3 Indications: Chronic/ recurrent tonsillitis Adenotonsillar hyperplasia with OSATonsillar hyperplasiaPeritonsillar abscessStreptococcal carriage with valvular heart diseaseAdenoiditisRecurrent/ chronic rhino sinusitis/Otitis media
4 Indications: Suspicion of malignancy Hemorrhagic tonsillitis Abnormal maxillofacial growthFailure to thriveChronic halitosisSpeech impairmentDysphagia
5 Contraindications: Systemic infection Uncorrected coagulopathy Occult/ frank cleft palateBifid uvula: clue to occult cleft palateSx: hypernasal speech,velopharyngeal incompetenceAdenoidectomy: partial
6 History: Infection Obstructive sleep apnea Bleeding tendencies, sickle cell diseaseUse of Acetylsalicylic acid ingestion: defer for 10 days…
7 URI: proceed??Higher incidence of respiratory complications but little residual morbidityRisk factors:ETT in child <5yrsPrematurityReactive airway diseaseParental smokingAirway surgeryCopious secretionsNasal congestionTait AR et al. Risk factors for perioperative adverse events in children with respiratory tract infections. Anesthesiology 2001;95: …
16 Armoured LMA: Disadvantages: Advantages: Risk of aspiration Inadequate positioningPilot balloon snaredTonsillar enlargement: difficult placementAdvantages:Patent with Boyle-Davis gagAvoid intubation& its complications
17 LMA:In the presence of a URI : evidence that a LMA may be superior to an ETT.Some evidence that the incidence of airway complications is lower than with an ETT. Most anesthesiologists, however, prefer the intraoperative security of an ETT.Robin G. Anesthetic management of pediatric adenotonsillectomy.CAN J ANESTH 2007 / 54: 12 / pp 1021–1025..
18 Extubation: Larngoscopy &thorough suction Positive airway pressure: Attenuates excitation of superior laryngeal nerve & diminish laryngospasmExpel secretionsMaintain oxygenationAwake/ deepLateral position, head down
19 Laryngospasm: Prevention: Deep extubation/ fully awake (OSA) I.V. lidocaineTopical anesthesiaMagnesiumCPAP at extubation
21 NSAIDS:NSAIDs did not cause any increase in bleeding requiring return to theatre. There was significantly less nausea & vomiting when NSAIDs were used compared to alternative analgesics.Cardwell et.al. Non-steroidal anti-inflammatory drugs and perioperative bleeding in paediatric tonsillectomy. Cochrane Database of Systematic Reviews 2005, Issue 2.
22 NSAIDS:Francis et al. Analgesics for postoperative pain after tonsillectomy and adenoidectomy in children.(Protocol) Cochrane Database of Systematic Reviews 2007, Issue 3.
23 Opioids:Decreased doses in OSAOpioid sparing effect of NSAIDS
24 Local anesthetic:Bupivaciane infiltration pre and post surgery, with & without adr, sprayReduces bleedingNo evidence that the use of perioperative LA in Pts undergoing tonsillectomy improves post-operative painHollis LJ et al. Perioperative local anesthesia for reducing pain following tonsillectomy. Cochrane Database of Systematic Reviews 1999, Issue 4.
25 TENS:TENS for post tonsillectomy pain relief is a safe, easy and promising method over alternative analgesic regimes which can be safely employed by the recovery staff.A.K.Gupta et al. POST - TONSILLECTOMY PAIN : DIFFERENT MODES OF PAIN RELIEF. Indian Journal of Otolaryngology and Head and Neck Surgery Vol. 54 No. 2, April - June 2002…
27 Antiemetics:Good evidence: prophylactic anti-emetic effect of dexamethasone, ondansetron, granisetron, tropisetron & dolasetron, metoclopramide are efficacious.Not sufficient evidence: dimenhydrinate/ perphenazine/ droperidol/ gastric aspiration/ acupuncture are efficaciousC. M. Bolton et al. Prophylaxis of postoperative vomiting in children undergoing tonsillectomy: A systematic review and meta-analysis. Br J Anaesth 2006; 97: 593–6041
28 Antiemetics: Concealed hemorrhage: with tropisetron, ondansetron P G Herreen et al. Concealed post-tonsillectomy hemorrhage associated with the use of the antiemetic; Anesthesia and Intensive Care; Aug 2001; 29, 4
29 PACU: Bleeding: Pain: Obstruction: PONV: severe C/I Oral intake not required for dischargeAdenoidectomy: safely discharged
30 American Academy Of Otolaryngology Head & Neck Surgery Pediatric Otolaryngology Committee Age ≤3 yrAbnormal coagulation with/without identified bleeding disorder in patient/familyEvidence of OSA/apneaCraniofacial/ other airway abnormalities, syndrome disorders: choanal atresia & laryngotracheal stenosisBarash 5th edition
31 Procedure done: acute peritonsillar abscess American Academy Of Otolaryngology Head & Neck Surgery Pediatric Otolaryngology CommitteeSystemic disorders: preop cardiopulmonary, metabolic/ general medical riskProcedure done: acute peritonsillar abscessExtended travel time, weather conditions & home social conditions not consistent with close observation, cooperation & ability to return to the hospital quickly
32 Post tonsillectomy bleeding: 1ºh’gge: < 24hrs, generally < 6 hrsMore brisk, fatal, profuse,slipping of ligatures2ºh’gge: 24hrs – 5/6 days post opEschar on tonsillar bed sloughsMeasures:Post nasal packRe-exploration
33 Re-exploration: O.1%incidence of re-exploration Mortality: 1:14000 Issues:Bleeding and HypovolemiaDifficult airwayAspiration
34 Bleeding: Signs and symptoms of hypovolemia: mild- severe Large bore i.v. accessCorrection: colloids and crystalloidsDifficult to estimate blood loss: adrenergic drive, swallowing of bloodHCT measurement
35 Difficult airway: Emergent tracheostomy Experienced anesthesiologist 2 large bore suction cathetersExtra laryngoscope handles and bladesCuffed ETT and stylets
37 OSADef: recurrent episodes of partial/ complete obstruction of upper airways during sleep resulting in disruption of normal ventilation & sleep patterns.2% prevalencePeak: 2-8 yrsLevel of obstruction: soft palate & base of tongue
41 OSA: clinical features ChildrenAdultsPeak agePreschoolMiddle ageGender ratioM=FM>F, postmenopausalCausesAdenotonsillar hypertrophy, obesity, craniofacial abnormalitiesObesityBody habitusFailure to thrive, normal, obese
42 OSA clinical features Daytime somnolence Uncommon Very common ChildrenAdultDaytime somnolenceUncommonVery commonNeurobehavioralHyperactivity, developmental delay, cognitive impairmentCognitive impairment, impaired vigilanceTreatment1º: surgical (adenotonsillectomy)2º: CPAP1º: CPAP2º: surgical (uvulopharyngoplasty)
43 Evaluation: Gold standard: polysomnography Any age Diff 1ºsnoring & OSASMay predict success of treatment/ postop complicationsDesaturate with relatively short apneas: <10sec maybe significantNormal children: usually not > 1 apnea/hr
45 Effect of treatment:Treating OSA by tonsillectomy &/or adenoidectomy is associated with increased gain in ht, wt & BMI in most children, including the obese &morbidly obeseNeurobehavioral, cor-pulmonale improvementZafer Soultan et al. Effect of Treating Obstructive Sleep Apnea by Tonsillectomy and/or Adenoidectomy on Obesity in Children. Pediatr Adolesc Med. 1999;153:33-37