Patient supine, head ring/shoulder roll, mouth gag (e.g. Boyle–Davis) inserted and suspended, shared airway throughout.
Tonsillectomy: dissection of palatine tonsil from tonsillar fossa (cold steel dissection, bipolar diathermy, coblation, or other energy devices).
Haemostasis: bipolar/monopolar diathermy, ties
Adenoidectomy: transoral approach with soft palate retraction, curettage/suction diathermy/coblation of adenoid tissue in nasopharynx.
Frequent suctioning of blood/secretions, throat pack may be inserted and removed at end (must be documented and confirmed).
At end: haemostasis check, pack removal, suction of oropharynx, patient turned lateral/head-down briefly by some teams to drain secretions.
Anaesthetic management
Type of anaesthesia: General anaesthesia
Airway device: Cuffed oral RAE ETT preferred (protects airway from blood, allows controlled ventilation, reduces OR contamination), SGA generally avoided due to bleeding/aspiration risk and surgical access, but may be used in some units with experienced teams.
Induction: IV if cannulated, inhalational induction common in younger children, anticipate airway obstruction if OSA.
Maintenance: Volatile or TIVA, controlled ventilation, consider FiO2 management (diathermy fire risk, avoid high FiO2 if possible while maintaining oxygenation).
Duration: Typically 20–45 min for tonsillectomy ± adenoids
How painful: Tonsillectomy is significantly painful (moderate–severe, often for 7–10 days), adenoidectomy alone is usually mild–moderate.
PONV: High risk, use prophylaxis (dexamethasone + ondansetron).
Extubation: Fully awake with protective reflexes, lateral position, suction under direct vision, be prepared for laryngospasm and post-op obstruction (especially OSA).
Indications and patient factors
Tonsillectomy: recurrent tonsillitis, obstructive symptoms/OSA, peritonsillar abscess (quinsy) in selected cases, suspected malignancy (rare in children).
Adenoidectomy: nasal obstruction, recurrent otitis media with effusion (often with grommets), chronic adenoiditis, OSA (often combined with tonsillectomy).
Age: common in children, adults have higher bleeding risk and often more pain.
Preoperative assessment
History: snoring, witnessed apnoeas, daytime symptoms, growth/behaviour issues, recurrent infections, previous anaesthetic issues, bleeding history (epistaxis, easy bruising, family history).
OSA assessment: severity, desaturation history, previous sleep study (AHI), home oximetry, CPAP use, plan for opioid-sparing and post-op monitoring/admission.
Examination: airway (mouth opening, tonsillar size), nasal obstruction, chest (wheeze), hydration status if recurrent infection.
Investigations: routine coagulation tests not indicated without history, FBC if clinical concern (anaemia, infection) or significant comorbidity, group &, save not routine but consider in adults/complex cases/high bleeding risk.
Airway and intraoperative considerations
Shared airway: ensure secure fixation of tube, confirm position after gag insertion (tube can kink/displace), use bite block as needed.
Cuffed tube: reduces leak and aspiration, use appropriate size and cuff pressure monitoring.
Throat pack: if used, MUST be recorded and removed with formal pack sign-in/out process.
Fire risk: diathermy in oxygen-enriched field, use lowest FiO2 compatible with safe SpO2, avoid nitrous if it increases FiO2 requirement, ensure communication before diathermy activation.
Blood loss: usually small but can be brisk, have suction working, IV access reliable, consider second IV in adults/high risk, weigh swabs if significant bleeding.
Ventilation: controlled ventilation preferred, avoid excessive PEEP if venous bleeding problematic, maintain normocapnia.
Opioids: titrate small doses intra-op (fentanyl/alfentanil/morphine) with caution in OSA, consider short-acting opioid and avoid large long-acting doses in severe OSA.
Adjuncts: dexamethasone (also reduces PONV and may reduce pain), consider clonidine or ketamine (low dose) in selected cases for opioid-sparing, magnesium occasionally used.
Post-op: ensure a written plan for regular analgesia for 7–10 days, educate carers on scheduled dosing and hydration.
PONV and aspiration risk
High PONV risk due to swallowed blood (emetogenic), opioids, airway surgery.
Minimise blood swallowing: suction stomach/oropharynx under direct vision before extubation, consider orogastric tube suction if significant blood swallowed (weigh against stimulation/trauma).
Extubate awake with intact reflexes, suction under direct vision, consider lidocaine (IV) to reduce coughing (balanced against airway tone in OSA).
Laryngospasm: common, treat with jaw thrust, CPAP/100% O2, deepen anaesthesia (propofol), then suxamethonium if persistent, consider atropine for bradycardia in children.
Post-op obstruction: particularly in OSA/obesity—positioning, oxygen, consider CPAP/NIV, opioid-sparing, admit for monitoring if moderate–severe OSA, <,3 years, significant comorbidity, or peri-op events.
