AAU-CHS SCHOOL OF ANESTHESIA

Anesthesia for tonsillectomy

BY MERON GIRMA
Advisor: Mr. Leulayehu Akalu
May 2014
Out line of the presentation
 Objective
 Introduction
 Anatomy & Physiology
 Epidemiology & Etiology
 Pathophysiology
 Clinical manifestation
 Medical mgt & Surgical mgt
 ANESTHETIC mgt
 Summary
 References
Objectives:
General: To improve the practice in the anesthetic
management of patients undergoing tonsillectomy and
adenectomy.

Specific: At the end of this presentation, you will be able

to:
Define and clinically identify tonsillitis
Mention the signs and clinical manifestations of tonsillitis
Provide smooth anesthesia for tonsillectomy.
Mention the indications for surgical tonsillectomy
Manage possible complications of tonsillectomy
Introduction

 Acute tonsillitis is a disease of childhood with a peak

incidence at around 5 to 6 years of age, but it can occur
in children under 3 years of age and in adults over 50
years.
Cont…
 The patient's history often helps identify the type of
tonsillitis (i.e., acute, recurrent, chronic) that is
present.
 The most common problems affecting the tonsils and
adenoids are
 recurrent infections (throat or ear) and
 significant enlargement or obstruction that
causes breathing and swallowing problems.
 Anatomy of the tonsil
 The tonsils are 3 separate pieces of tissue:
 lingual,
 pharyngeal (adenoid)
 palatine tonsil.
 The tonsillar branch of the facial artery forms the main arterial
blood supply. While the venous drainage is via a plexus
surrounding the tonsil, which drains into the pharyngeal plexus.
 The external palatine vein enters the tonsillar bed from the soft
palate. This large vein is usually responsible for the venous
haemorrhage following tonsillectomy.
blood supply
 Cont…
 scattered lymphoid tissue throughout the remainder of the
pharynx but especially behind the posterior pharyngeal
pillars and along the posterior pharyngeal wall.

 Lymphoid tissue located between the palatoglossal fold

(anterior tonsillar pillar) and the palatopharyngeal fold
(posterior tonsillar pillar) forms the palatine tonsils
Cont…
 This lymphoid tissue is separated from the surrounding pharyngeal
musculature by a thick fibrous capsule.

 The adenoid is a single aggregation of lymphoid tissue that occupies

the space between the nasal septum and the posterior pharyngeal
wall. A thin fibrous capsule separates it from the underlying
structures; the adenoid does not contain the complex crypts that are
found in the palatine tonsils but rather more simple crypts.

 Lymphoid tissue at the base of the tongue forms the lingual tonsil
that also contains simple tonsillar crypts.
physiology
 Approximately 65% of the lymphocytes that make up the
lymphoid tissue are B lymphocytes, the remainder being
either T lymphocytes or plasma cells .

 The immunologic role

A. Induce
secretory immunity to regulate the production of the
secretory immunoglobulins.
B . The tonsils and
adenoid are in a position to provide primary defense
against foreign matter.
Cont…
 Deep crevices within tonsillar tissue form tonsillar crypts
that are lined with squamous epithelium but have a
concentration of lymphocytes at their bases.

. Lymphoid tissue are most immunologically active

between 4 and 10 yr of age, with a decrease after puberty.
.
No major immunologic deficiency has been demonstrated
after removal of either or both of the tonsils and adenoid.
Disorder of the tonsil (Tonsillitis)
 The tonsils and adenoids are part of Waldeyer's ring of
lymphoid tissue around the pharynx and are often the sites
of acute and chronic inflammation.

Chronic tonsillitis is less common and may be mistaken for

other disorders such as allergy, asthma, and sinusitis.

Infection of the adenoids frequently accompanies acute

tonsillitis. Group A beta-streptococcus is the most common
organism associated with tonsillitis and adenoiditis.
epidemiology
 Acute tonsillitis secondary to group A beta-hemolytic
streptococcal infection commonly occurs in children under
10-years of age and may occasionally present in epidemic
form.
Also can occur in adult age group.
Etiology:
Streptococcus bacteria (most common cause)
Adenoviruses
Influenza virus
Epstain- Barr virus
Parainfluenza virus
Enteroviruses
PATHOLOGY
ACUTE INFECTION
1. Most episodes of acute pharyngotonsillitis are caused by
viruses . Group A β-hemolytic streptococcus (GABHS) is
the most common cause of bacterial infection in the
pharynx .

2. Additional bacterial organisms can include other β-

hemolytic streptococcal species (group C),
Staphylococcus aureus, gram-negative organisms,
Mycoplasma pneumoniae, and, rarely, Neisseria
gonorrhoeae and Corynebacterium diphtheriae .
Path……
 Acute tonsillitis may in some instances extend beyond
the tonsillar tissue into the space between the anterior
and posterior tonsillar pillars into the soft palate,
producing a peritonsillar abscess, or quinsy, which is
frequently associated with S pyogenes infection.

