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Anesthesia for tonsillectomy with or without adenoidectomy in children

Senthilkumar Sadhasivam, MD, MPH
Section Editor
Andrew Davidson, MD
Deputy Editor
Marianna Crowley, MD


Tonsillectomy with or without adenoidectomy is one of the most common surgical procedures performed in children. Airway obstruction, resulting in sleep-disordered breathing or obstructive sleep apnea (OSA), and recurrent infection are the most common indications for adenotonsillectomy. Forty years ago, the majority of tonsillectomies were performed for infection, while OSA is now the most common indication, accounting for over 75 percent of cases.

The following features make airway management for adenotonsillectomy particularly challenging:

The airway is shared between the anesthesiologist and the surgeon and must be protected from blood and secretions.

The incidence of laryngospasm is higher than during other surgical procedures.

Children who undergo the procedure for OSA are at particularly high risk of significant respiratory complications in the postoperative period.

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Literature review current through: Oct 2017. | This topic last updated: Aug 29, 2017.
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  1. von Ungern-Sternberg BS, Boda K, Chambers NA, et al. Risk assessment for respiratory complications in paediatric anaesthesia: a prospective cohort study. Lancet 2010; 376:773.
  2. Viitanen H, Annila P, Viitanen M, Tarkkila P. Premedication with midazolam delays recovery after ambulatory sevoflurane anesthesia in children. Anesth Analg 1999; 89:75.
  3. Viitanen H, Annila P, Viitanen M, Yli-Hankala A. Midazolam premedication delays recovery from propofol-induced sevoflurane anesthesia in children 1-3 yr. Can J Anaesth 1999; 46:766.
  4. Connolly LA. Anesthetic management of obstructive sleep apnea patients. J Clin Anesth 1991; 3:461.
  5. Rooke GA, Choi JH, Bishop MJ. The effect of isoflurane, halothane, sevoflurane, and thiopental/nitrous oxide on respiratory system resistance after tracheal intubation. Anesthesiology 1997; 86:1294.
  6. Dikmen Y, Eminoglu E, Salihoglu Z, Demiroluk S. Pulmonary mechanics during isoflurane, sevoflurane and desflurane anaesthesia. Anaesthesia 2003; 58:745.
  7. von Ungern-Sternberg BS, Saudan S, Petak F, et al. Desflurane but not sevoflurane impairs airway and respiratory tissue mechanics in children with susceptible airways. Anesthesiology 2008; 108:216.
  8. Nyktari V, Papaioannou A, Volakakis N, et al. Respiratory resistance during anaesthesia with isoflurane, sevoflurane, and desflurane: a randomized clinical trial. Br J Anaesth 2011; 107:454.
  9. Dhonneur G, Combes X, Leroux B, Duvaldestin P. Postoperative obstructive apnea. Anesth Analg 1999; 89:762.
  10. Eastwood PR, Platt PR, Shepherd K, et al. Collapsibility of the upper airway at different concentrations of propofol anesthesia. Anesthesiology 2005; 103:470.
  11. Brouillette RT, Thach BT. A neuromuscular mechanism maintaining extrathoracic airway patency. J Appl Physiol Respir Environ Exerc Physiol 1979; 46:772.
  12. Brown K. A pragmatic approach to pediatric obstructive sleep apnea. In: Pediatric Anesthesia: Basic principles -- State of the art -- Future, Bissonnette B (Ed), PMPH-USA, Shelton 2011. p.988.
  13. Hoffstein V, Zamel N, Phillipson EA. Lung volume dependence of pharyngeal cross-sectional area in patients with obstructive sleep apnea. Am Rev Respir Dis 1984; 130:175.
  14. Klemola UM, Hiller A. Tracheal intubation after induction of anesthesia in children with propofol--remifentanil or propofol-rocuronium. Can J Anaesth 2000; 47:854.
  15. Batra YK, Al Qattan AR, Ali SS, et al. Assessment of tracheal intubating conditions in children using remifentanil and propofol without muscle relaxant. Paediatr Anaesth 2004; 14:452.