Bleeding: primary (within 24 h) vs secondary (5–10 days), any post-tonsillectomy bleeding is an emergency—risk of aspiration and rapid deterioration.
Discharge advice: hydration, regular analgesia, return if bleeding, persistent vomiting, fever, or signs of dehydration.
Surgical: haemorrhage (primary/secondary), infection, velopharyngeal insufficiency (rare, more relevant in adenoidectomy with occult cleft), taste disturbance, referred otalgia, Grisel’s syndrome (atlantoaxial subluxation—rare).
Bleeding risk factors: older age (adults), infection/inflammation, surgical technique, coagulopathy/anticoagulants, dehydration and scab separation in secondary bleed.
Test yourself…
You are anaesthetising a 5-year-old for tonsillectomy and adenoidectomy. Talk me through your anaesthetic technique.
Pre-op: assess OSA symptoms (snoring, witnessed apnoeas, daytime sleepiness/behaviour), recent URTI, asthma control, bleeding history, check weight for dosing, confirm fasting, plan opioid-sparing if OSA.
Monitoring: standard paediatric monitoring, consider temperature, ensure suction working and backup available.
Induction: inhalational induction if no IV, otherwise IV induction. Anticipate obstruction in OSA—use airway manoeuvres, consider CPAP during induction, avoid heavy sedative premed.
Airway: cuffed oral RAE ETT, confirm bilateral air entry and secure well, re-check after mouth gag insertion (tube displacement/kinking).
Maintenance: volatile, controlled ventilation, maintain normocapnia, lowest FiO2 consistent with safe oxygenation (diathermy fire risk).
Analgesia: paracetamol + NSAID (if appropriate) + small opioid titration, consider dexamethasone. If severe OSA to reduce opioids.
Before extubation: confirm throat pack removal, suction oropharynx under direct vision, consider gastric suction if significant blood swallowed.
Extubation: fully awake, lateral position, be prepared for laryngospasm/obstruction, oxygen in PACU.
Post-op: regular analgesia plan, observe for bleeding, airway obstruction, PONV, consider admission/overnight oximetry if moderate–severe OSA, <,3 years, obesity, comorbidity, or peri-op airway events.
How does obstructive sleep apnoea (OSA) change your management for tonsillectomy?
Pre-op: quantify severity (sleep study AHI if available, oximetry nadir, CPAP use), identify high-risk features (age <,3, obesity, craniofacial/neuromuscular disease, pulmonary hypertension).
Induction: higher risk of obstruction, gentle technique, maintain airway tone, consider CPAP during induction, avoid sedative premedication or use minimal dose with monitoring.
Intra-op: opioid sensitivity, use opioid-sparing multimodal analgesia, consider short-acting opioids and avoid large morphine doses, consider adjuncts (dexmedetomidine / clonidine / ketamine) where appropriate.
Extubation: fully awake, ensure complete reversal of neuromuscular block, cautious with residual anaesthetic, lateral positioning.
Post-op: increased risk of obstruction and desaturation—enhanced monitoring, consider HDU/overnight oximetry, early use of CPAP if used at home, cautious opioid prescribing and clear escalation plan.
What are the causes of postoperative airway obstruction after tonsillectomy and how would you manage it?
Immediate management: call for help, airway positioning (chin lift/jaw thrust), suction, high-flow oxygen, consider adjuncts (oropharyngeal/nasopharyngeal airway if appropriate).
If laryngospasm: CPAP with 100% O2, deepen anaesthesia (propofol), treat bradycardia, suxamethonium if persistent/complete spasm.
If ongoing obstruction or bleeding suspected: return to theatre for airway control and surgical review, consider re-intubation with RSI if aspiration/bleeding risk.
Post-event: monitor for pulmonary oedema, consider CXR/ABG if severe, admit for observation.
Discuss postoperative haemorrhage after tonsillectomy and your anaesthetic management of a child returning to theatre with bleeding.
Define: primary haemorrhage <,24 h, secondary haemorrhage typically 5–10 days (slough/scab separation, infection).
Risks: aspiration of blood, hypovolaemia, anaemia, difficult laryngoscopy due to blood/poor view, laryngospasm.
Assessment: ABC, quantify bleeding (history, vomiting blood, clots), check vitals, cap refill, IV access, bloods (FBC, coagulation if indicated), group and crossmatch, consider VBG/ABG if unstable.
Resuscitation: high-flow O2, fluid bolus if shocked, early blood if ongoing significant haemorrhage, activate major haemorrhage protocol if needed, tranexamic acid may be used per local policy (evidence evolving).
Preparation: experienced anaesthetist/ENT surgeon present, difficult airway trolley, suction x2 with wide-bore yankauer, appropriate blades, bougie, plan for rapid re-intubation, warm patient.
Induction strategy (child): treat as full stomach—modified RSI often used. Preoxygenate, gentle mask ventilation may be necessary to avoid desaturation (balance aspiration risk).
