Tonsillectomy & Adenoidectomy (Pediatric)
Patient phenotype
Usually 3–10 years old. Recurrent tonsillitis or OSA. Often current/recent URI. Mask induction, IV after asleep. Outpatient unless OSA or comorbidity requires admission.
Procedure
Direct laryngoscopy + adenoid + tonsil removal. Surgeon shares the airway with anesthesia. Brief surgery (15–25 min) with high airway complication rate.
Anesthetic plan
Mask induction (sevoflurane in O₂/N₂O), IV insertion after asleep, oral RAE tube + throat pack. Multimodal analgesia (fentanyl, dexamethasone, acetaminophen — NO ketorolac due to bleeding risk). Deep extubation common.
Setup
- ·Pediatric ASA monitors
- ·Pediatric airway cart at bedside (multiple LMA/ETT sizes)
- ·Mapleson D or pediatric circle
- ·Atropine drawn for sux pretreatment if needed
- ·Suction at the head of the bed (always)
- ·Postop position: lateral / lateral recovery (tonsillar position)
Biggest concerns by phase
Recent URI — proceed or postpone?
Symptomatic URI within 2 weeks → 7-fold increase in respiratory adverse events (laryngospasm, bronchospasm, breath-holding, desat). Indications to postpone: fever, mucopurulent rhinorrhea, productive cough, wheeze. Otherwise, proceed cautiously with deep anesthesia + LMA over ETT when possible.
Mask induction + airway management
Sevo + N₂O for smooth induction (kids hate IV). Watch for breath-holding, laryngospasm in stage 2. Once asleep, get IV. Standard intubation with cuffed RAE tube (tonsils involve oral cavity). Throat pack to prevent aspiration of blood.
Shared airway — communication + bleeding
Surgeon's instruments enter through the mouth. If ETT cuff leak, bleeding, or movement, surgeon will tell you. You manage ventilation + watch ETCO₂ + listen for circuit changes. Brief case but complications happen fast.
PONV — extremely high baseline + dexamethasone helps
T&A is one of the highest PONV-risk pediatric procedures. Multimodal: dex 0.15 mg/kg (max 8 mg) at induction + ondansetron 0.1 mg/kg at end. Avoid N₂O after induction, propofol-based maintenance helps.
Deep extubation vs. awake — smooth airway
Deep extubation: less coughing, less bleeding from raw tonsillar bed. Risk: airway obstruction post-extubation. Awake extubation: protects airway but risks bleeding. Most pediatric otolaryngology defaults to deep extubation followed by lateral 'tonsillar position' recovery.
Post-tonsillectomy bleeding — emergency RSI
Primary bleeding (24 h) or secondary (5–10 days post-op). Patient may have swallowed substantial blood. Treat as full stomach + hypovolemic. RSI with cricoid, large-bore PIV, type & cross, suction. Ketamine 1 mg/kg + sux 2 mg/kg = traditional cardiovascular-stable RSI.
Mock-defense scenarios
Practice answering these out loud. The probes show what an examiner is listening for.
Your 5-year-old just finished a routine T&A. You extubate deep, position lateral. In PACU at 30 minutes, the parent says the kid looks pale and is swallowing repeatedly. What's happening and what do you do?
What an examiner probes for
- ▹Recognizes occult bleeding from tonsillar bed (the kid is swallowing blood)
- ▹Action: vital signs, IV access verification, surgeon to bedside, OR ready
- ▹Anticipates: possible re-anesthesia for hemostasis — full-stomach RSI
- ▹Differentiates: anxiety/pain vs. real bleed
Same patient comes back to the OR 4 hours postop with active oral bleeding, BP 90/50, HR 140, pale, anxious. Walk me through the induction.
What an examiner probes for
- ▹Pre-position: large-bore PIV, type & cross, suction, two suctions
- ▹Drug choice: ketamine + sux RSI (preserves CV stability + protects airway)
- ▹Acknowledges full stomach (swallowed blood)
- ▹Plan B: fiberoptic vs. surgical airway if can't see
Sources
- AAP Pediatric Anesthesia 4e
- ASA Practice Advisory: Pediatric OSA
- Coté Practice of Anesthesia for Infants & Children
Anatomy reference
Sourced reference images. 4 matches for "pharynx tonsil oral".
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