  16. Blair JM, Hill DA, Wilson CM, Fee JP. Assessment of tracheal intubation in children after induction with propofol and different doses of remifentanil. Anaesthesia 2004; 59:27.
  17. Raman V, Tobias JD, Bryant J, et al. Effect of cuffed and uncuffed endotracheal tubes on the oropharyngeal oxygen and volatile anesthetic agent concentration in children. Int J Pediatr Otorhinolaryngol 2012; 76:842.
  18. Hern JD, Jayaraj SM, Sidhu VS, et al. The laryngeal mask airway in tonsillectomy: the surgeon's perspective. Clin Otolaryngol Allied Sci 1999; 24:122.
  19. Tait AR, Pandit UA, Voepel-Lewis T, et al. Use of the laryngeal mask airway in children with upper respiratory tract infections: a comparison with endotracheal intubation. Anesth Analg 1998; 86:706.
  20. Peng A, Dodson KM, Thacker LR, et al. Use of laryngeal mask airway in pediatric adenotonsillectomy. Arch Otolaryngol Head Neck Surg 2011; 137:42.
  21. Webster AC, Morley-Forster PK, Dain S, et al. Anaesthesia for adenotonsillectomy: a comparison between tracheal intubation and the armoured laryngeal mask airway. Can J Anaesth 1993; 40:1171.
  22. Doksrød S, Løfgren B, Nordhammer A, et al. Reinforced laryngeal mask airway compared with endotracheal tube for adenotonsillectomies. Eur J Anaesthesiol 2010; 27:941.
  23. Sierpina DI, Chaudhary H, Walner DL, et al. Laryngeal mask airway versus endotracheal tube in pediatric adenotonsillectomy. Laryngoscope 2012; 122:429.
  24. Gravningsbråten R, Nicklasson B, Raeder J. Safety of laryngeal mask airway and short-stay practice in office-based adenotonsillectomy. Acta Anaesthesiol Scand 2009; 53:218.
  25. Lalwani K, Richins S, Aliason I, et al. The laryngeal mask airway for pediatric adenotonsillectomy: predictors of failure and complications. Int J Pediatr Otorhinolaryngol 2013; 77:25.
  26. Lescanne E, Chiron B, Constant I, et al. Pediatric tonsillectomy: clinical practice guidelines. Eur Ann Otorhinolaryngol Head Neck Dis 2012; 129:264.
  27. Chen HP, Hsu YH, Hua KC, et al. Comparison of sevoflurane versus propofol under auditory evoked potential monitoring in female patients undergoing breast surgery. Biomed J 2013; 36:125.
  28. Bolton CM, Myles PS, Nolan T, Sterne JA. Prophylaxis of postoperative vomiting in children undergoing tonsillectomy: a systematic review and meta-analysis. Br J Anaesth 2006; 97:593.
  29. Ferrari LR, Donlon JV. Metoclopramide reduces the incidence of vomiting after tonsillectomy in children. Anesth Analg 1992; 75:351.
  30. Furst SR, Rodarte A. Prophylactic antiemetic treatment with ondansetron in children undergoing tonsillectomy. Anesthesiology 1994; 81:799.
  31. Steward DL, Grisel J, Meinzen-Derr J. Steroids for improving recovery following tonsillectomy in children. Cochrane Database Syst Rev 2011; :CD003997.
  32. Baugh RF, Archer SM, Mitchell RB, et al. Clinical practice guideline: tonsillectomy in children. Otolaryngol Head Neck Surg 2011; 144:S1.
  33. Czarnetzki C, Elia N, Lysakowski C, et al. Dexamethasone and risk of nausea and vomiting and postoperative bleeding after tonsillectomy in children: a randomized trial. JAMA 2008; 300:2621.
  34. Splinter WM, Roberts DJ. Dexamethasone decreases vomiting by children after tonsillectomy. Anesth Analg 1996; 83:913.
