1. Tonsillectomy – case presentation
Moderator : Dr(Prof.) Maya
Presenter: Priyanka jain

2. ANKUR
16 years old male
Student of class 10 th
Noida ( U.P.)

3. Chief complaints:
Difficulty in breathing through nose × 13 yrs
Associated with recurrent episodes of URI

4. HOPI :
The parents noticed difficulty in breathing through nose since 2-3 years of age
sleeping with open mouth
occasional episodes of difficulty in breathing and restlessness during sleep .
no h/o morning headache , nocturnal awakening , feeling sleepy during daytime .

5. h/o regular use of nasal decongestant drops to relieve obstruction recurrent episodes of URI once every month No current h/o fever , cough , cold, earache No h/o orthopnea, syncope, cyanosis

6. No H/O
excessive bleeding from any site
blood transfusion
seizures, cyanosis , drug allergy .

7. Past history : no h/o any other medical and surgical illness .
Family history : no h/o bleeding disorder
Personal history : school performance good
vegetarian
bowel bladder habits N

8. EXAMINATION GPE: Alert awake and cooperative
Well oriented to time space and person
Average build
Speech quality : normal
Facies : prominent nose, maxillary hypoplasia,

9. EXAMINATION
Wt : 45 kg Ht : 160 cm VITALS : PR : 80/min rt. radial , regular , normal volume and character, no radioradial and radiofemoral delay BP: 106/ 74 mm Hg , RUAS. Afebrile

10. EXAMINATION
No pallor, icterus , cyanosis , clubbing , edema Oral and airway examination : MMP I, NM and MO wnl TMD 6 cm B/L tonsils enlarged ( grade II) No deviated nasal septum B/L nostrils patent . No loose teeth

11. Respiratory system: Inspection : trachea central,
Chest was symmetrical in shape , both sides moving equally with respiration.
Palpation : findings on inspection confirmed.
Auscultation: B/L NVBS

12. CVS Apex beat in 5th intercostal space midclavicular line
No visible swelling ,abnormal pulsations
S1S2 heard , no murmur

13. Investigations: Hb : 13.9gm/dl TLC : 11,200/ cu mm
DLC : N 70, L 20, M 2
Platelet : 3,04,000/ cu mm
Bleeding time : 3.15 min ( upto 7 min)
Clotting time : 6.40 min( upto 11 min)

14. Tonsil size: grading
Barash,5th edition …

15. Anesthetic concerns Age URTI OSA Difficult airway Airway surgery Ponv
Pain management
Bleeding
Post op complications

16. Post tonsillectomy bleeding:
Primary : < 24hrs, generally < 6 hrs
More brisk, fatal, profuse,
slipping of ligatures
Secondary: 24hrs – 5/6 days post op
Eschar on tonsillar bed sloughs
Measures:
Post nasal pack
Re-exploration

17. Re-exploration: Issues: Bleeding and Hypovolemia Difficult airway
Aspiration
Emergency surgery full stomach with blood

18. Anesthetic management
Assessment
Volume repletion
OT preparation : suction , iv lines large bore ,
Difficult airway
Positioning
RSI
Tracheostomy

19. Bleeding: Large bore i.v. access
Correction: crystalloids ,colloids , blood
Difficult to estimate blood loss: adrenergic drive, swallowing of blood
HCT measurement

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

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

22. Laryngospasm Risk factors : Anesthesia related Inadequate depth
Airway irritation with volatiles( D> I> E>H=S), mucus or blood and suction catheter or laryngoscope.
Thiopentone  increase incidence
Propofol< Sevo
Less experience

23. Patient related
Age
URI
Smoking
GERD
H/o choking during sleep

24. Surgery related
T&A (21-26%)
Appendicectomy,
cervical dilation,
hypospadias,
thyroid

25. Prevention
adequate depth
Awake vs deep extubation
Positive pressure before extubation ( artificial cough)
Drugs : anticholinergics , BZD, lidocaine , magnesium ( 15mg/kg in 30 ml 0.9% NS over 20 min after intubation)
Acupunture

26. Treatment
Remove the stimulus Jaw thrust Laryngospasm notch Oral or nasal airway PPV with 100% oxygen Deepen anesthesia Drugs propofol mg/kg Sch mg/kgiv , 4 mg/kg im Doxapram 1.5 mg/kg NTG 4 g/kgiv SLN block

27. Indications for surgery:
Chronic/ recurrent tonsillitis
Adenotonsillar hyperplasia with OSA
Tonsillar hyperplasia
Peritonsillar abscess
Adenoiditis
Recurrent/ chronic rhino sinusitis/Otitis media

28. Indications: Suspicion of malignancy Hemorrhagic tonsillitis
Abnormal maxillofacial growth
Failure to thrive
Speech impairment
Dysphagia

29. 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: …

30. 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

31. 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…

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

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

34. Monitoring:
SPO2
ETCO2
Precordial stetho
ECG
Temp BP
PAP
Blood loss

35. Airway management Intravenous/ inhalational
Preformed RAE ETT cuffed/ uncuffed
Oral packing
Armoured LMA
Midline fixation
Brown- Davis mouth gag

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

37. 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

38. 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 / 54: 12 / pp 1021–1025..

39. Extubation: Laryngoscopy & thorough suction Positive airway pressure:
Attenuates excitation of superior laryngeal nerve & diminish laryngospasm
Expel secretions
Maintain oxygenation
Awake/ deep
Lateral position, head down

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

41. Pain management:
NSAIDS
Opioids
Local infiltration
TENS

42. 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.

43. NSAIDS:
Francis et al. Analgesics for postoperative pain after tonsillectomy and adenoidectomy in children.
(Protocol) Cochrane Database of Systematic Reviews 2007, Issue 3.

44. Opioids:
Decreased doses in OSA
Opioid sparing effect of NSAIDS

45. 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.

46. 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…

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

48. 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

49. 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

50. PACU: Bleeding: Pain: Obstruction: PONV: severe C/I
Oral intake not required for discharge
Adenoidectomy: safely discharged

51. 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

52. 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

53. 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

54. OSA
Def: recurrent episodes of partial/ complete obstruction of upper airways during sleep resulting in disruption of normal ventilation & sleep patterns.

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

56. 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

57. 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

58. 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

59. 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)

60. 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

61. Treatment : Surgery: Adenotonsillectomy Uvulopharyngoplasty
Tongue reduction
CPAP/ BIPAP
SUPPLEMENTAL OXYGEN
TRACHEOSTOMY

62. 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

63. PREANESTHESIA EVALUATION
Polysomnography
ECG: PHT,RVH, cor- pulmonale
ABG: hypercarbia, hypoxia
Antireflux medications
Sedation: monitoring, titrated

64. 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

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

66. 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