Oropharyngeal Surgery

Question 1

What are the most common indications for

tonsillectomy?

Answer 1

Chronic tonsillitis or chronic adenoiditis, obstructive sleep apnea, nasal airway obstruction, asymmetric enlargement of the tonsils, snoring, and peritonsillar abscess.

Question 2

What are the potential complications of untreated

tonsillar and adenoidal hyperplasia?

Answer 2

Adenoidal hyperplasia can result in nasopharyngeal obstruction resulting in obligate mouth breathing. Both adenoidal and tonsillar hyperplasia are linked to sleep apnea with the potential for cor pulmonale and failure to thrive.

Question 3

What type of endotracheal tube is recommended for

tonsillectomy and why?

Answer 3

An armored (anode) endotracheal tube is recommended because it resists kinking and compression by the mouth gag.

Question 4

Where should the endotracheal tube be secured for

tonsillectomy and adenoidectomy?

Answer 4

The tube should be secured to the midline of the lower lip.

Question 5

What airway difficulties would you anticipate in the

patient presenting for tonsillectomy?

Answer 5

Because snoring and sleep apnea are often the reason they are undergoing surgery, they are typically difficult to mask ventilate
and/or intubate.

Question 6

What is the incidence of postoperative vomiting in

patients undergoing tonsillectomy?

Answer 6

Up to 65% of patients undergoing tonsillectomy experience postoperative vomiting.

Question 7

When is postoperative bleeding most likely to occur

following tonsillectomy?

Answer 7

Seventy-five percent of postoperative tonsillar bleeding occurs within the first 6 hours following surgery, but may occur at any point up to about 6 days postoperatively.

Question 8

You are performing a preoperative assessment on apatient with Down syndrome planning to undergo
tonsillectomy. What diagnostic test might be
considered for this patient that is related specifically
to Down syndrome?

Answer 8

Patients with Down syndrome are at risk for atlantoaxial instability. During tonsillectomy the neck is typically extended to increase surgical exposure. This position places these patients
at increased risk for cervical damage. A c-spine x-ray would be prudent to determine if subluxation is present prior to surgery to avoid spinal trauma.

Question 9

A patient presenting for tonsillectomy and
adenoidectomy exhibits slight fever and green
sputum on coughing. How should you proceed with
the anesthetic?

Answer 9

You shouldn’t. Patients with symptoms of an upper respiratory infection should be postponed for any elective procedure including tonsillectomy until their symptoms have resolved. This is often about 1 to 2 weeks.

Question 10

What is the recommended position in which
tonsillectomy patients should be placed
postoperatively and why?

Answer 10

They should be placed in the lateral position with their head slightly down to protect the airway from bleeding or gastric aspiration until they are fully awake. This is referred to as the ‘tonsillar’ position.

Question 11

Why is it important to avoid narcotic-induced

hypoventilation on emergence from a tonsillectomy?

Answer 11

The hypoventilation seen with heavy narcotic use (or that occurs with increased sensitivity to narcotics in patients with sleep apnea) results in hypercapnia which can cause vasodilation and increased risk for postoperative bleeding.

Question 12

What is the most common postoperative
complication in the pediatric patient who has
undergone tonsillectomy?

Answer 12

Although aspiration and tooth damage can occur due to tonsillectomy, the most common complication following tonsillectomy is bleeding which occurs in 1 out of every 25 patients.

Question 13

What is the ‘Rose’ position? The ‘Rose’ position for

tonsillectomy may be contraindicated in patients with what disorder?

Answer 13

The ‘Rose’ position involves extension of the neck in the supine position with the use of a shoulder roll. Neck extension may be contraindicated for patients with high risk for subluxation of C1 and C2 due to conditions such as achondroplasia and Down
syndrome.

Question 14

Following tonsillectomy, a patient exhibits airway
obstruction and you cannot ventilate. What are the
most common potential causes?

Answer 14

It is possible that the pharyngeal gauze pack was not removed and is obstructing the airway. If this is the case, it should be removed under direct laryngoscopy with Magill forceps. It is imperative to verify with the surgeon that the throat pack has
been removed prior to extubation. Laryngospasm is another common complication, especially in pediatric patients. Apply CPAP via mask with 100% oxygen and jaw thrust. If the episode persists, a rapid sequence induction and possibly reintubation may be necessary to recover the airway.

