tonsillectomy & adenoidectomy & its anesthetic implication
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Tonsillectomy & adenoidectomy & its anesthetic implicationTRANSCRIPT
Tonsillectomy & adenoidectomy & its
anesthetic implication
-DR MAYURI GOLHAR
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.
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.
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.
contraindicationsPersisitent acute infection.Abnormal coagulation profile.Children with cleft lip/palate< 5yrs of ageEpidemic of polio
Tonsillectomy methodsSUBCAPSULAR/ TOTAL INTRACAPSULAR/SUBTOTAL
blunt dissection bipolar radio frequency/Coblation
bipolar radio frequency LASER
electrocautery Powered microdebrider
Ultrasonic dissection
Cold knife
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
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.
EVENTS LEADING TO COR- PULMONALE
Hypoxemia &
hypercarbia
Increase airway
resistance
Pulmonary/
arteriolar
constiction
Pulmonary artery hyperten
sion
Right side
heart failure
COR PULMONALE
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.
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 .
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.
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.
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.
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.
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%
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.
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.
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.
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.
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.
Rapid relief of obstruction venous return increases hydrostatic pressure increases. - hyperemia positive counterbalancing
mechanism fail pulmonary edema.
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.
THANK YOU….