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Moderator: Dr. Anjolie Presenters: Dr. Senthil Dr. Dipal

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1 Moderator: Dr. Anjolie Presenters: Dr. Senthil Dr. Dipal
Adenotonsillectomy & OSA Moderator: Dr. Anjolie Presenters: Dr. Senthil Dr. Dipal


3 Indications: Chronic/ recurrent tonsillitis
Adenotonsillar hyperplasia with OSA Tonsillar hyperplasia Peritonsillar abscess Streptococcal carriage with valvular heart disease Adenoiditis Recurrent/ chronic rhino sinusitis/Otitis media

4 Indications: Suspicion of malignancy Hemorrhagic tonsillitis
Abnormal maxillofacial growth Failure to thrive Chronic halitosis Speech impairment Dysphagia

5 Contraindications: Systemic infection Uncorrected coagulopathy
Occult/ frank cleft palate Bifid uvula: clue to occult cleft palate Sx: hypernasal speech, velopharyngeal incompetence Adenoidectomy: partial

6 History: Infection Obstructive sleep apnea
Bleeding tendencies, sickle cell disease Use of Acetylsalicylic acid ingestion: defer for 10 days…

7 URI: proceed?? Higher incidence of respiratory complications but little residual morbidity Risk factors: ETT in child <5yrs Prematurity Reactive airway disease Parental smoking Airway surgery Copious secretions Nasal congestion Tait AR et al. Risk factors for perioperative adverse events in children with respiratory tract infections. Anesthesiology 2001;95: …

8 Examination: Oral & nasal airway patency: mouth breathing, nasal quality of speech, chest retractions, wheeze, stridor, rales Adenoid facies: elongated face, high arched palate, retrognathic mandible Tonsil size: Loose teeth: age, laryngoscopy, mouth gag Syndromes

9 Syndromes: Treacher Collins syndrome Crouzon's syndrome
Goldenhar syndrome Pierre Robin C.H.A.R.G.E. association Achondroplasia Down syndrome Mucopolysccharidoses: Hunter 1& 2…

10 Tonsil size: Classification of tonsil size, including percentage of oropharyngeal area occupied by hypertrophied tonsils Barash,5th edition

11 Investigations: HB, Hct, Platelet count Bleeding time Clotting time
X-ray: neck lateral view: adenoids PT/ aPTT vWD, factor VIII deficiency XRAY chest: LRI

12 Premedication: Sedation: oral midazolam 0.5mg/kg
Antisialagouge: dry secretions better operating field NPO Consent Blood arranged

13 Monitoring: SPO2 ETCO2 Precordial stetho ECG Temp BP PAP Blood loss
Appropriate size i.v. catheter

14 Airway management Intravenous/ inhalational
Preformed RAE ETT cuffed0.5-1 cm smaller size Oral packing: uncuffed tube Armoured LMA Midline fixation Brown- Davis mouth gag

15 Anesthesia: Maint: propofol infusion/ inhalational/ muscle relaxant
Spontaneous/ controlled ventilation Pain management PONV prophylaxis

16 Armoured LMA: Disadvantages: Advantages: Risk of aspiration
Inadequate positioning Pilot balloon snared Tonsillar enlargement: difficult placement Advantages: Patent with Boyle-Davis gag Avoid 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 laryngospasm Expel secretions Maintain oxygenation Awake/ deep Lateral position, head down

19 Laryngospasm: Prevention: Deep extubation/ fully awake (OSA)
I.V. lidocaine Topical anesthesia Magnesium CPAP at extubation

20 Pain management: NSAIDS Opioids Local infiltration TENS

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 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 OSA Opioid sparing effect of NSAIDS

24 Local anesthetic: Bupivaciane infiltration pre and post surgery, with & without adr, spray Reduces bleeding No evidence that the use of perioperative LA in Pts undergoing tonsillectomy improves post-operative pain Hollis 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…

26 PONV: Incidence: 40-70% Irritant blood in stomach Inflammation/ edema
Dehydration: poor oral intake Prophylaxis: Maintain adequate hydration Gastric decompression Antiemetic drugs Acupuncture

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 efficacious C. 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 discharge Adenoidectomy: safely discharged

30 American Academy Of Otolaryngology Head & Neck Surgery Pediatric Otolaryngology Committee
Age ≤3 yr Abnormal coagulation with/without identified bleeding disorder in patient/family Evidence of OSA/apnea Craniofacial/ other airway abnormalities, syndrome disorders: choanal atresia & laryngotracheal stenosis Barash 5th edition

