Tonsillectomy – case presentation Moderator : Dr(Prof.) Maya Presenter: Priyanka jain www.anaesthesia.co.in anaesthesia.co.in@gmail.com

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

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

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 .

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

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

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

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

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

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

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

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

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)

Tonsil size: grading Barash,5th edition …

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

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

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

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

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

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

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

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

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

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

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

Treatment Remove the stimulus Jaw thrust Laryngospasm notch Oral or nasal airway PPV with 100% oxygen Deepen anesthesia Drugs propofol 0.25-0.8 mg/kg Sch 0.1-3 mg/kgiv , 4 mg/kg im Doxapram 1.5 mg/kg NTG 4 g/kgiv SLN block

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

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

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;95:299-306 …

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

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…

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

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

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

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

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

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

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..

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

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

Pain management: NSAIDS Opioids Local infiltration TENS

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.

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

Opioids: Decreased doses in OSA Opioid sparing effect of NSAIDS

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.

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…

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

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

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

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

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

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

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

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

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

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

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

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

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)

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

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

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

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

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

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

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 www.anaesthesia.co.in anaesthesia.co.in@gmail.com