Anesthesia for Ear, Nose and Throat Surgery in Children

Abstract

Ear, nose and throat surgery is the commonest reason for anesthesia in children. It has unique challenges of a shared and potentially soiled airway as well as the possibility of postoperative airway obstruction. This chapter discusses common, elective ENT procedures as well as pain management and complications. It also details the management of potentially life-threatening emergencies such as the bleeding tonsil and neck abscesses. Tonsillectomy is usually performed for obstructive sleep apnea (OSA) in preschool-aged children. Children with OSA have an increased sensitivity to opioids and multimodal analgesia is essential to minimize the opioid dose, or to avoid opioids altogether. Syndromic children with anatomical narrowing of the upper airway are at additional risk. Non-steroidal anti-inflammatory drugs are important after tonsillectomy, but there are still concerns regarding bleeding. Dexamethasone improves oral intake, reduces pain, nausea and vomiting, and should be given routinely. Bleeding after tonsillectomy occurs in about 1% of cases, although most cases have a small bleeding point and the main anesthetic issue is blood in the stomach. Rarely, others have an arterial bleeding point, and their mouth fills with blood between induction and laryngoscopy. The LMA potentially retrieves the airway in these cases when intubation is not possible. Superficial neck abscesses are common in children and are caused by infected lymph nodes. Deeper neck abscesses are rare, but can cause airway obstruction and difficult intubation.

Review Questions

• 1. A 3 year old child has been intubated and ventilated for tonsillectomy. Part-way through surgery, the ETCO₂ trace becomes irregular and the oxygen saturation falls. What will you do?

• 2. A 6-year-old boy with Trisomy 21 syndrome presents with a day 6 post tonsillectomy bleed pale and lethargic. He was previously a grade 3 intubation. What is your anesthetic plan?

• 3. You have just induced a child for ear grommet insertion. Just before you are about to place the LMA you get an urgent call from recovery telling you that the previous tonsillectomy patient is blue and not breathing. You are the sole anesthetist in the hospital at this time. What is your approach?

• 4. A child with Von Willebrand’s disease presents for elective tonsillectomy. Describe your management

• 5. You are asked to see a 16-year-old boy with a large tonsillar abscess.

  • (a) What are the treatment options?

  • (b) What clinical signs and symptoms would particularly concern you?

  • (c) How would you anesthetize this patient?

• 6. A 10 year old girl with Trisomy 21 presents for adenotonsillectomy. She has recurrent respiratory infections and tires easily when playing. On examination SaO₂ is 93% in air, temperature 37.2 °C and she has a non-radiating grade 3/6 systolic murmur.

• 7. Why might it be best not to proceed with anesthesia