Tonsillectomies: A Case Study

Tonsillectomies are among the most common surgical procedures performed on children. Children younger than 15 years of age receive more than 530,000 tonsillectomies each year in the United States.1 The most common surgical indications are recurrent upper respiratory infections and sleep apnea caused by airway obstruction.1 After the 1970s, indications of surgical necessity have gone from being associated with infections to being more commonly caused by upper airway obstruction.2 Tonsillectomies are usually performed in an outpatient setting, and patients are discharged a few hours after the procedure. The reported list of possible postoperative complications include adverse effects of anesthesia, pain, bleeding, dehydration, burn injuries, …show more content…
The ASA difficult airway algorithm should be used as a guideline.14 ETT tubes should be prepared at half a size smaller in case of laryngeal edema and with two sets of each size in case one becomes blocked by clots. Rapid sequence induction and intubation (RSII) with cricoid pressure and a low dose of the induction agent are considered in patients with hypovolemia. Use of laryngeal mask airway (LMA) is reported to be successful in post-tonsillectomy hemorrhage after initial ETT attempts fail.15,16 By using LMA-ProsealTM as a channel to guide a flexible bronchoscope in to locate the trachea, then inserting ETT over the bronchoscope can be considered.17 The LMA device can also act as a tamponade on the bleeding area; however, this option should be discussed with the surgeon before using it. Difficult airway management in this situation can be challenging and possibly lead to anoxic brain …show more content…
Combining acetaminophen with opioids is another option. Nonsteroidal anti-inflammatory drugs (NSAIDs), particularly ketorolac, should be avoided in this setting because of the increased risk of post-tonsillectomy bleeding.1 The American Academy of Otolaryngology–Head and Neck Surgery Foundation (AAO-NSF) recommends postoperatively administering nausea and vomiting prophylaxis with a single dose of dexamethasone.1 However, the association between dexamethasone and increased post-tonsillectomy bleeding remains controversial. A systematic review and meta-analysis showed no increase in the risk of post-tonsillectomy hemorrhage with dexamethasone with or without NSAID use in children19; in a randomized trial study, however, the risk for post-tonsillectomy bleeding was shown to increase with a 0.5 mg/kg dosage of dexamethasone, but the study was terminated early for safety reasons.20 Medication use in this setting should be closely discussed with the