Drugs: induction agent (propofol/ketamine depending on haemodynamics), rocuronium (with sugammadex available) or suxamethonium, consider atropine in small child if bradycardic risk.
Intubation: cuffed tube, suction during laryngoscopy, consider head-down tilt, have surgeon ready to suction and pack.
Intra-op: secure IV access (consider second cannula), blood products available, correct coagulopathy, maintain normothermia and calcium if transfusing.
Extubation: only when fully awake, haemostasis secured, stomach/oropharynx suctioned, consider post-op HDU/ICU if significant bleed, transfusion, or airway concerns.
What is your approach to analgesia for tonsillectomy? Include discussion of NSAIDs and opioids.
Principles: significant nociceptive pain, aim for multimodal, opioid-sparing (especially with OSA).
Paracetamol: weight-based dosing, ensure given early and continued regularly post-op.
NSAIDs: effective opioid-sparing, historical concern about bleeding—current practice commonly uses ibuprofen with acceptable safety, avoid if contraindications (renal impairment, severe NSAID-exacerbated respiratory disease, known bleeding disorder).
Opioids: titrate to effect, avoid codeine in children (CYP2D6 ultrarapid metaboliser risk and MHRA contraindication), consider morphine cautiously, or fentanyl intra-op with careful PACU observation.
Adjuncts: dexamethasone (also antiemetic), consider clonidine/dexmedetomidine or low-dose ketamine in selected patients, consider local infiltration by surgeon if used locally.
Discharge: provide clear plan for scheduled analgesia and hydration, safety-net for excessive sedation/respiratory depression.
How do you minimise PONV in tonsillectomy/adenoidectomy?
Risk factors: airway surgery, swallowed blood, opioids, history of PONV/motion sickness, older children/adolescents.
Prophylaxis: dexamethasone + ondansetron, consider third agent in high-risk cases (droperidol/cyclizine per age/local policy).
Technique: minimise opioids, ensure adequate hydration, suction blood from oropharynx, consider gastric suction if significant blood swallowed.
Rescue: antiemetic from different class, assess for ongoing bleeding if persistent vomiting of blood.
What are the key airway risks specific to tonsillectomy and adenoidectomy?
Shared airway and surgical instrumentation (mouth gag) can displace/kink ETT, need to re-check ventilation after gag insertion and any repositioning.
Blood/secretions increase risk of laryngospasm, aspiration, and tube obstruction.
Fire risk with diathermy in oxygen-enriched environment.
Post-op obstruction in OSA, residual anaesthetic/opioids, or laryngospasm.
Dental/lip/tongue trauma from gag, pressure injury if prolonged.
A child has a recent URTI but is listed for tonsillectomy. How do you decide whether to proceed?
Consider risk modifiers: age <,1–2 years, prematurity, reactive airway disease, passive smoke exposure, OSA severity.
If proceeding: optimise (bronchodilator if wheezy), experienced anaesthetist, minimise airway irritation, ensure deep enough anaesthesia for instrumentation, consider IV induction, be prepared for laryngospasm/bronchospasm, enhanced PACU monitoring.
Discuss the role and risks of dexamethasone in tonsillectomy.
Benefits: reduces PONV, may reduce pain and swelling, improves oral intake.
Dose: commonly weight-based in children (local protocols vary).
Risks: transient hyperglycaemia, theoretical concern about bleeding has been debated—current practice widely supports use for PONV benefit, consider individual bleeding risk and local guidance.
Contraindications/cautions: poorly controlled diabetes, active severe infection considerations (rarely relevant for single dose).
What is your plan if you cannot intubate during induction for post-tonsillectomy haemorrhage?
Call for help early, ensure suction and oxygenation.
Use videolaryngoscope if available, bougie, consider changing blade size/position, suction continuously.
If cannot intubate but can ventilate: consider waking if feasible (often not in active bleeding), or place second-generation SGA as a rescue to oxygenate, note it does not protect from aspiration.
If cannot intubate/cannot oxygenate: follow DAS paediatric CICO pathway—front-of-neck access appropriate to age (needle cricothyroidotomy/tracheal access as per local kit and training), while ENT surgeon prepares surgical airway.
Describe the management of post-tonsillectomy haemorrhage presenting to the emergency department.
ABC approach, high-flow oxygen, sit forward if bleeding, suction available.
IV access, bloods (FBC, group &, crossmatch, coagulation if indicated), consider VBG, resuscitate with fluids/blood, consider TXA per protocol.
Early ENT and anaesthetic involvement, prepare for urgent theatre.
Treat as full stomach, anticipate difficult airway, plan RSI/modified RSI with suction and experienced staff.
Post-op: HDU/ICU if significant bleed or comorbidity, monitor for re-bleed and aspiration complications.
Discuss strategies to reduce laryngospasm in paediatric ENT surgery.
Avoid airway stimulation at light planes, ensure adequate depth for gag insertion and suctioning.
Clear secretions/blood, gentle suction under direct vision.
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