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Tonsillectomy & adenoidectomy & its anesthetic implication -DR MAYURI GOLHAR

Tonsillectomy & adenoidectomy & its anesthetic implication

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Page 1: Tonsillectomy & adenoidectomy & its anesthetic implication

Tonsillectomy & adenoidectomy & its

anesthetic implication

-DR MAYURI GOLHAR

Page 2: Tonsillectomy & adenoidectomy & its anesthetic implication

INTRODUCTIONAir flows through the upper respiratory

passages into the trachea, bronchi, bronchioles & the alveoli.

However airway obstruction due to malformation, tumour, infection or trauma may significantly alter the clinical presentation & make gas exchange a laborious, energy consuming process.

The increase work of breathing leaves the patient exhausted, incapable of maintaining adequate gas exchange & finally succumb to ventilatory failure.

Page 3: Tonsillectomy & adenoidectomy & its anesthetic implication

Introduction & pathophysiologyTonsillectomy is defined as surgical excision

of tonsils.It was first described in 1000BC.Tonsils are 3 masses of tissue: lingual tonsils,

pharyngeal(adenoids) tonsils, and the palatine tonsils

Tonsils are lymphoid tissue covered by respiratory epithelium which is invaginated and forms crypts.

Healthy tonsils offer immune protection by producing lymphocytes while diseased tonsils act as a focus of infection.

Page 4: Tonsillectomy & adenoidectomy & its anesthetic implication

TONSILLITIS & TONSILLECTOMYMost commonly performed pediatric surgeries.Indications- American association of otolaryngology &

head & neck surgery(AAO-HNS) chronic/recurrent tonsillitisPeritonsillar abcess.Abnormal dento-facial growth/malocclusion.Persistent halitosis or foul taste.Upper airway obstruction-Obstructive sleep apnea

syndrome,dysphagia.Suspicion of malignant disease as in tonsil assymmetry.Reccurent or chronic otitis mediaCardiac vascular diseases at the risk of endocarditis.

Page 5: Tonsillectomy & adenoidectomy & its anesthetic implication

contraindicationsPersisitent acute infection.Abnormal coagulation profile.Children with cleft lip/palate< 5yrs of ageEpidemic of polio

Page 6: Tonsillectomy & adenoidectomy & its anesthetic implication
Page 7: Tonsillectomy & adenoidectomy & its anesthetic implication

Tonsillectomy methodsSUBCAPSULAR/ TOTAL INTRACAPSULAR/SUBTOTAL

blunt dissection bipolar radio frequency/Coblation

bipolar radio frequency LASER

electrocautery Powered microdebrider

Ultrasonic dissection

Cold knife

Page 8: Tonsillectomy & adenoidectomy & its anesthetic implication

Problems due to hypertrophied adenoids & tonsilsAdenoid hyperplasia 1.nasopharyngeal

obstruction 2. failure to thrive 3. speech

disorders 4. obligate mouth

breathing 5. sleep

disturbances 6. orofacial

abnormalities 7. dental

abnormalities 8. narrowing of the

upper

airways

Page 9: Tonsillectomy & adenoidectomy & its anesthetic implication

Hypertrophied tonsils obstructive obstruction to the oropharyngeal airway Sleep Apnea apnea during sleep SyndromeLevels of obstruction:-soft palate & base of tongue.Management –relieve the airway obstruction - increase the cross sectional area of the

pharynx , nasal continuous positive pressure ventilation during sleep.

-some may require tracheostomy. -tremendous improvement after tonsillectomy.

Page 10: Tonsillectomy & adenoidectomy & its anesthetic implication

EVENTS LEADING TO COR- PULMONALE

Hypoxemia &

hypercarbia

Increase airway

resistance

Pulmonary/

arteriolar

constiction

Pulmonary artery hyperten

sion

Right side

heart failure

COR PULMONALE

Page 11: Tonsillectomy & adenoidectomy & its anesthetic implication

Patients of cor pulmonale – 1. dysfunctions in medulla / hypothalamic

areas persistent elevated CO2 despite of relieve of obstruction.

2. Hyperreactive pulmonary vascular bed+ increased vascular resistance & myocardial depression much higher than expected.

3. Cardiac enlargement is reversible with digitalization & surgical removal of tonsils & adenoids.

Page 12: Tonsillectomy & adenoidectomy & its anesthetic implication

PRE-OPERATIVE EVALUATONThorough history frequent infections, bruising,

gingival bleeding, epistaxis, bleeding diathesis use of antibiotics,

antihistaminics sleep apnea syndromePhysical examination observation of the patient audible respiration mouth breathing nasal quality of speech chest retractions elongated face,

retrognathia, oropharynx- high arched palate, size of the tonsils. wheeze/rales/ stridor .

Page 13: Tonsillectomy & adenoidectomy & its anesthetic implication

Pre-op evaluation conti..Measure hematocrit, coagulation parameters( cold

medications contain aspirin) chest radiograph & ECG not

required unless there is history- recurrent pnemonia,

bronchitis, URI, cor pulmonale.