Question 15

Rigid bronchoscopy is associated with a large
intrinsic air leak around the scope. How would you
compensate for this during a general anesthetic?

Answer 15

High gas flows, large tidal volumes, and high inspired volatile agent concentrations are often necessary to compensate for the large intrinsic air leak around the rigid bronchoscope and
maintain adequate ventilation and anesthetic depth.

Question 16

What are the drawbacks to a ventilating

bronchoscope?

Answer 16

Traditional positive pressure ventilation is usually only possible during breaks in the performance of a bronchoscopy. Because of this, most anesthetists employ one of three methods to maintain oxygenation during the procedure: 1) apneic
oxygenation by means of a small catheter positioned beside the bronchoscope, 2) conventional ventilation through side-arm of a
specially designed ventilating bronchoscope, or 3) highfrequency jet ventilation through an injector-type
bronchoscope. A drawback of the ventilating bronchoscope is that positive pressure is lost during periods of suctioning, making effective ventilation inconsistent.

Question 17

How do myringotomy, tonsillectomy, bronchoscopy,
and adenoidectomy compare with respect to
postoperative pain?

Answer 17

In order from least amount of expected postoperative pain to the greatest is myringotomy (pain score of 1-3 on a scale of 1-10), bronchoscopy (pain score 3-4), adenoidectomy (pain score3-5), and tonsillectomy (pain score 6-9).

Question 18

What are the airway considerations for a patient
returning to the operating room for evaluation of
persistent postoperative bleeding?

Answer 18

Patients returning to surgery following tonsillectomy for evaluation of bleeding should be considered to have a full stomach regardless of NPO status. The blood loss in these patients averages 4 ml/kg and significant amounts can accumulate in the stomach due to swallowing. Nausea and vomiting is a common symptom in patients who have ingested
significant amounts of blood.

Question 19

How does the degree of postoperative pain with
tonsillectomy compare with that experienced
following an adenoidectomy?

Answer 19

Tonsillectomy is associated with severe pain, while

adenoidectomy is associated with minimal pain.

Question 20

How is hemostasis achieved when performing

tonsillectomy and adenoidectomy?

Answer 20

Electrocautery and gauze packs are used to achieve hemostasis in the tonsillar bed. For adenoidectomy, packs are placed in the nasopharynx.

Question 21

How is the patient positioned for a tonsillectomy?

Answer 21

The patient is supine with the shoulders elevated on a shoulder
roll or pillow.

Question 22

What preoperative medications should be
administered to patients undergoing oropharyngeal
surgery?

Answer 22

Preoperative sedation with midazolam is typically administered unless the patient has sleep apnea or exhibits signs of upper airway obstruction. An antisialagogue such as glycopyrrolate may also be administered to create a dry surgical field.

Question 23

How can you determine whether stridor is due to

obstruction of the upper or lower airway?

Answer 23

Inspiratory stridor results from upper airway obstruction. Lowerairway obstruction results in expiratory stridor.

Question 24

A patient with a chronic cardiac valvular disorder and chronic tonsillitis is at risk for developing endocarditis due to which bacterial organism?

Answer 24

Chronic tonsillar infection places the patient with cardiacvalvular disease at risk for endocarditis due to chronicstreptococcal bacteremia.

Question 25

How does airway management differ between a

patient undergoing a LeFort osteotomy and a patientundergoing repair of a LeFort II fracture?

Answer 25

Nasal intubation is acceptable and occasionally preferable in most oral and dental surgeries, but is specifically contraindicated in LeFort II and LeFort III fractures because of the risk of a coexisting basilar skull fracture and CSF rhinorrhea.

Question 26

You are preparing to perform nasal intubation for a
patient undergoing dental surgery and are
administering 4% cocaine intranasally to constrict
the nasal passages. What is maximum volume of
the cocaine solution that can be administered?

Answer 26

The maximum amount of 4% cocaine solution that may beadministered for vasoconstriction of the nasal passages is 4 mL.