Anaesthesia for paediatric ear,

nose, and throat surgery

Radha Ravi FRCA
Tanya Howell FRCA

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Children account for approximately one-third eliminates obstruction in 85–95% of children, Key points
of all patients undergoing ear, nose, and throat yielding improvement of symptoms and quality Safe conduct of anaesthesia
(ENT) surgery. Procedures range from simple of life. for paediatric ear, nose, and
day-case operations, such as myringotomy, to throat surgery requires a good
complex airway reconstruction surgery under- understanding of airway
Preoperative assessment anatomy and physiology and
taken in specialist centres. This article des-
cribes the anaesthetic management of some of Preoperative assessment should elicit features knowledge of the common
pathologies affecting the
the commonly performed paediatric ENT pro- of OSA, especially in the younger child, in
paediatric airway.
cedures, including adenotonsillectomy, oeso- whom obstructive symptoms rather than
phagoscopy, and middle ear surgery. Paediatric recurrent infections are commonly the indi- The airway is often shared
bronchoscopy has been dealt with in detail in cation for surgery ( prevalence of OSA 1–3%). with the surgeon permitting
only limited access during the
an earlier review in this journal.1 Symptoms of OSA include heavy snoring,
procedure.
apnoeas, restless sleep, extended neck position
during sleep, and daytime hypersomnolence. The reinforced laryngeal mask
Adenotonsillectomy Over time, this can lead to neurocognitive airway offers a suitable
alternative to the tracheal
Tonsillectomy is one of the most frequently impairment, behaviour problems, failure to
tube for airway management
performed surgical operations in children. thrive, and rarely cor pulmonale.
in adenotonsillectomy.
According to the Department of Health Children with severe OSA have a higher
Hospital Episode Statistics (http://www.heson incidence of perioperative complications and Obstructive sleep apnoea
syndrome is increasingly an
line.nhs.uk) .25 000 tonsillectomies and 6500 may need postoperative HDU/ICU care.
indication for adenoton
adenoidectomies were performed in children Specifically, they are at an increased risk of
sillectomy in young children
,15 y of age in England in 2003– 4. desaturation, laryngospasm, and developing and is a risk factor for
The tonsils and adenoids are lymphoid airway obstruction during induction of anaes- increased perioperative
tissues forming part of the Waldeyer’s ring thesia.2 They have increased sensitivity to the respiratory complications.
encircling the pharynx. They appear in the respiratory depressant effects of sedatives and
Postoperative nausea and
second year of life, are largest between 4 opioids and a diminished ventilatory response vomiting can be a major cause
and 7 yr of age and then regress. Children with to CO2 compared with normal.2,3 The overall of morbidity in patients
adenotonsillar hypertrophy can present with incidence of postoperative respiratory compli- undergoing adenoton-
nasal obstruction, recurrent infections, secretory cations in children with severe OSA is 16– sillectomy and ear surgery.
otitis media and deafness (secondary to 27% compared with an incidence of 1% in
Eustachian tube dysfunction), and obstructive children without OSA. Other risk factors for
Radha Ravi FRCA
sleep apnoea (OSA). Tonsillectomy is indicated respiratory complications include age ,3 yr,
Specialist Registrar in Anaesthesia
in children with recurrent tonsillitis if they have craniofacial abnormalities, neuromuscular dis- Royal Manchester Children’s Hospital
had five or more episodes of sore throat per orders, failure to thrive, and obesity.3 Pendlebury
year because of tonsillitis, or if symptoms have Preoperative investigations are not routinely Manchester M27 4HA
UK
persisted for at least 1 yr and are disabling, that indicated for patients undergoing adenotonsil-
is, interfering with normal functioning (SIGN lectomy (NICE Guideline on Preoperative Tanya Howell FRCA
publication no. 34, available from http://www. Tests, available from http://www.nice.org.uk). It Consultant Anaesthetist
sign.ac.uk). Other indications for tonsillectomy is difficult to confirm the diagnosis and quan- Royal Manchester Children’s Hospital
Pendlebury
include chronic tonsillitis, peritonsillar abscess, tify the severity of OSA. The gold standard for Manchester M27 4HA
and OSA. Adenoidectomy is indicated when diagnosis is nocturnal polysomnography, but UK
there is evidence of enlarged adenoids causing there is a great deal of variability in scoring Tel: þ44 0161 992 2439
Fax: þ0161 992 2439
nasal obstruction, OSA, or hearing loss. In the methods between different sleep laboratories, E-mail: [email protected]
presence of OSA, adenotonsillectomy and the test is expensive to perform. Recent (for correspondence)
doi:10.1093/bjaceaccp/mkm004
Continuing Education in Anaesthesia, Critical Care & Pain | Volume 7 Number 2 2007 33
& The Board of Management and Trustees of the British Journal of Anaesthesia [2007].
All rights reserved. For Permissions, please email: [email protected]
Anaesthesia for paediatric ear, nose, and throat surgery

