Moderator: Dr. Anjolie Presenters: Dr. Senthil Dr. Dipal

Adenotonsillectomy & OSA
Moderator: Dr. Anjolie
Presenters: Dr. Senthil
Dr. Dipal
www.anaesthesia.co.in
[email protected]
Indications:
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2.
3.
4.
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6.
7.
Chronic/ recurrent tonsillitis
Adenotonsillar hyperplasia with OSA
Tonsillar hyperplasia
Peritonsillar abscess
Streptococcal carriage with valvular heart disease
Adenoiditis
Recurrent/ chronic rhino sinusitis/Otitis media
Indications:
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2.
3.
4.
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6.
7.
Suspicion of malignancy
Hemorrhagic tonsillitis
Abnormal maxillofacial growth
Failure to thrive
Chronic halitosis
Speech impairment
Dysphagia
Contraindications:
 Systemic infection
 Uncorrected coagulopathy
 Occult/ frank cleft palate
Bifid uvula: clue to occult cleft palate
Sx: hypernasal speech,
velopharyngeal incompetence
Adenoidectomy: partial
History:
 Infection
 Obstructive sleep apnea
 Bleeding tendencies, sickle cell disease
 Use of Acetylsalicylic acid ingestion: defer for 10 days…
URI: proceed??
 Higher incidence of respiratory complications but little residual
morbidity
 Risk factors:
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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
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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…
Tonsil size:
Classification of tonsil size,
including percentage of
oropharyngeal area
occupied by hypertrophied
tonsils
Barash,5th edition
…
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
Appropriate size i.v. catheter
Airway management
 Intravenous/ inhalational
 Preformed RAE ETT cuffed0.5-1 cm smaller size
 Oral packing: uncuffed tube
 Armoured LMA
 Midline fixation
 Brown- Davis mouth gag
Anesthesia:
 Maint: propofol infusion/ inhalational/ muscle relaxant
 Spontaneous/ controlled ventilation
 Pain management
 PONV prophylaxis
Armoured LMA:
Advantages:
 Patent with Boyle-Davis
gag
 Avoid intubation& its
complications
Disadvantages:
 Risk of aspiration
 Inadequate positioning
 Pilot balloon snared
 Tonsillar enlargement:
difficult placement
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:
 Larngoscopy &thorough suction
 Positive airway pressure:
1.
2.
3.
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Attenuates excitation of superior laryngeal nerve & diminish
laryngospasm
Expel secretions
Maintain oxygenation
Awake/ deep
Lateral position, head down
Laryngospasm:
 Prevention:
1.
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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%
1. Irritant blood in stomach
2. Inflammation/ edema
3. Dehydration: poor oral intake
Prophylaxis:
1. Maintain adequate hydration
2. Gastric decompression
3. Antiemetic drugs
4. 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:
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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
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
Re-exploration:
 O.1%incidence of re-exploration
 Mortality: 1:14000
 Issues:
 Bleeding and Hypovolemia
 Difficult airway
 Aspiration
Bleeding:
 Signs and symptoms of hypovolemia: mild- severe
 Large bore i.v. access
 Correction: colloids and crystalloids
 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
OSA
 Def: recurrent episodes of partial/ complete obstruction of upper
airways during sleep resulting in disruption of normal ventilation
& sleep patterns.
 2% prevalence
 Peak: 2-8 yrs
 Level of obstruction: soft palate & base of tongue
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
Features
Children
Adults
Peak age
Preschool
Middle age
Gender ratio
M=F
M>F, postmenopausal
Causes
Adenotonsillar hypertrophy, Obesity
obesity, craniofacial
abnormalities
Body habitus
Failure to thrive, normal,
obese
Obesity
OSA clinical features
Features
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: metabolic acidosis, hypercarbia
 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
Thank you
www.anaesthesia.co.in
[email protected]