Anesthetic Considerations in Tonsillectomy & Adenoidectomy

TONSILLECTOMY & ADENOIDECTOMY

Pathophysiology

Lymphoid hyperplasia can lead to upper airway obstruction, obligate mouth breathing, and even pulmonary hypertension with cor pulmonale. Although these extremes of pathology are unusual, all children undergoing tonsillectomy or adenoidec-tomy should be considered to be at increased risk for perioperative airway problems.

Anesthetic Considerations

Surgery should be postponed if there is evidence of acute infection or suspicion of a clotting dysfunc-tion (eg, recent aspirin ingestion). Administration of an anticholinergic agent will decrease pharyn-geal secretions. A history of airway obstruction or apnea suggests an inhalational induction without paralysis until the ability to ventilate with posi-tive pressure is established. A reinforced or pre-formed endotracheal tube (eg, RAE tube) may decrease the risk of kinking by the surgeon’s self-retaining mouth gag. Blood transfusion is usually not necessary, but the anesthesiologist must be wary of occult blood loss. Gentle inspection and suctioning of the pharynx precede extubation. Although deep extubation decreases the chance of laryngospasm and may prevent blood clot dis-lodgment from coughing, most anesthesiologists prefer an awake extubation because of the risks of aspiration. Postoperative vomiting is common. The anesthesiologist must be alert in the recovery room for postoperative bleeding, which may be evidenced by restlessness, pallor, tachycardia, or hypotension. If reoperation is necessary to con-trol bleeding, intravascular volume must first be restored. Evacuation of stomach contents with a nasogastric tube is followed by a rapid-sequence induction with cricoid pressure. Because of the possibility of bleeding and airway obstruction, children younger than 3 years old may be hospital-ized for the first postoperative night. Sleep apnea and recent infection increase the risk of postop-erative complications.