studies suggest that overnight oximetry to score the frequency and The main disadvantages of the LMA are that it does not offer
depth of desaturation events may be useful in identifying patients the definitive airway provided by a tracheal tube and it may restrict
with severe OSA.4 In children with long-standing OSA, a full surgical access in younger patients. However, with both the tra-
blood count will reveal polycythaemia and an ECG may show a cheal tube and the LMA, dislodgement or compression can occur
right ventricular strain pattern. during positioning of the mouth gag, and airway patency must be
re-confirmed before surgery proceeds.
A postal survey of anaesthetic techniques used in paediatric
Anaesthetic considerations tonsillectomy in the UK in 1996–7 suggested that only 16% of
The main areas of anaesthetic concern are airway management, anaesthetists used the reinforced LMA routinely.7 I.V. induction
provision of analgesia, and prevention of postoperative nausea and with propofol, tracheal intubation with succinylcholine, and spon-

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vomiting (PONV). taneous ventilation with isoflurane were the commonest anaesthetic
techniques.7 Concern about the danger of succinylcholine-induced
hyperkalaemic cardiac arrest in children with undiagnosed muscle
Airway management
disease has led to a decline in the use of this drug for elective
Sharing the airway with the surgeon, remote access, and the need
intubation. Alternative techniques for intubation include deep inha-
to prevent soiling of the respiratory tract are factors that need to be
lation anaesthesia, combinations of propofol with a short-acting
taken into consideration in airway management. Two techniques
opioid, or the use of a short-acting non-depolarizing neuromuscular
are commonly used: the tracheal tube and the reinforced laryngeal
blocking agent during light anaesthesia.
mask airway (LMA).5,6 The advantages and disadvantages of these
techniques are compared in Table 1. Analgesia
The tracheal tube provides a definitive airway, and a ‘south- Adequate postoperative analgesia is best provided with a combina-
facing’ RAE tube positioned in the midline provides good surgical tion of simple analgesics and small doses of opioids. Paracetamol8
access. The disadvantages of intubation are that muscle paralysis and NSAIDs have a morphine-sparing effect. The concerns around
or a deep plane of anaesthesia are required, bronchial intubation or the potential for increased perioperative bleeding with NSAIDs have
accidental extubation can occur with surgical movement of the largely been discounted, with the exception of ketorolac, which
neck, and there is variable protection against airway soiling. The should be avoided. Administering the simple oral analgesics before
dilemma of whether to extubate the patient when fully awake and operation is safe and ensures effectiveness by the end of surgery.
able to protect their airway or still deeply anaesthetized to avoid a Alternatively, the rectal route can be used after induction of anaes-
stormy emergence and bleeding always exists. The reinforced thesia. However, this route is less acceptable to many patients and
LMA offers a good airway with no soiling of the respiratory tract, will not achieve therapeutic levels by the end of surgery in most
avoidance of the use of neuromuscular blocking agents, smooth cases. A single dose of dexamethasone 0.1–0.5 mg kg 2 1 has also
emergence, and airway protection until awake. To avoid soiling the been shown to reduce postoperative analgesic requirements, whereas
laryngeal inlet, the LMA should be removed with the cuff still local anaesthetic infiltration of the tonsillar bed has not been found
inflated. To ensure best surgical access, the smallest LMA for size to be superior to placebo. Regular doses of paracetamol and an
should be used, and when positioned correctly, the cuff should not NSAID after operation provide good analgesia.
be visible once the Boyle –Davis gag has been opened to its fullest
extent. An incorrectly sized LMA, or too large a blade on the Prevention of PONV
mouth gag, can cause obstruction. The incidence of PONV can be as high as 70% after adenotonsillect-
omy and a multimodal approach is indicated to combat this.
Minimizing starvation, avoiding the use of nitrous oxide (N2O), and
Table 1 Comparison of the LMA and the tracheal tube for tonsillectomy
balanced analgesia with prophylactic administration of antiemetics
LMA Tracheal tube
reduce the incidence of PONV. A combination of ondansetron
Advantages Straightforward airway More secure airway 0.1–0.2 mg kg21 and dexamethasone 0.1–0.5 mg kg21 (maximum
No soiling of airway with blood Good surgical access 8 mg) intraoperatively have been shown to greatly reduce the inci-
Smooth emergence dence of PONV.9 Intraoperative fluid administration has also been
Paralysis not required
Airway protection until awake shown to decrease the incidence of postoperative nausea. Rescue
Minimizes trauma to the airway antiemesis can be provided by further doses of ondansetron with or
Disadvantages Less secure airway Risk of airway trauma without cyclizine 0.5–1 mg kg21 (up to 50 mg).
May impair surgical access Oesophageal/bronchial
intubation
Requires paralysis Special considerations
Soiling of airway with
blood Severe OSA
Problems associated with
extubation
In general, sedative premedication and long-acting opioids are best
avoided in patients with severe OSA. Inhalation induction is

