Adenotonsillectomy & OSA Moderator: Dr. Anjolie Presenters: Dr. Senthil Dr. Dipal www.anaesthesia.co.in anaesthesia.co.in@gmail.com Indications: 1. 2. 3. 4. 5. 6. 7. Chronic/ recurrent tonsillitis Adenotonsillar hyperplasia with OSA Tonsillar hyperplasia Peritonsillar abscess Streptococcal carriage with valvular heart disease Adenoiditis Recurrent/ chronic rhino sinusitis/Otitis media Indications: 1. 2. 3. 4. 5. 6. 7. Suspicion of malignancy Hemorrhagic tonsillitis Abnormal maxillofacial growth Failure to thrive Chronic halitosis Speech impairment Dysphagia Contraindications:  Systemic infection  Uncorrected coagulopathy  Occult/ frank cleft palate Bifid uvula: clue to occult cleft palate Sx: hypernasal speech, velopharyngeal incompetence Adenoidectomy: partial History:  Infection  Obstructive sleep apnea  Bleeding tendencies, sickle cell disease  Use of Acetylsalicylic acid ingestion: defer for 10 days… URI: proceed??  Higher incidence of respiratory complications but little residual morbidity  Risk factors: 1. 2. 3. 4. 5. 6. 7. ETT in child <5yrs Prematurity Reactive airway disease Parental smoking Airway surgery Copious secretions Nasal congestion Tait AR et al. Risk factors for perioperative adverse events in children with respiratory tract infections. Anesthesiology 2001;95:299-306 … Examination:  Oral & nasal airway patency: mouth breathing, nasal quality of     speech, chest retractions, wheeze, stridor, rales Adenoid facies: elongated face, high arched palate, retrognathic mandible Tonsil size: Loose teeth: age, laryngoscopy, mouth gag Syndromes Syndromes:  Treacher Collins syndrome  Crouzon's syndrome  Goldenhar syndrome  Pierre Robin  C.H.A.R.G.E. association  Achondroplasia  Down syndrome  Mucopolysccharidoses: Hunter 1& 2… Tonsil size: Classification of tonsil size, including percentage of oropharyngeal area occupied by hypertrophied tonsils Barash,5th edition … Investigations:  HB, Hct, Platelet count  Bleeding time  Clotting time  X-ray: neck lateral view: adenoids  PT/ aPTT  vWD, factor VIII deficiency  XRAY chest: LRI Premedication:  Sedation: oral midazolam 0.5mg/kg  Antisialagouge: dry secretions better operating field  NPO  Consent  Blood arranged Monitoring:  SPO2  ETCO2  Precordial stetho  ECG  Temp  BP  PAP  Blood loss Appropriate size i.v. catheter Airway management  Intravenous/ inhalational  Preformed RAE ETT cuffed0.5-1 cm smaller size  Oral packing: uncuffed tube  Armoured LMA  Midline fixation  Brown- Davis mouth gag Anesthesia:  Maint: propofol infusion/ inhalational/ muscle relaxant  Spontaneous/ controlled ventilation  Pain management  PONV prophylaxis Armoured LMA: Advantages:  Patent with Boyle-Davis gag  Avoid intubation& its complications Disadvantages:  Risk of aspiration  Inadequate positioning  Pilot balloon snared  Tonsillar enlargement: difficult placement LMA:  In the presence of a URI : evidence that a LMA may be superior to an ETT.  Some evidence that the incidence of airway complications is lower than with an ETT. Most anesthesiologists, however, prefer the intraoperative security of an ETT.  Robin G. Anesthetic management of pediatric adenotonsillectomy.CAN J ANESTH 2007 / 54: 12 / pp 1021–1025.. Extubation:  Larngoscopy &thorough suction  Positive airway pressure: 1. 2. 3.   Attenuates excitation of superior laryngeal nerve & diminish laryngospasm Expel secretions Maintain oxygenation Awake/ deep Lateral position, head down Laryngospasm:  Prevention: 1. 2. 3. 4. 