 Physical examination reveals an edematous, bulging,

anterior tonsillar pillar with medial displacement of the
soft palate and uvula.
 CHRONIC INFECTION
 The tonsils and adenoid can be chronically infected by
multiple microbes, which may include a high incidence of
β-lactamase–producing organisms. Both aerobic species,
such as streptococci and Haemophilus influenzae, and
anaerobic species, such as Peptostreptococcus, Prevotella,
and Fusobacterium, predominate.

 The tonsillar crypts can accumulate desquamated

epithelial cells, lymphocytes, bacteria, and other debris,
causing cryptic tonsillitis. With time, these cryptic plugs
can calcify into tonsillar concretions or tonsillolith.
Clinical Manifestations
 Sore throat is a term that includes any painful condition in the oropharynx;
associated with acute tonsillitis over the years.
 fever,
 snoring, and difficulty swallowing.
 low-grade, smoldering process that eventually may cause permanent
deafness.

Enlarged adenoids may cause

 mouth breathing,
 earache, draining ears,
 frequent head colds,
 bronchitis, foul-smelling breath,
 voice impairment, and noisy respiration.
Diagnosis:
 involves examination of the two palatine tonsils-if they
are normal ,they appear as fleshy folds of tissue .
 However ,if they are infected, they will be red and swollen
and may have red streaks and pus like secretions .
A throat swab culture is performed for the identification
of streptococcus pyogenes.

A blood test may also be done to rule out a more serious

infection or condition ,and to check the white blood cell
count to see if the body is responding to the infection.
Medical Management
Specific treatment plan is based on:

 Patient’s age, overall health and medical history

 Extent of the disease
 Expectation for the course of the disease
 Patient’s tolerance for specific medications,
procedures or therapy
 Patient’ preference
 The course of the infection
Surgical Management
Tonsillectomy is indicated if there are :-

 4-6 documented episodes of acute tonsillitis per year,

 3-4 episodes in each of the preceding 2 years OR

 3 episodes in each of the preceding 3 years.

The indications may be absolute or relative.

Absolute indications:
Upper airway obstruction, dysphagia and OSA

 Peritonsillar abscess, which is unresponsive to Medical

management and Surgical drainage.

Recurrent tonsillitis with associated febrile convulsions.

The requirement for biopsy to confirm tissue pathology.

Relative indications include:

1. Sore throat secondary to tonsillitis.

2. More than 5 episodes of tonsillitis in one year.
3. To have had the symptoms for more than one year.
4. The episodes of sore throats are significantly
disabling.
Contraindications for surgery are
Bleeding diathesis.
 Acute infection.
Anaemia.
Significant anaesthetic risk.
Anesthetic consideration
 The restricted spaces in the airway require an
understanding and cooperative relationship between
surgeon and anesthetist,

Despite only mild-to-moderate tonsillar enlargement on

physical examination, children with obstructive sleep
apnea have upper airway obstruction while awake and
apnea during sleep.
OBSTRUCTIVE SLEEP APNEA

 OSA syndrome may be associated with behavior and growth

disturbances

 Symptoms include
snoring, sleep disturbances and daytime
hypersomnolence, decreased school performance and
personality changes, recurrent enuresis, hyponasal
speech, and growth disturbances.

 Patients with OSA are often obese with potentially difficult upper
airway management.

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OSA…
Precautions 

- Avoid heavy sedation

- Expect apnea (post op.)
- Perform bleeding time prior to operation (Danger of
post op bleeding)
- Expect intubation difficulty in case of extreme
lymphoid hypertrophy
 
 Evaluating the Airway
Airway obstruction due to malformation, tumor,
infection, or trauma may significantly alter the clinical
presentation & make gas exchange a laborious energy-
consuming process.
 The increased work of breathing can leave the patient
exhausted, incapable of maintaining adequate gas exchange,
and finally ventilatory failure.
 Significant obstruction and anatomic distortion may be
present in a patient with minimal evidence of disease because
clinically evident upper airway obstruction is a late sign.
Discovery of a large, unexpected, obstructed upper airway at
the time of attempted tracheal intubation.
Cont…
 In the presence of tumor, other mass lesions, or infection
in the airway, it may be useful to obtain radiologic
evaluation of the airway with plain films of the tracheal and
laryngeal air columns or computed tomography and
magnetic resonance imaging studies of the airway.

 Significant anatomic distortion is usually evident and

may help the anesthetist determine the most appropriate
technique for securing the airway.
Cont…
 Obstruction of the oropharyngeal airway by hypertrophied
tonsils leading to apnea during sleep is an important clinical
constellation referred to as obstructive sleep apnea syndrome.

