intravenous paracetamol

Perioperative management ….
 One dose of dexametasone is necessary for the control

of emesis and pain

 Multimodal antiemetic therapy should also be used

because postoperative nausea and vomiting is a

frequent causes delay of discharge.

 Fluid therapy according to established criteria and

preoperative fasting
 Surgeons are meticulous about ensuring a dry
Tonsilar bed at the end of surgery and often place a
pack in the posterior of the pharynx to limit
draining of blood into the stomach during the
procedure.
 Inserting an orogastric tube into the stomach
before extubating the trachea while being careful
to not traumatize the adenoidectomy site is a
frequent maneuver to remove any blood that may
have drained into the stomach.
Extubation
 Extubation can be accomplished either deep

 Extubation can be accomplished either awake

 Depending on the performance and skill of the

recovery room staff .

 The patient should be in the head-down left lateral

position with guedel airway
 Infiltration of the local anesthetics into tonsillar bed
provide good postoperative analgesia.

 Blind or aggressive suctioning of the pharynx may

cause bleeding from the tonsillar bed and should be
avoided
Post-operative
 Keep the patient in tonsil position until airway reflexes

return.

 High quality recovery are essential.

 Post operative analgesia with opioids or NSAID

 Leave IV cannula in place in case of bleeding

 Beware of continually swallowing in recovery, a sign

of bleeding form the tonsil/adenoids

Tonsillar position
POSTOPERATIVE COMPLICATIONS
Common postoperative complication
of tonsillectomy
• Emesis (occurs in 30%–65% of patients; mechanism
unknown but may include the presence of irritant blood in
the stomach)
• Dehydration
• Hemorrhage (75% occurs in first 6 hours after surgery; if
surgical homeostasis is required, a full stomach and
hypovolemia should be considered)
• Pain (minimal after adenoidectomy and severe after
tonsillectomy)
• Post obstructive pulmonary edema (rare but possible if the
patient has had a prior acute upper airway obstruction;
treatment may include supplemental oxygen and
administration of diuretics)
 BLEEDING
 Not most common BUT most serious and most
challenging for the anesthesiologist

 It requires often dealing with

 Parents: Anxious
 Surgeon: Upset
 Child:
 Frightened • Anemic
 With a stomach full of blood • Hypo-volemic

 Role of anesthesia
 Review of record of original surgery (Difficult airway, medical
disease & intraop blood loss and fluid replacement)
 Ask about (Duration of bleeding attack & amount of blood vomitied)
 Quick history & examination ( childs volume status, s/s of hypotension)
 The presence of orthostatic hypotension indicates > 20% loss of
circulatory volume  aggressive resuscitation  blood
transfusion.
 !!!!!!! The onset of hypotension maybe delayed or even absent in
an awake patient  with anesthesia induced VD 
PRFOUND HYPOTENSION.

 Before Induction
 Vigorous resuscitation to
 Crystalloids (repeated bolus 20mg/kg)
 Colloids
 Hct , Hb & coagulation profile
 Cross-matching & preparation of 2 units of packed RBCs
  Induction
 Make available ; a styletted ETT/ 2 sets of illuminated
laryngoscopes/ 2 large bore rigid suction
 Left lateral position with head down to drain blood out of mouth.
 Place in supine position & Rapid sequence crash induction +
cricoid pressure after good oxygenation
 A reduced doses of these induction agents thiopental (2-3mg/kg)
, Propofol (1-2mgkg), Ketamine (1-2mgkg) followed by
Atropine (0.02mg/kg) combined e’ sux (1-2mgkg) for tracheal
intubation allow rapid control of airway without hypotension.
 There is no evidence that cricoid pressure risk of aspiration,
although it is common practice.
 Note that aspiration of blood does not have a similar effect as acid
aspiration unless the amount of blood aspirated compromises
oxygenation.
 Maintenance
 Titration of a volatile anesthetic such as sevoflurane or
desflurane e’ nitrous oxide & O2 supplemented
e’fentanyl (1-2ug/kg)
 Suction of the stomach under vision + prophylactic
antiemetic (Ondansetron 0.1mg/kg)

 Extubation: FULLY AWAKE in the lateral position

2. VOMITING
 Vomiting is the commonest cause of morbidity; re-
admission after day-case tonsillectomy & accounts for 30%
of re-admissions.
 Reasons for the high rate of vomiting after
tonsillectomy
 Surgical factors
 Trigeminal nerve stimulation
 Diathermy
 Swallowed blood

 Anesthetic factors
 Opiates
 Steroids
 Anti-emetics
 Inhalational anesthesia
 Laryngeal mask airway

 Patient factors :Age & Sex

 Anesthesia factors
 Opiates: + CRT zone  Vomiting center
 Steroids:
 Single, IV, intra-op dose of dexamethasone (0.15–1mg/kg halves
the risk of vomiting.
 Mechanism of action: Unknown

 Antiemetics
 Prophylactic ondansetron works better than either droperidol or
metoclopramide in reducing PONV
 Anti-emetics work best in combination because of their different
mechanisms of action.

 Inhalational anesthetics
 About 25% of patients suffer from PONV after volatile
anaesthetics.
 When total IV anaesthetic with Propofol is substituted for the
volatile anaesthetic, the risk of vomiting is reduced by 20%.
  LMA
 NO agreement in the literature on whether LMA reduces vomiting or not
 theoretically, it should be LESS as
 no muscle relaxant reversal is required
 less swallowed blood.

 Age factor
 Peak in late childhood (between 6–16 years) before decreasing in adulthood

 Sex factor
 Postoperative vomiting is 2–3 times more common in adult females than
adult males
Negative-pressure pulmonary edema
 Acute airway obstruction such as Laryngospasam can
 lead to negative-pressure pulmonary edema. This
occurs
 as the patient breathes against a closed glottis and
negative intrathoracic pressure is created. This pressure
is transmitted to interstitial tissue, where the
hydrostatic pressure gradient is increased and enhances
fluid movement out of the pulmonary circulation into
the alveoli. Airway obstruction in the postoperative
period can also be associated with retention of a
pharyngeal pack.