5. Deep extubation/ fully awake (OSA) I.V. lidocaine Topical anesthesia Magnesium CPAP at extubation Pain management:  NSAIDS  Opioids  Local infiltration  TENS NSAIDS:  NSAIDs did not cause any increase in bleeding requiring return to theatre. There was significantly less nausea & vomiting when NSAIDs were used compared to alternative analgesics.  Cardwell et.al. Non-steroidal anti-inflammatory drugs and perioperative bleeding in paediatric tonsillectomy. Cochrane Database of Systematic Reviews 2005, Issue 2. NSAIDS:  Francis et al. Analgesics for postoperative pain after tonsillectomy and adenoidectomy in children. (Protocol) Cochrane Database of Systematic Reviews 2007, Issue 3. Opioids:  Decreased doses in OSA  Opioid sparing effect of NSAIDS Local anesthetic:  Bupivaciane infiltration pre and post surgery, with & without adr, spray  Reduces bleeding  No evidence that the use of perioperative LA in Pts undergoing tonsillectomy improves post-operative pain Hollis LJ et al. Perioperative local anesthesia for reducing pain following tonsillectomy. Cochrane Database of Systematic Reviews 1999, Issue 4. TENS:  TENS for post tonsillectomy pain relief is a safe, easy and promising method over alternative analgesic regimes which can be safely employed by the recovery staff. A.K.Gupta et al. POST - TONSILLECTOMY PAIN : DIFFERENT MODES OF PAIN RELIEF. Indian Journal of Otolaryngology and Head and Neck Surgery Vol. 54 No. 2, April - June 2002… PONV: Incidence: 40-70% 1. Irritant blood in stomach 2. Inflammation/ edema 3. Dehydration: poor oral intake Prophylaxis: 1. Maintain adequate hydration 2. Gastric decompression 3. Antiemetic drugs 4. Acupuncture Antiemetics:  Good evidence: prophylactic anti-emetic effect of dexamethasone, ondansetron, granisetron, tropisetron & dolasetron, metoclopramide are efficacious.  Not sufficient evidence: dimenhydrinate/ perphenazine/ droperidol/ gastric aspiration/ acupuncture are efficacious  C. M. Bolton et al. Prophylaxis of postoperative vomiting in children undergoing tonsillectomy: A systematic review and meta-analysis. Br J Anaesth 2006; 97: 593–6041 Antiemetics:  Concealed hemorrhage: with tropisetron, ondansetron P G Herreen et al. Concealed post-tonsillectomy hemorrhage associated with the use of the antiemetic; Anesthesia and Intensive Care; Aug 2001; 29, 4 PACU: 1. 2. 3. 4. 5. 6. Bleeding: Pain: Obstruction: PONV: severe C/I Oral intake not required for discharge Adenoidectomy: safely discharged American Academy Of Otolaryngology Head & Neck Surgery Pediatric Otolaryngology Committee  Age ≤3 yr  Abnormal coagulation with/without identified bleeding disorder in patient/family  Evidence of OSA/apnea  Craniofacial/ other airway abnormalities, syndrome disorders: choanal atresia & laryngotracheal stenosis Barash 5th edition American Academy Of Otolaryngology Head & Neck Surgery Pediatric Otolaryngology Committee  Systemic disorders: preop cardiopulmonary, metabolic/ general medical risk  Procedure done: acute peritonsillar abscess  Extended travel time, weather conditions & home social conditions not consistent with close observation, cooperation & ability to return to the hospital quickly Post tonsillectomy bleeding:  1ºh’gge: < 24hrs, generally < 6 hrs More brisk, fatal, profuse, slipping of ligatures  2ºh’gge: 24hrs – 5/6 days post op Eschar on tonsillar bed sloughs Measures: Post nasal pack Re-exploration Re-exploration:  O.1%incidence of re-exploration  Mortality: 1:14000  Issues:  Bleeding and Hypovolemia  Difficult airway  Aspiration Bleeding:  Signs and symptoms of hypovolemia: mild- severe  Large bore i.v. access  Correction: colloids and crystalloids  Difficult to estimate blood loss: adrenergic drive, swallowing of blood  HCT measurement Difficult airway:  Emergent tracheostomy  Experienced anesthesiologist  2 large bore suction catheters  Extra laryngoscope handles and blades  Cuffed ETT and stylets Anesthesia:  Sedation:??  