Tonsillectomy (Adult)
Patient phenotype
Adults: chronic tonsillitis, OSA from large tonsils, tumor. Higher complication rate than pediatric: more pain, more bleeding (delayed). OSA common.
Procedure
Same as peds — McIvor mouth gag, tonsillar fossa dissected, cautery hemostasis. ~30-60 min. Outpatient unless OSA.
Anesthetic plan
GETA with oral RAE south-pointing or reinforced ETT. Multimodal opioid-sparing (acetaminophen + ketorolac + dex). PONV prophylaxis.
Setup
- ·Oral RAE or reinforced ETT
- ·Standard monitors + temp
- ·PIV
- ·Dex 8 mg + ondansetron
- ·Glycopyrrolate (decrease secretions)
- ·Forced air warmer
Biggest concerns by phase
OSA — postop respiratory monitoring
Adult OSA + tonsillectomy + opioids = high risk respiratory event. Multimodal opioid-sparing. Plan for postop CPAP. Some institutions admit OSA patients post-T&A.
Shared airway + tube security
Mouth gag retracts ETT — confirm bilateral breath sounds + ETCO2 after gag placement. Reposition tube as needed.
Ketorolac controversy
NSAID + tonsillar bleeding traditionally avoided; recent evidence (meta-analyses) shows no increased bleeding. Local protocol.
Smooth extubation, lateral recovery position
Awake extubation, suction blood/clots, lateral recovery position. Watch for laryngospasm.
Post-tonsillectomy bleeding
Primary (< 24h, surgical) or secondary (5-10 d, scab off). Either is airway emergency. Aspiration risk if returning to OR — RSI, expect difficult airway (blood-filled), have suction + multiple tubes. Two large-bore PIVs + type & cross.
Mock-defense scenarios
Practice answering these out loud. The probes show what an examiner is listening for.
35-yo M, BMI 32, OSA on CPAP, recurrent tonsillitis. Tonsillectomy planned. Plan?
What an examiner probes for
- ▹OSA-conscious anesthetic (multimodal opioid-sparing)
- ▹Postop CPAP
- ▹Smooth extubation + lateral position
- ▹Discharge criteria + admission threshold
- ▹Bleeding warning signs taught
Sources
- Miller's Ch 66
- Society of Otorhinolaryngology Adult T&A Guidelines
Anatomy reference
Sourced reference images. 4 matches for "pharynx tonsil oral".
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