34 Continuing Education in Anaesthesia, Critical Care & Pain j Volume 7 Number 2 2007
 Anaesthesia for paediatric ear, nose, and throat surgery

preferred, as airway obstruction commonly occurs during induc- and potentially difficult to intubate because of poor visualization
tion, and children with associated craniofacial anomalies may of the larynx. Tachycardia, tachypnoea, delayed capillary refill,
prove to be difficult to intubate.2 Consideration should be given to and decreased urine output are early indicators of hypovolaemia,
the use of a small dose of fentanyl to supplement simple analgesia, whereas hypotension and altered sensorium are indicators of
as this is associated with less postoperative respiratory depression. advanced volume depletion.
The incidence of complications varies with the time of day that the Preoperative resuscitation (guided by trends in monitoring) is
procedure is performed. Children undergoing surgery in the essential, even if this requires the insertion of an interosseous
morning have fewer desaturations than those undergoing the same needle. Induction of anaesthesia in a hypovolaemic child can
procedure in the afternoon. Close postoperative monitoring and the precipitate cardiovascular collapse. Haemoglobin and coagulation
availability of an ICU bed is required. variables should be checked. Blood and blood products should be

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available and transfused as necessary. Before induction, in addition
to the standard equipment, a selection of laryngoscope blades,
Day-case tonsillectomy
smaller than expected tracheal tubes, and two suction catheters
Tonsillectomy was included in the suggested list of suitable oper-
should be immediately available. Anaesthesia is induced once
ations for day-surgery in Day Surgery: An Operational Guide
the child is haemodynamically stable. Preoxygenation and rapid
Department of Health in 2002. Successful and safe implementation
sequence induction with slight head-down positioning of the
of day-case tonsillectomy requires careful patient selection.
patient ensures rapid control of the airway and protection from pul-
Exclusion criteria include age ,3 yr, significant co-morbidity,
monary aspiration. Consideration should be given to adopting the
OSA, and living .1 h drive from the hospital or having no private
left lateral position if bleeding is excessive. Controlled ventilation
transport. Thought also needs to be given to the risk of early haem-
provides good conditions for haemostasis.
orrhage and the management of postoperative pain and PONV.
Fluid resuscitation and transfusion of blood and blood products
The incidence of early postoperative bleeding is ,1% and the
should continue intraoperatively as necessary. Once haemostasis is
majority of these occur within the first 4 h after surgery. An
achieved, a large-bore stomach tube is passed under direct vision
extended observation period of 4– 6 h before discharge is therefore
and the stomach emptied. Neuromuscular block is antagonized and
recommended; this limits surgery to morning lists. A multimodal
the trachea is extubated, with the child fully awake in the recovery
analgesic and antiemetic regime as previously discussed is very
position. After operation, the child should be monitored closely for
important, as the main reasons for overnight admission are PONV,
any recurrence of bleeding.
pain, and poor oral intake.

