TONSILLECTOMY AND ADENOIDECTOMY (T&A)

 

A Tonsillectomy and Adenoidectomy, commonly referred to as T&A, are surgical procedures to remove the tonsils and adenoids. These are typically performed to address chronic infections or breathing problems.

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1. Tonsillectomy: This involves the removal of the tonsils, two small glands located in the back of your throat. Tonsillectomies are often recommended for patients who experience frequent bouts of tonsillitis or other tonsil-related issues.

2. Adenoidectomy: This surgery involves the removal of the adenoids, which are small lumps of tissue at the back of the nose above the roof of the mouth. Adenoids help fight off infections in young children but become less important as a child gets older. An adenoidectomy is often recommended if the adenoids are enlarged and causing breathing difficulties, chronic infections, or other complications.

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Clinical indications for a T&A include upper airway obstruction, obstructive sleep apnea with snoring, massive hypertrophy, and chronic upper respiratory infection (URI).

                                                                                                 

                                          Anesthetic Implications for Tonsillectomy and Adenoidectomy

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Anesthesia type: General

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Airway: ETT, oral RAE may be used, LMA

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Preoperative:

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• The majority of these patients are pediatric

• Patients may have obstructive sleep apnea (OSA)

• OSA patients may have cardiovascular involvement (pulmonary hypertension, altered right ventricular diastolic function, arrhythmias) 

• Suggestive of OSA: mouth breathing, daytime somnolence, nighttime awakening, snoring

• ETT is secured to center of the lower jaw

• An anticholinergic agent may be administered to decrease oral secretions

• Muscle relaxation is not needed

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Intraoperative:

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• "Shared airway" 

• The mouth is retracted open by a surgical mouth gag and the tongue is depressed

• Surgeon normally places a throat pack in the hypopharynx

• Position: Supine, with a shoulder roll used to extend the head, arms tucked, bed turned 90 degrees

• If cautery or laser is used, airway fire is a risk. Decrease FiO2 to 30%.

• Duration: 30 minutes

• EBL 10-200 mL

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Postoperative:

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• Surgeon will insert an orogastric tube to suction out the stomach

• Mouth gag is removed

• Smooth emergence

• Avoid airway obstruction and aspiration

• PONV prophylaxis

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Complications:

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• Bleeding requiring emergent re-exploration

• Laryngospasm

• Hypoxemia

• Airway edema

• Accidental extubation

• Compression of ETT

• Aspiration

• Tooth/dental damage

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Sources:

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Elisha, S. (2010). Case Studies in Nurse Anesthesia.

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Macksey, L. F. (2011). Surgical procedures and anesthetic implications: A handbook for nurse anesthesia practice. 

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Jaffe, R. A. (2020). Anesthesiologist's Manual of Surgical Procedures (6th ed.). 

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Singh-Radcliff, N. (2013). 5-Minute Anesthesia Consult.

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