  35. April MM, Callan ND, Nowak DM, Hausdorff MA. The effect of intravenous dexamethasone in pediatric adenotonsillectomy. Arch Otolaryngol Head Neck Surg 1996; 122:117.
  36. Tom LW, Templeton JJ, Thompson ME, Marsh RR. Dexamethasone in adenotonsillectomy. Int J Pediatr Otorhinolaryngol 1996; 37:115.
  37. Pappas AL, Sukhani R, Hotaling AJ, et al. The effect of preoperative dexamethasone on the immediate and delayed postoperative morbidity in children undergoing adenotonsillectomy. Anesth Analg 1998; 87:57.
  38. Fazel MR, Yegane-Moghaddam A, Forghani Z, et al. The effect of dexamethasone on postoperative vomiting and oral intake after adenotonsillectomy. Int J Pediatr Otorhinolaryngol 2007; 71:1235.
  39. 42.Tonsillectomy for Obstructive Sleep-Disordered Breathing or Recurrent Throat Infection in Children, Comparative Effectiveness Review Number 183, Agency for Healthcare Research and Quality. Available at: https://www.effectivehealthcare.ahrq.gov/ehc/products/620/2424/tonsillectomy-report-170113.pdf.
  40. Geva A, Brigger MT. Dexamethasone and tonsillectomy bleeding: a meta-analysis. Otolaryngol Head Neck Surg 2011; 144:838.
  41. Shargorodsky J, Hartnick CJ, Lee GS. Dexamethasone and postoperative bleeding after tonsillectomy and adenotonsillectomy in children: A meta-analysis of prospective studies. Laryngoscope 2012; 122:1158.
  42. Bellis JR, Pirmohamed M, Nunn AJ, et al. Dexamethasone and haemorrhage risk in paediatric tonsillectomy: a systematic review and meta-analysis. Br J Anaesth 2014; 113:23.
  43. Plante J, Turgeon AF, Zarychanski R, et al. Effect of systemic steroids on post-tonsillectomy bleeding and reinterventions: systematic review and meta-analysis of randomised controlled trials. BMJ 2012; 345:e5389.
  44. Cho HK, Park IJ, Jeong YM, et al. Can perioperative acupuncture reduce the pain and vomiting experienced after tonsillectomy? A meta-analysis. Laryngoscope 2016; 126:608.
  45. Starke PR, Weaver J, Chowdhury BA. Boxed warning added to promethazine labeling for pediatric use. N Engl J Med 2005; 352:2653.
  46. Brown KA, Laferrière A, Lakheeram I, Moss IR. Recurrent hypoxemia in children is associated with increased analgesic sensitivity to opiates. Anesthesiology 2006; 105:665.
  47. Brown KA, Brouillette RT. The elephant in the room: lethal apnea at home after adenotonsillectomy. Anesth Analg 2014; 118:1157.
  48. Stewart DW, Ragg PG, Sheppard S, Chalkiadis GA. The severity and duration of postoperative pain and analgesia requirements in children after tonsillectomy, orchidopexy, or inguinal hernia repair. Paediatr Anaesth 2012; 22:136.
  49. Nunez DA, Provan J, Crawford M. Postoperative tonsillectomy pain in pediatric patients: electrocautery (hot) vs cold dissection and snare tonsillectomy--a randomized trial. Arch Otolaryngol Head Neck Surg 2000; 126:837.
  50. Leinbach RF, Markwell SJ, Colliver JA, Lin SY. Hot versus cold tonsillectomy: a systematic review of the literature. Otolaryngol Head Neck Surg 2003; 129:360.
  51. Hanasono MM, Lalakea ML, Mikulec AA, et al. Perioperative steroids in tonsillectomy using electrocautery and sharp dissection techniques. Arch Otolaryngol Head Neck Surg 2004; 130:917.
  52. Kirazli T, Bilgen C, Midilli R, et al. Bipolar electrodissection tonsillectomy in children. Eur Arch Otorhinolaryngol 2005; 262:716.