Bleeding tonsil
Oesophagoscopy
Haemorrhage is the most serious complication after tonsillectomy
and can occur within the first 24 h ( primary haemorrhage) or up to Rigid oesophagoscopy is performed for the removal of an ingested
28 days after surgery (secondary haemorrhage). In the National foreign body. History of ingestion, dysphagia, and odynophagia are
Prospective Tonsillectomy Audit (July 2003 –September 2004), the the usual presenting symptoms, whereas a previous stricture is a
incidence of post-tonsillectomy haemorrhage patients was 3.5% predisposing factor for obstruction. The commonest site of impac-
and the overall rate of return to theatre was 0.9%. The incidence of tion of the foreign body is at the level of the cricopharyngeus
primary haemorrhage was 0.6% and the majority of these occurred muscle. Oesophagoscopy should be performed in all cases of
within the first 6 h after operation. Factors influencing haemorrhage suspected impacted foreign body to prevent complications of
rates were age (lower rates in children than adults), indication for perforation, mediastinitis, and fistula formation.
surgery (highest rates with quincy and recurrent tonsillitis, lowest Anaesthetic considerations include management of the shared
with obstructive symptoms), and surgical technique (higher rates airway and the risk of pulmonary aspiration or oesophageal perfor-
with use of diathermy and disposable equipment, lowest with blunt ation during the procedure. A rapid sequence induction protects
dissection). against pulmonary aspiration and ensures rapid control of the
The anaesthetic considerations in bleeding tonsil include hypo- airway. The tracheal tube should be secured on the left side to
volaemia, the risk of pulmonary aspiration (swallowed blood with allow easier access for the endoscopy. Adequate depth of anaesthe-
or without oral intake), potential for a difficult intubation because sia and muscle relaxation during the procedure are essential to
of excessive bleeding obscuring the view with or without oedema reduce the risk of oesophageal perforation. Analgesia is provided
after earlier airway instrumentation, a second general anaesthetic, by a combination of intravenously or rectally administered simple
and the stress to both child and parents. Blood loss is because of analgesics and a small dose of opioid. The patient is extubated
venous or capillary ooze from the tonsillar bed and is difficult to when fully awake. If oesophageal perforation is suspected, oral
measure, as it occurs over several hours and is partly swallowed. intake should be withheld, i.v. antibiotics commenced, and the
Excessive blood loss may lead to the child spitting blood. In these patient closely observed for features of mediastinitis, such as
cases, the child is likely to be seriously hypovolaemic, anaemic, severe chest pain, pyrexia, and s.c. emphysema.

Continuing Education in Anaesthesia, Critical Care & Pain j Volume 7 Number 2 2007 35
Anaesthesia for paediatric ear, nose, and throat surgery

Ear surgery these three procedures are similar; therefore, we shall described
their anaesthetic management collectively.
The most common surgical procedures on the ear are those
performed to treat otitis media and its complications. Otitis media Anaesthetic considerations
is the second most prevalent illness of childhood. This is because Typically, these procedures are performed in the older child or
of a combination of factors including Eustachian tube dysfunction teenager and can be of prolonged duration. The main factors that
and an increased susceptibility to upper respiratory tract infection have a bearing on anaesthetic management are the effect of N2O
(URTI) in early childhood. The short Eustachian tube in young on the middle ear, the need for a bloodless operative field, the use
children predisposes to reflux of nasopharyngeal secretions into the of facial nerve monitoring by the surgeon, and the high associated
middle ear space and thus to recurrent infections. Oedema of the incidence of PONV.