 The goals of treatment are to relieve airway obstruction and

increase the cross-sectional area of the pharynx.
 Some patients require the use of nasal continuous positive
airway pressure during sleep, whereas others may require a
tracheostomy to bypass the chronic upper airway obstruction.
 The two most frequent levels of obstruction during sleep are at
the soft palate and the base of the tongue.
Cont…
 These patients often have dysfunction in the medulla or
hypothalamic areas of the central nervous system causing
persistently elevated CO2, despite relief of airway obstruction.

 They have a hyper reactive pulmonary vascular bed,with

increased pulmonary vascular resistance and myocardial
depression in response to hypoxia, hypercarbia, and acidosis.

 Cardiac enlargement is frequently reversible with surgical

removal of the tonsils and adenoids.
Preoperative Evaluation
 A detailed history is the basis for the preoperative evaluation. Because
patients requiring tonsillectomy and adenoidectomy have frequent
infections, the parent should be questioned for current use of antibiotics,
antihistamines, or other medicines.
 A history of sleep apnea should be sought.

 The physical examination should begin with observation of the patient.

 The presence of audible respirations, mouth breathing, nasal quality of the

speech, and chest retractions should be noted. Mouth breathing may be the
result of chronic nasopharyngeal obstruction. An elongated face,
retrognathic mandible, and a high-arched palate may be present.
Preop.evaluation cont’d
 The oropharynx should be inspected for evaluation of tonsillar
size to determine the ease of mask ventilation and tracheal
intubation .

 The presence of wheezing or rales on auscultation of the chest

may be a lower respiratory manifestation of pharyngitis or
tonsillitis.
 The presence of inspiratory stridor or prolonged expiration
may indicate partial airway obstruction from hypertrophied
tonsils or adenoids.
Preop.evaluation cont’d
 Measurement of hematocrit and coagulation parameters is
suggested.
 Many nonprescription cold medications and antihistamines
contain aspirin, which may affect platelet function, and this
potential anticoagulation should be taken into consideration.

 Chest radiographs and electrocardiograms (ECGs) are not

required unless specific abnormalities are elicited during the
history, such as recent pneumonia, bronchitis, upper
respiratory infection (URI)
Anesthetic Management
 The goals of anesthesia for tonsillectomy and adenoidectomy To

 Provide the surgeon with optimal operating conditions,

 Establish intravenous access to provide a route for volume expansion and
medications when necessary, and
 Provide rapid emergence so the patient is awake and able to protect the
recently instrumented airway.

 Sedative premedication should be avoided in children with obstructive

sleep apnea, intermittent obstruction, or very large tonsils.

 Use of antisialagogue will minimize secretions in the operative field.

Induction
Inhalational or iv.
Nitrous oxide ,oxygen & halothane .
Propofol plus fentanyl plus short acting muscle relaxant.
Intra op opioid with morphine for adult because it is more
pain full.
Induction cont…
 Anesthesia is usually induced with a volatile anesthetic agent,
oxygen, and nitrous oxide (N2O) by mask.

 Parental presence in the operating room (OR) during mask

induction is often helpful in the anxious unpremedicated
child.

 Tracheal intubation is best accomplished under deep

inhalation anesthesia or aided by a short-acting
nondepolarizing muscle relaxant.
Maintenance of anesthesia
 Many clinicians may choose to eliminate the neuromuscular
blocking agent in favor of enhancing the depth of anesthesia
with the use of propofol.

 Blood in the pharynx may enter the trachea during the surgical
procedure. For this reason, the supraglottic area may be
packed with petroleum gauze, or a cuffed endotracheal tube
may be used.
 If a cuffed endotracheal tube is selected, careful attention to
the inflation pressure of the cuff is essential to avoided
postextubation croup.
Emergence
 Emergence from anesthesia , the child should be alert before
transfer to the recovery area.

 The child should be awake and able to clear blood or secretions

from the oropharynx as efficiently as possible before removal of
the endotracheal tube.

 Maintenance of airway and pharyngeal reflexes is essential .

Prevention of aspiration, laryngospasm, and airway obstruction.
 There is no difference in the incidence of airway complications
on emergence between patients who are extubated awake or
deeply anesthetized.
Complications
Post extubation Laryngospasm and Stridor
Post-tonsillectomy bleeding
Pain
Peritonsillar abscess, or quinsy tonsil
Acute postoperative pulmonary edema
Retention of throat pack
Postoperative nausea & vomiting
Post extubation Laryngospasm and Stridor

The incidence of laryngospasm and stridor after

removal of a tracheal tube is common.