  53. Potts KL, Augenstein A, Goldman JL. A parallel group analysis of tonsillectomy using the harmonic scalpel vs electrocautery. Arch Otolaryngol Head Neck Surg 2005; 131:49.
  54. Ishlah LW, Fahmi AM, Srinovianti N. Laser versus dissection technique of tonsillectomy. Med J Malaysia 2005; 60:76.
  55. Anand A, Vilela RJ, Guarisco JL. Intracapsular versus standard tonsillectomy: review of literature. J La State Med Soc 2005; 157:259.
  56. Hultcrantz E, Linder A, Markström A. Long-term effects of intracapsular partial tonsillectomy (tonsillotomy) compared with full tonsillectomy. Int J Pediatr Otorhinolaryngol 2005; 69:463.
  57. Arya A, Donne AJ, Nigam A. Double-blind randomized controlled study of coblation tonsillotomy versus coblation tonsillectomy on postoperative pain. Clin Otolaryngol Allied Sci 2003; 28:503.
  58. Nafiu OO, Shanks A, Abdo S, et al. Association of high body mass index in children with early post-tonsillectomy pain. Int J Pediatr Otorhinolaryngol 2013; 77:256.
  59. Sadhasivam S, Chidambaran V, Ngamprasertwong P, et al. Race and unequal burden of perioperative pain and opioid related adverse effects in children. Pediatrics 2012; 129:832.
  60. Kain ZN, Mayes LC, Caldwell-Andrews AA, et al. Preoperative anxiety, postoperative pain, and behavioral recovery in young children undergoing surgery. Pediatrics 2006; 118:651.
  61. Sadhasivam S, Chidambaran V. Pharmacogenomics of opioids and perioperative pain management. Pharmacogenomics 2012; 13:1719.
  62. Sadhasivam S, Chidambaran V, Olbrecht VA, et al. Genetics of pain perception, COMT and postoperative pain management in children. Pharmacogenomics 2014; 15:277.
  63. Cook-Sather SD, Li J, Goebel TK, et al. TAOK3, a novel genome-wide association study locus associated with morphine requirement and postoperative pain in a retrospective pediatric day surgery population. Pain 2014; 155:1773.
  64. Alhashemi JA, Daghistani MF. Effects of intraoperative i.v. acetaminophen vs i.m. meperidine on post-tonsillectomy pain in children. Br J Anaesth 2006; 96:790.
  65. Wong I, St John-Green C, Walker SM. Opioid-sparing effects of perioperative paracetamol and nonsteroidal anti-inflammatory drugs (NSAIDs) in children. Paediatr Anaesth 2013; 23:475.
  66. Uysal HY, Takmaz SA, Yaman F, et al. The efficacy of intravenous paracetamol versus tramadol for postoperative analgesia after adenotonsillectomy in children. J Clin Anesth 2011; 23:53.
  67. Anderson BJ, Holford NH, Woollard GA, et al. Perioperative pharmacodynamics of acetaminophen analgesia in children. Anesthesiology 1999; 90:411.
  68. Birmingham PK, Tobin MJ, Fisher DM, et al. Initial and subsequent dosing of rectal acetaminophen in children: a 24-hour pharmacokinetic study of new dose recommendations. Anesthesiology 2001; 94:385.
  69. Capici F, Ingelmo PM, Davidson A, et al. Randomized controlled trial of duration of analgesia following intravenous or rectal acetaminophen after adenotonsillectomy in children. Br J Anaesth 2008; 100:251.
  70. St Charles CS, Matt BH, Hamilton MM, Katz BP. A comparison of ibuprofen versus acetaminophen with codeine in the young tonsillectomy patient. Otolaryngol Head Neck Surg 1997; 117:76.
  71. Kelly LE, Sommer DD, Ramakrishna J, et al. Morphine or Ibuprofen for post-tonsillectomy analgesia: a randomized trial. Pediatrics 2015; 135:307.