Page 14: Tonsillectomy & adenoidectomy & its anesthetic implication

ANESTHETIC MANAGEMENTGoalunconscious in atraumatic way. provide optimal operating conditions establish IV access –fluid expansion+

medications rapid emergence to protect the instrumented

airway.PRE-MEDS- 1. used as determined by the anesthesiologist2. Sedative medications should be avoided.3. Antisialagogues to prevent secretions in the

surgical field.

Page 15: Tonsillectomy & adenoidectomy & its anesthetic implication

Anesthetic managementINDUCTION- volatile anesthetic agent ,

N2O,O2 by mask.INTUBATION-accomplished by deep

inhalation anesthesia or by a short acting non-depolarizing muscle relaxant.

PACKING- of supragolttic area should be done with petroleum gauze, cuffed ETT, (avoid blood entering the trachea).

Cuffed-ETT attention is to be given to cuff preesure to avoid post-extubation croup.

Page 16: Tonsillectomy & adenoidectomy & its anesthetic implication

Anesthetic managementEmergence should be rapid, the child should

be alert before shifting to the recovery.Should be alert, clear blood & secretions

from oropharynx.Maintenance of airway & pharyngeal reflexes

is essential to prevent aspiration, laryngeal spasm, airway obstruction.

Page 17: Tonsillectomy & adenoidectomy & its anesthetic implication

COMPLICATIONSEmesis- (30-65%)irritant blood in the

stomach. gag reflexes

(inflammation/edema) stimulation of CNS from

GITT/T- ondensteron(0.10-0.15 mg/kg) with or

without dexamethasoneDehydrationPain 1%Post-op hemorrhage 0.1-8.1%, coblation

tonsillectomy-11.1%

Page 18: Tonsillectomy & adenoidectomy & its anesthetic implication

POST-OPERATIVE HEMORRHAGE75%- 6hrs of surgery25%- 24hrs of surgery can continue till 6th post-

op day.Origin of bleeding tonsillar fossa 67% nasopharynx 26% both 7%T/T- pharyngeal packing, cautery,e xploration &

surgical hemostasis.Rapid sequence induction with cricoid pressure.Monitering BP in supine/erect

posture(orthostatic hypotension).IV access-hydration, good functioning

suctioning apparatus.

Page 19: Tonsillectomy & adenoidectomy & its anesthetic implication

PAINSevere after tonsillectomy than after

adenoidectomy.Poor oral intake . discomfort to the patient.T/T- adequate use of analgesics, -intra-op corticosteroids to reduce discomfort.Pain is more in electrocautery/ laser surgeries

than in sharp surgical dissection.

Page 20: Tonsillectomy & adenoidectomy & its anesthetic implication

PERITONSILLAR ABCESSAlso know as quinsy. Needs immediate exploration

to relieve potential or existing airway obstruction.Occurs- acutely infected tonsils may undergo

abscess formation large mass in the lateral pharynx

It interferes with swallowing & breathing.Symptoms-fever, pain & trimusT/T- surgical drainage of abscess with/without

tonsillectomy. Iv antibiotics.Laryngoscopy should be carefully performed to

avoid manipulation of pharynx & surrounding structures.

Intubation-carefully done as tonsillar area is tense & friable & to avoid rupture & spillage of the purulent material in the trachea.

Page 21: Tonsillectomy & adenoidectomy & its anesthetic implication

PULMONARY EDEMA

Infrequent & potentially life threatening complication.

Occurs when airway obstruction is suddenly relieved.

Mechanism during inspiration before adenotonsillectomy the negative intrapleural pressure that is generated causes the increase in the venous return enhancing the pulmonary blood volume.

Normal pressure -2.5cms to -10cmsH2o during inspiration.

Page 22: Tonsillectomy & adenoidectomy & its anesthetic implication

However during airway obstruction the pressure is as high as -30cmsdistruption of the capillary walls of the pulmonary microvasculature & its transmitted to the peribronchial & perivascular spaces.

Negative transpulmonary gradient increases venous returnto the right heart, preload increases,transudation of the fluid into the alveolar space.

To counter balance the positive intrapleural & alveolar pressure rises during exhalation which decreases pul.pressure & blood vol.

Page 23: Tonsillectomy & adenoidectomy & its anesthetic implication

Rapid relief of obstruction venous return increases hydrostatic pressure increases. - hyperemia positive counterbalancing

mechanism fail pulmonary edema.

Page 24: Tonsillectomy & adenoidectomy & its anesthetic implication

Discharging criteriaPatients can be safely discharged on the

same day after recovering from anesthesia.Patient should be observed for early

hemorrhage for a minimum 4-6 hours.Pt should be free from nausea,vomiting &

pain prior to dischargeIntravenous hydration should be adequate to

prevent dehydration.Excessive somnolence & vomiting are

indications for admission.

Page 25: Tonsillectomy & adenoidectomy & its anesthetic implication

THANK YOU….