Preoxygenation  Rapid sequence induction  Induction: thiopentone/ propofol/ etomidate/ ketamine  MR: succinylcholine/ rocuronium  Gastric tube  Extubation: fully awake, normal gag & cough reflexes OSA  Def: recurrent episodes of partial/ complete obstruction of upper airways during sleep resulting in disruption of normal ventilation & sleep patterns.  2% prevalence  Peak: 2-8 yrs  Level of obstruction: soft palate & base of tongue Pathophysiology:  Anatomical: upper airway narrowing: adenotonsillar hypertrophy, craniofacial anomalies  Obesity: strongest predictor  Neuromotor factors: reduced central mediated activation of upper airway muscles, neuromuscular diseases Clinical features: Daytime:  Mouth breathing  Poor school performance  Daytime somnolence  Morning headaches  Fatigue  Hyperactivity  Aggression  Social withdrawal Nocturnal: Snoring Labored breathing Paradoxical respiratory effort Apnea Sweating Unusual sleep positions Enuresis Complications:  Growth impairment: failure to thrive  PHT, cor-pulmonale, heart failure  BP dysregulation  Each apneic episode-increased PAP-significant PAH & systemic HT- ventricular dysfunction- dysrrhythmias  CNS dysfunction: persistent hypercarbia OSA: clinical features Features Children Adults Peak age Preschool Middle age Gender ratio M=F M>F, postmenopausal Causes Adenotonsillar hypertrophy, Obesity obesity, craniofacial abnormalities Body habitus Failure to thrive, normal, obese Obesity OSA clinical features Features Children Adult Daytime somnolence Uncommon Very common Neurobehavioral Hyperactivity, developmental delay, cognitive impairment Cognitive impairment, impaired vigilance Treatment 1º: surgical (adenotonsillectomy) 2º: CPAP 1º: CPAP 2º: surgical (uvulopharyngoplasty) Evaluation:  Gold standard: polysomnography  Any age  Diff 1ºsnoring & OSAS  May predict success of treatment/ postop complications  Desaturate with relatively short apneas: <10sec maybe significant  Normal children: usually not > 1 apnea/hr Treatment :  Surgery: Adenotonsillectomy Uvulopharyngoplasty Tongue reduction  CPAP/ BIPAP  SUPPLEMENTAL OXYGEN  TRACHEOSTOMY Effect of treatment:  Treating OSA by tonsillectomy &/or adenoidectomy is associated with increased gain in ht, wt & BMI in most children, including the obese &morbidly obese  Neurobehavioral, cor-pulmonale improvement Zafer Soultan et al. Effect of Treating Obstructive Sleep Apnea by Tonsillectomy and/or Adenoidectomy on Obesity in Children. Pediatr Adolesc Med. 1999;153:33-37 PREANESTHESIA EVALUATION  Polysomnography  ECG: PHT,RVH, cor- pulmonale  ABG: metabolic acidosis, hypercarbia  Antireflux medications  Sedation: monitoring, titrated Anesthetic plan:  Inhaled/ intravenous: titrated  CPAP 10-15 cm  Oral airway/ jaw thrust/ other  Difficult airway management: FOB/ LMA  Pain: opioid sparing adjuncts, non-opioid analgesics, nonpharmacological preferred  Extubation: awake in OT/ ICU PERIOP COMPLICATIONS  Apnea  Pulmonary edema  PHT crisis  Pneumonia  ICU care  Prognosis: 13% recurrence Peritonsillar abscess  Older children  Severe sore throat, odynophagia, high fever, trismus  Limited mouth opening-difficult airway  Head down position, turned to side of abscess  I &D: sedation/ topical/ LA/ GA  Spontaneous breathing maintained  Gentle laryngoscopy, suction  Cuffed ETT Thank you www.anaesthesia.co.in anaesthesia.co.in@gmail.com