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Eustachian tube mucosa secondary to recurrent URTI, and mech- As the relative solubility of N2O in blood is 34 times that of
anical obstruction of the Eustachian tube orifice by enlarged nitrogen, it diffuses across into the non-compliant middle-ear
adenoids, lead to a negative pressure in the middle ear and a trans- cavity much more rapidly than nitrogen can leave. This can lead to
udative effusion (secretory otitis media). Children with otitis pressures as high as 350 mm H2O within 30 min of commencing
media present with deafness and complications such as perforation, N2O, especially in the presence of Eustachian tube dysfunction.11
ossicular chain damage, and cholesteatoma. Surgery is performed Displacement of tympanoplasty grafts, worsening of deafness,
to improve hearing and to eradicate middle-ear disease. rupture of the tympanic membrane, and increased PONV have all
been associated with elevated middle-ear pressures. In addition,
after discontinuation of N2O, rapid re-absorption of the gas leads
Myringotomy to negative pressures in the middle ear and this can lead to ‘lifting
Myringotomy and insertion of pressure-equalizing tubes are used off’ of the underlay tympanic membrane graft. As the middle ear
to improve middle-ear aeration and hearing in chronic otitis media. remains open until the surgeon places the graft over the tympanic
It is a short procedure performed as a day-case. The preoperative membrane, N2O can be used up to 10 –15 min before graft place-
assessment should elicit features of URTI, as otitis media is associ- ment and then discontinued. However, it may be best to avoid its
ated with recurrent URTI and these children can consequently use in middle-ear surgery completely.
have increased airway irritability. A small percentage of this popu- Any bleeding during middle-ear surgery distorts the view
lation may also display symptoms of OSA secondary to adenoidal through the operating microscope and can make the procedure dif-
hypertrophy. The anaesthetic technique usually involves the patient ficult. Venous ooze can be minimized by a head-up tilt of 108–158
breathing spontaneously via a facemask or LMA, with the head and ensuring unimpeded venous drainage. Epinephrine infiltra-
positioned to one side. Mild postoperative pain can occur in up to tion by the surgeon, relative hypotension (mean arterial pressure
75% of patients, but this can be avoided with the preoperative 10 –20% , normal), and avoidance of tachycardia minimize
administration of paracetamol, NSAIDs, or both.10 arterial bleeding.
In its course through the temporal bone, the facial nerve runs
through the middle ear in close relation to the ossicles and through
the mastoid before emerging from the stylomastoid foramen.
Myringoplasty, tympanoplasty, and mastoidectomy
Therefore, it is vulnerable to damage during middle-ear surgery,
Children with complications of chronic otitis media need more especially as the disease process can distort the anatomical
complex ear surgery. Myringoplasty involves repair of a tympanic relationship of the nerve to the ear structures and make identifi-
membrane perforation in a dry ear. Tympanoplasty is performed cation difficult. Intraoperative facial nerve monitoring is useful for
when there is extensive middle-ear damage and involves recon- identification and preservation of the nerve during ear surgery. A
struction of the tympanic membrane and the ossicular chain. The single dose of a short-intermediate-acting relaxant can be used to
approach to the ear can be permeatal or postaural, the latter provid- aid tracheal intubation, its effects should have worn off sufficiently
ing better surgical access. Two surgical techniques of tympanic before the stage in the operation when facial nerve monitoring is
membrane grafting are used, the underlay and the overlay. The required. However, it may be prudent to avoid the use of relaxants
underlay technique involves elevation of a tympanomeatal flap and altogether by using other agents to facilitate intubation or by avoid-
placing the graft material underneath (or medial to) the eardrum. ing intubation. Whether using a tracheal tube or an LMA, the
The overlay technique involves stripping the lateral epithelium off patient requires controlled ventilation for this procedure. Much of
the eardrum and placing the graft material on the outer side of the surgery is performed using an operating microscope; therefore,
(or distal to) the eardrum. Various graft materials may be used, if paralysis is to be avoided, a deep plane of anaesthesia is required
the most common being temporalis fascia, tragal perichondrium, to guarantee immobility. Controlled ventilation also allows control
and fat. of the end-tidal CO2, which helps to minimize bleeding.
Mastoidectomy is performed to eradicate chronic suppurative The options for airway management are a tracheal tube or a
middle-ear disease. The anaesthetic considerations associated with reinforced LMA. The advantages of a tracheal tube over an LMA

36 Continuing Education in Anaesthesia, Critical Care & Pain j Volume 7 Number 2 2007
 Anaesthesia for paediatric ear, nose, and throat surgery

are a secure airway and ease of controlled ventilation, though a (21%).13 There is also a high incidence of congenital heart disease
stormy emergence contributing to graft displacement is a potential (19%) and craniofacial anomalies. The main anaesthetic concern is
problem. Smoother emergence can be ensured by tracheal extuba- an increased incidence of difficult intubation. In most instances,
tion in a deep plane of anaesthesia. A reinforced LMA has the after inhalation induction, the airway can be safely and easily
potential advantages of less airway stimulation and smooth emer- maintained using a reinforced LMA. However, equipment for
gence, but care must be taken to limit airway inflation pressures in fibreoptic intubation and appropriately trained staff should be avail-
order to prevent gastric distension during controlled ventilation. able in the event of a need for intubation. Analgesia is provided
For either technique, maintenance of anaesthesia with propofol with a combination of paracetamol, NSAID, and a small dose of
and remifentanil, or sevoflurane and remifentanil, offers many opioid. Routine antiemetics are indicated, as PONV is common.
advantages. They allow controlled ventilation without neuromuscu-

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lar blocking agents, thus permitting unimpeded facial nerve moni-
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Continuing Education in Anaesthesia, Critical Care & Pain j Volume 7 Number 2 2007 37