  72. Sutters KA, Levine JD, Dibble S, et al. Analgesic efficacy and safety of single-dose intramuscular ketorolac for postoperative pain management in children following tonsillectomy. Pain 1995; 61:145.
  73. Gunter JB, Varughese AM, Harrington JF, et al. Recovery and complications after tonsillectomy in children: a comparison of ketorolac and morphine. Anesth Analg 1995; 81:1136.
  74. Splinter WM, Rhine EJ, Roberts DW, et al. Preoperative ketorolac increases bleeding after tonsillectomy in children. Can J Anaesth 1996; 43:560.
  75. Judkins JH, Dray TG, Hubbell RN. Intraoperative ketorolac and posttonsillectomy bleeding. Arch Otolaryngol Head Neck Surg 1996; 122:937.
  76. Rusy LM, Houck CS, Sullivan LJ, et al. A double-blind evaluation of ketorolac tromethamine versus acetaminophen in pediatric tonsillectomy: analgesia and bleeding. Anesth Analg 1995; 80:226.
  77. Cardwell M, Siviter G, Smith A. Non-steroidal anti-inflammatory drugs and perioperative bleeding in paediatric tonsillectomy. Cochrane Database Syst Rev 2005; :CD003591.
  78. Bean-Lijewski JD, Hunt RD. Effect of ketorolac on bleeding time and postoperative pain in children: a double-blind, placebo-controlled comparison with meperidine. J Clin Anesth 1996; 8:25.
  79. Lewis SR, Nicholson A, Cardwell ME, et al. Nonsteroidal anti-inflammatory drugs and perioperative bleeding in paediatric tonsillectomy. Cochrane Database Syst Rev 2013; :CD003591.
  80. Li X, Zhou M, Xia Q, Li J. Parecoxib sodium reduces the need for opioids after tonsillectomy in children: a double-blind placebo-controlled randomized clinical trial. Can J Anaesth 2016; 63:268.
  81. Tan L, Taylor E, Hannam JA, et al. Pharmacokinetics and analgesic effectiveness of intravenous parecoxib for tonsillectomy ± adenoidectomy. Paediatr Anaesth 2016; 26:1126.
  82. Murto K, Lamontagne C, McFaul C, et al. Celecoxib pharmacogenetics and pediatric adenotonsillectomy: a double-blinded randomized controlled study. Can J Anaesth 2015; 62:785.
  83. Olutoye OA, Glover CD, Diefenderfer JW, et al. The effect of intraoperative dexmedetomidine on postoperative analgesia and sedation in pediatric patients undergoing tonsillectomy and adenoidectomy. Anesth Analg 2010; 111:490.
  84. Patel A, Davidson M, Tran MC, et al. Dexmedetomidine infusion for analgesia and prevention of emergence agitation in children with obstructive sleep apnea syndrome undergoing tonsillectomy and adenoidectomy. Anesth Analg 2010; 111:1004.
  85. Olutoye O, Kim T, Giannoni C, Stayer S. Dexmedetomidine as an analgesic for pediatric tonsillectomy and adenoidectomy. Paediatr Anaesth 2007; 17:1007.
  86. Koroglu A, Demirbilek S, Teksan H, et al. Sedative, haemodynamic and respiratory effects of dexmedetomidine in children undergoing magnetic resonance imaging examination: preliminary results. Br J Anaesth 2005; 94:821.
  87. Guler G, Akin A, Tosun Z, et al. Single-dose dexmedetomidine reduces agitation and provides smooth extubation after pediatric adenotonsillectomy. Paediatr Anaesth 2005; 15:762.
  88. Shukry M, Clyde MC, Kalarickal PL, Ramadhyani U. Does dexmedetomidine prevent emergence delirium in children after sevoflurane-based general anesthesia? Paediatr Anaesth 2005; 15:1098.
  89. Ibacache ME, Muñoz HR, Brandes V, Morales AL. Single-dose dexmedetomidine reduces agitation after sevoflurane anesthesia in children. Anesth Analg 2004; 98:60.