 Attempts to reduce the incidence of laryngospasm

involve:
 topical anesthesia to the upper airway,
 limiting the exaggerated glottic closure reflex & subsequent
laryngospasm, or intravenous agents administered close to
extubation,
 increasing the depth of anesthesia and limiting glottic closure
reflex–mediated laryngospasm.
PONV
Postoperative administration of meperidine increases the probability
of emesis, and other analgesic agents should be administered.

 Treatment with ondansetron, 0.10 to 0.15 mg/kg, either with or

without dexamethasone, has been shown to be very effective in
reducing post tonsillectomy nausea and vomiting.

Dehydration secondary to poor oral intake as a result of nausea,

vomiting, or pain can occur after tonsillectomy in 1% of cases.
 Vigorous intravenous hydration during surgery can offset the
physiologic effects of lower postoperative fluid intake.
Post-tonsillectomy bleeding
 The most serious complication of tonsillectomy is postoperative hemorrhage, which
occurs at a frequency of 0.1 to 8.1%. The recent innovation of coblation
tonsillectomy may result in an incidence of post tonsillectomy hemorrhage up to
11.1%.

 Approximately 75% of postoperative tonsillar hemorrhage occurs within 6 hours of

surgery. Most of the remaining 25% occurs within the first 24 hours of surgery,
although bleeding may be noted until the sixth postoperative day

 Sixty-seven percent of postoperative bleeding originates from the tonsillar fossa,

26% in the nasopharynx, and 7% in both.

 Initial attempts to control bleeding may be made using pharyngeal packs and
cautery. If this fails, patients must return to the OR for exploration and surgical
hemostasis.
Anesthetic considerations for post tonsilectomy
bleeding
 Unappreciated large volumes of blood originating from the
tonsillar bed may be swallowed. These patients must be
considered to have a full stomach, and anesthetic precautions
addressing this situation must be taken.

 A rapid-sequence induction accompanied by cricoid pressure

and a styletted endotracheal tube is controversial but may be of
benefit in some circumstances. Because the amount of blood
swallowed can be considerable.

 Intravenous access and hydration must be established before

the induction of anesthesia (considering the b/p).
bleeding cont….
 A variety of laryngoscope blades and endotracheal tubes, as
well as functioning suction apparatus, should be prepared in
duplicate because blood in the airway may impair visualization
of the vocal cords and cause plugging of the endotracheal tube.

 Laryngoscopy can be difficult because of the presence

of blood clots, continuous oozing of blood, and
reduced venous and lymphatic drainage causing
intraoral swelling and edema.
Pain
 pain after tonsillectomy is severe. This contributes to poor
fluid intake and overall discomfort of patients.
 Analgesics (Narcotics) to prevent postop. pain

 Although infiltration of the peritonsillar space with local

anesthetic and epinephrine has been shown to be effective in
reducing intraoperative blood loss, it does not decrease
postoperative pain.
Acute postoperative pulmonary edema

Intraoperative administration of corticosteroids may

decrease edema formation and subsequent patient
discomfort.

Use of diuretics may be given with caution. B/c pt

may be complicated with dehydration and electrolyte
disturbance
Summary

 Acute tonsillitis is a disease of childhood with a peak

incidence at around 5 to 6 years.
 The most common problems affecting the tonsils and
adenoids are
 recurrent infections (throat or ear) and
 significant enlargement or obstruction that
causes breathing and swallowing problems.
Summary……
 The restricted spaces in the airway require an
understanding and cooperative relationship between
surgeon and anesthetist, and the use of specially
adapted equipment suitable to these cramped areas.
 Smooth induction and recovery is the mainstay.
NEVER ALLOW THE CHILD TO CRY!!!
 Maintenance of airway and pharyngeal reflexes is essential .
Prevention of aspiration, laryngospasm, and airway obstruction.
 The most serious complication of tonsillectomy is postoperative
hemorrhage,
Summary……
The anaesthetist must consider:
 The patient may have a full stomach of blood and therefore
is a significant aspiration risk.
 The intubation may be difficult due to blood in the airway
and edema from recent intubation.
 Fluid resuscitation may be necessary. The fluid status of
the patient must be assessed prior to induction:
Refernces
Paul G.Barash,; Cullen, Bruce F.; Stoelting, Robert K.;
Cahalan, Michael K.; Stock, M. Christine(: Clinical
Anesthesia, 6th Edition)
clínical tratamen to tonsilitis, São Paulo: Yendis, 2009.
JÁCOMO, AL. Anatomia do sistema linfático. In GUEDES NETO,
HIB.
JÁCOMO, AL. and ANDRADE, M. Anatomia médico-cirúrgica do
JÁCOMO, AL. and RODRIGUES Jr., AJ. Anatomia clínica do
sistema
Wikipidea free encyclopidea
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