- The main indication is obstructive, sleep-disordered breathing due to adenotonsillar hyperplasia, which may be improved or cured by tonsillectomy
- The other main indication is recurrent tonsillitis based on the Paradise criteria
- The evidence base for this is moderate (at best)
- Some patients may have elements of both pathological processes, or more of the latter but "over-egg" the symptoms of sleep-disordered breathing in order to qualify for surgery
Tonsillectomy
Tonsillectomy
Tonsillectomy was the subject of a CRQ in March 2021 (89.5% pass rate).
Post-tonsillectomy bleed, the major complication following this surgery, is covered in a separate page.
Resources
- Paediatric adenotonsillectomy, part 1: surgical perspectives relevant to the anaesthetist (BJA Education, 2020)
- Paediatric adenotonsillectomy, part 2: considerations for anaesthesia (BJA Education, 2020)
- PROSPECT guideline for tonsillectomy: systematic review and procedure-specific postoperative pain management recommendations (Anaesthesia, 2020)
- Adenotonsillectomy is one of the most common surgeries performed worldwide
- It is performed in children, representing ∽15% of all paediatric surgeries, and young adults
| Immediate | Early (<24hrs) | Late (>24hrs) |
| Trauma/burns to airway structures | Pain | Pain (may be profound) |
| Compression/dislodgement of airway devices | PONV (up to 32%) | Dehydration |
| Intra-operative bleeding | Primary post-tonsillectomy bleeding (1.5 - 4.2%) | Secondary bleeding (up to 28 days post-op.) |
| Airway fire | Major respiratory events (5.8%) e.g. aspiration, broncho/laryngospasm | Speech disorders |
| Mortality (0.3/10,000) from haemorrhage/respiratory events | Recurrent OSA/tonsillitis | |
| IJV thrombosis |
Perioperative management of the paediatric patient undergoing tonsillectomy
- Typically performed as a day-case, although:
- May need prolonged period of post-operative observation to detect early post-operative bleeding
- May need admission and observation overnight if at high risk of perioperative respiratory adverse events e.g. severe OSA, <3yrs, recent URTI, other comorbidities
- Only half of the children who suffer adverse events have easily identifiable comorbidity criteria
- A full history, examination including airway and review of comorbidities should be performed
- Investigations are rarely needed in healthy children
- One should review sleep studies and plan post-operative care accordingly
- Obese adolescents may require investigation for:
- Metabolic syndrome, including tests for insulin resistance, LFT's and lipids
- RV dysfunction using TTE if signs of HTN, severe desaturation during polysomnography or right heart strain
Pre-medication
- Oral analgesic pre-medication e.g. paracetamol + NSAID
- Although midazolam is less impactful than other agents on airway neuromotor tone, pre-medication with BZD's is associated with perioperative respiratory adverse events
- One can use half-dose (e.g. 0.25mg/kg) midazolam or ɑ2 agonists instead
Airway
- Children presenting for adenotonsillectomy may have features which make airway management more challenging;
- Concurrent medical syndromes
- Obesity
- OSA airway endotypes
- Frequent URTI's/asthma
- These patients are at a 1.5x RR of severe perioperative respiratory adverse events compared to other paediatric surgeries
- Reinforced LMA's are generally preferred in paediatric patients, as they avoid need for tracheal intubation, use of NMBA and subsequent risks of airway events
- Adults undergoing tonsillectomy are usually intubated e.g. south-facing RAE
Anaesthetic agents
- The child with OSA has:
- An upper airway which is more collapsible at less negative pressures
- Impaired ventilatory drive and control
- Impaired airway self-rescue reflexes
- This should prompt choice of anaesthetic agents with the least impact on blunting airway neuromotor function:
| Higher impact | Lower impact |
| Sevoflurane & desflurane | Topical lidocaine |
| Propofol | Ketamine |
| Opioids | ɑ2 agonists |
| Midazolam |
PONV
- Patients are at a higher risk of PONV and associated dehydration
- Methods to reduce this include:
- Surgical technique - to reduce the amount of swallowed blood
- Generous crystalloid hydration (10 - 30ml/kg)
- Prophylactic ondansetron (0.15mg/kg) and dexamethasone (0.15mg/kg)
- Avoidance of opioids
- Adenotonsillectomy causes moderate - severe pain
- Pain peaks during the first 72hrs but persists for 1 week in half of children
- Dynamic pain on swallowing can limit oral intake, causing dehydration
- Functional limitations are common e.g. difficulty coughing, being woken from sleep
- Inadequate pain control is a common reason for re-presentation to hospital - an analysis of the PAIN OUT infant registry showed 20% of tonsillectomy patients had a desire for more pain relief
- Naturally, a multi-modal analgesic approach is best
- There is a statistically significant & inverse relationship between the number of non-opioid analgesic drug classes used & the degree of post-operative pain
- This holds true across both paediatric and adult patients
| Drug class | Notes |
| Paracetamol | Regularly |
| NSAID | Ideally COX-2 specific inhibitor e.g. diclofenac, celecoxib May increase risk of post-op. bleeding |
| Local anaesthetic | Topical, or injected into the tonsillar fossa can reduce pain for first 24hrs |
| Opioids | In general, avoid entirely Titrate short-acting agents to effect Use half-doses e.g. 0.05mg/kg morphine Consider tramadol if >12yrs |
| Adjuncts | Ketamine ɑ2 agonists Gabapentinoids |
| Non-analgesic techniques | IV dexamethasone Surgical coblation technique Difflam mouthwash |