Tonsillectomy and adenoidectomy

Surgical approach

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.
Analgesia: Multimodal; paracetamol + NSAID (if not contraindicated) + opioid; consider dexamethasone (also antiemetic).
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).
Key comorbidities: OSA (severity, CPAP, daytime somnolence), obesity, craniofacial syndromes, neuromuscular disease, asthma, bleeding disorders, recurrent URTI.
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.
Fluids: maintenance + replace losses; avoid dehydration (reduces PONV and pain exacerbation).

Analgesia strategy

Baseline: regular paracetamol (weight-based) + NSAID (e.g. ibuprofen) unless contraindicated (renal disease, severe asthma sensitivity, bleeding disorder).
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.
Prophylaxis: dexamethasone + 5-HT3 antagonist; consider additional agent (cyclizine) in high-risk older children/adults.
Minimise blood swallowing: suction stomach/oropharynx under direct vision before extubation; consider orogastric tube suction if significant blood swallowed (weigh against stimulation/trauma).
Aspiration: ensure fully awake extubation; lateral recovery position; vigilant PACU monitoring.

Extubation and postoperative care

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.

Complications (anaesthetic + surgical)

Anaesthetic: laryngospasm, bronchospasm, aspiration, airway obstruction (OSA), dental/lip trauma from gag, PONV, emergence delirium.
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.

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.
PONV: dexamethasone + ondansetron; minimise swallowed blood (suction).
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?

Causes: residual anaesthetic/opioids; OSA-related collapse; laryngospasm; blood clot/secretions; tongue swelling/position; negative pressure pulmonary oedema after obstruction; rarely haematoma.
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?

Balance urgency vs increased perioperative respiratory adverse events (laryngospasm, bronchospasm, desaturation).
Assess severity: fever, purulent secretions, productive cough, wheeze, lethargy, reduced intake; examine chest; consider postponing if systemic symptoms, lower respiratory involvement, or significant wheeze.
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.
Prioritise oxygenation: two-person mask ventilation with airway adjuncts; consider gentle ventilation despite aspiration risk.
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.
Consider IV lidocaine (where appropriate), minimise irritant agents, treat URTI/wheeze, ensure smooth emergence.
Extubate awake (or deep extubation only in selected cases with low aspiration/bleeding risk—generally less suitable for tonsillectomy).
Have a clear treatment algorithm: jaw thrust/CPAP → deepen (propofol) → suxamethonium if persistent.