  90. Pestieau SR, Quezado ZM, Johnson YJ, et al. High-dose dexmedetomidine increases the opioid-free interval and decreases opioid requirement after tonsillectomy in children. Can J Anaesth 2011; 58:540.
  91. Bell RF, Dahl JB, Moore RA, Kalso E. Perioperative ketamine for acute postoperative pain. Cochrane Database Syst Rev 2006; :CD004603.
  92. Laskowski K, Stirling A, McKay WP, Lim HJ. A systematic review of intravenous ketamine for postoperative analgesia. Can J Anaesth 2011; 58:911.
  93. Cho HK, Kim KW, Jeong YM, et al. Efficacy of ketamine in improving pain after tonsillectomy in children: meta-analysis. PLoS One 2014; 9:e101259.
  94. Dahmani S, Michelet D, Abback PS, et al. Ketamine for perioperative pain management in children: a meta-analysis of published studies. Paediatr Anaesth 2011; 21:636.
  95. Brown KA, Laferrière A, Moss IR. Recurrent hypoxemia in young children with obstructive sleep apnea is associated with reduced opioid requirement for analgesia. Anesthesiology 2004; 100:806.
  96. Waters KA, McBrien F, Stewart P, et al. Effects of OSA, inhalational anesthesia, and fentanyl on the airway and ventilation of children. J Appl Physiol (1985) 2002; 92:1987.
  97. Raghavendran S, Bagry H, Detheux G, et al. An anesthetic management protocol to decrease respiratory complications after adenotonsillectomy in children with severe sleep apnea. Anesth Analg 2010; 110:1093.
  98. Brown KA. Intermittent hypoxia and the practice of anesthesia. Anesthesiology 2009; 110:922.
  99. Hollis LJ, Burton MJ, Millar JM. Perioperative local anaesthesia for reducing pain following tonsillectomy. Cochrane Database Syst Rev 2000; :CD001874.
  100. Subramanyam R, Varughese A, Willging JP, Sadhasivam S. Future of pediatric tonsillectomy and perioperative outcomes. Int J Pediatr Otorhinolaryngol 2013; 77:194.
  101. Ohlms LA. Injection of local anesthetic in tonsillectomy. Arch Otolaryngol Head Neck Surg 2001; 127:1276.
  102. Bean-Lijewski JD. Glossopharyngeal nerve block for pain relief after pediatric tonsillectomy: retrospective analysis and two cases of life-threatening upper airway obstruction from an interrupted trial. Anesth Analg 1997; 84:1232.
  103. Coté CJ, Posner KL, Domino KB. Death or neurologic injury after tonsillectomy in children with a focus on obstructive sleep apnea: houston, we have a problem! Anesth Analg 2014; 118:1276.
  104. Goldman JL, Baugh RF, Davies L, et al. Mortality and major morbidity after tonsillectomy: etiologic factors and strategies for prevention. Laryngoscope 2013; 123:2544.
  105. Patino M, Sadhasivam S, Mahmoud M. Obstructive sleep apnoea in children: perioperative considerations. Br J Anaesth 2013; 111 Suppl 1:i83.
  106. Food and Drug Administration. Safety review update of codeine use in children; new boxed warning and contraindication on use after tonsillectomy and/or adenoidectomy. FDA Drug Safety Communication 2013. http://www.fda.gov/Drugs/DrugSafety/ucm339112.htm (Accessed on February 13, 2015).
  107. European Medicines Agency. Codeine-containing medicinal products for the treatment of cough or cold in paediatric patients. http://www.ema.europa.eu/ema/index.jsp?curl=pages/medicines/human/referrals/Codeine_containing_medicinal_products_for_the_treatment_of_cough_and_cold_in_paediatric_patients/human_referral_prac_000039.jsp&mid=WC0b01ac05805c516f (Accessed on July 01, 2015).
  108. Fields RG, Gencorelli FJ, Litman RS. Anesthetic management of the pediatric bleeding tonsil. Paediatr Anaesth 2010; 20:982.