31 Procedure done: acute peritonsillar abscess
American Academy Of Otolaryngology Head & Neck Surgery Pediatric Otolaryngology Committee Systemic disorders: preop cardiopulmonary, metabolic/ general medical risk Procedure done: acute peritonsillar abscess Extended 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 hrs More brisk, fatal, profuse, slipping of ligatures 2ºh’gge: 24hrs – 5/6 days post op Eschar on tonsillar bed sloughs Measures: Post nasal pack Re-exploration

33 Re-exploration: O.1%incidence of re-exploration Mortality: 1:14000
Issues: Bleeding and Hypovolemia Difficult airway Aspiration

34 Bleeding: Signs and symptoms of hypovolemia: mild- severe
Large bore i.v. access Correction: colloids and crystalloids Difficult to estimate blood loss: adrenergic drive, swallowing of blood HCT measurement

35 Difficult airway: Emergent tracheostomy Experienced anesthesiologist
2 large bore suction catheters Extra laryngoscope handles and blades Cuffed ETT and stylets

36 Anesthesia: Sedation:?? Preoxygenation Rapid sequence induction
Induction: thiopentone/ propofol/ etomidate/ ketamine MR: succinylcholine/ rocuronium Gastric tube Extubation: fully awake, normal gag & cough reflexes

37 OSA Def: recurrent episodes of partial/ complete obstruction of upper airways during sleep resulting in disruption of normal ventilation & sleep patterns. 2% prevalence Peak: 2-8 yrs Level of obstruction: soft palate & base of tongue

38 Pathophysiology: Anatomical: upper airway narrowing: adenotonsillar hypertrophy, craniofacial anomalies Obesity: strongest predictor Neuromotor factors: reduced central mediated activation of upper airway muscles, neuromuscular diseases

39 Clinical features: Daytime: Mouth breathing Poor school performance
Daytime somnolence Morning headaches Fatigue Hyperactivity Aggression Social withdrawal Nocturnal: Snoring Labored breathing Paradoxical respiratory effort Apnea Sweating Unusual sleep positions Enuresis

40 Complications: Growth impairment: failure to thrive
PHT, cor-pulmonale, heart failure BP dysregulation Each apneic episode-increased PAP-significant PAH & systemic HT- ventricular dysfunction- dysrrhythmias CNS dysfunction: persistent hypercarbia

41 OSA: clinical features
Children Adults Peak age Preschool Middle age Gender ratio M=F M>F, postmenopausal Causes Adenotonsillar hypertrophy, obesity, craniofacial abnormalities Obesity Body habitus Failure to thrive, normal, obese

42 OSA clinical features Daytime somnolence Uncommon Very common
Children Adult Daytime somnolence Uncommon Very common Neurobehavioral Hyperactivity, developmental delay, cognitive impairment Cognitive impairment, impaired vigilance Treatment 1º: surgical (adenotonsillectomy) 2º: CPAP 1º: CPAP 2º: surgical (uvulopharyngoplasty)

43 Evaluation: Gold standard: polysomnography Any age
Diff 1ºsnoring & OSAS May predict success of treatment/ postop complications Desaturate with relatively short apneas: <10sec maybe significant Normal children: usually not > 1 apnea/hr

44 Treatment : Surgery: Adenotonsillectomy Uvulopharyngoplasty

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 obese Neurobehavioral, cor-pulmonale improvement Zafer 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

Polysomnography ECG: PHT,RVH, cor- pulmonale ABG: metabolic acidosis, hypercarbia Antireflux medications Sedation: monitoring, titrated

47 Anesthetic plan: Inhaled/ intravenous: titrated CPAP 10-15 cm
Oral airway/ jaw thrust/ other Difficult airway management: FOB/ LMA Pain: opioid sparing adjuncts, non-opioid analgesics, nonpharmacological preferred Extubation: awake in OT/ ICU

48 PERIOP COMPLICATIONS Apnea Pulmonary edema PHT crisis Pneumonia
ICU care Prognosis: 13% recurrence

49 Peritonsillar abscess
Older children Severe sore throat, odynophagia, high fever, trismus Limited mouth opening-difficult airway Head down position, turned to side of abscess I &D: sedation/ topical/ LA/ GA Spontaneous breathing maintained Gentle laryngoscopy, suction Cuffed ETT

50 Thank you

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