Describe the essential elements of preoperative evaluation for adenotonsillectomy.
Preoperative evaluation of the patient presenting for adenotonsillectomy focuses on airway obstruction. Air movement through the nasal cavity indicates that ade-noidal tissue is not obstructing the nasopharynx. A history of dysphagia, sleep apnea, daytime somnolence, or snoring may predict difficult mask ventilation and/or difficult laryngoscopy and intubation.
Preoperative examination of the oral pharynx may reveal enlarged tonsillar tissues encroaching on the airway and predisposing to obstruction during induction. Jugular venous distention, pretibial edema, hepatojugular reflux, and the signs of right-sided congestive heart failure must be searched for to determine the possible need for preop-erative digoxin and diuretics. Uncorrected congestive heart failure markedly increases the morbidity and mortality of any surgical procedure including adenotonsillectomy.
Hemorrhage is a major source of concern in the peri-operative period. A coagulation history is essential for all patients, although the necessity for international normal-ized ratio (INR), prothrombin time (PT), and activated partial thromboplastin time (aPTT) is controversial with-out clinical correlation. Salicylate ingestion, which impairs platelet function, is a probable basis for postponement of an elective adenotonsillectomy. Other nonsteroidal com-pounds such as ibuprofen or parenteral ketorolac have been proven to be a significant risk for perioperative hem-orrhage. However, early data suggest that the COX-2 inhibitors may not be a significant risk for perioperative hemorrhage and may be quite useful as a non-opiate peri-operative analgesic.
The potential for dental trauma requires inspection of the oropharynx. Dentition should be carefully observed for ill-fitting removable prostheses, fixed dental prostheses such as crowns or bridges, and orthodontic appliances. Most importantly, the oropharynx should be inspected for grossly carious and loose teeth. Adenotonsillectomy is a common procedure in childhood when the primary teeth are exfoliat-ing, risking accidental avulsion. Dental trauma may be the result of oropharyngeal airway placement, laryngoscopy, or the mouth gag used to maintain adequate surgical exposure.