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.
Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist’s
Manual of Surgical Procedures. 5th ed. Philadelphia, PA:
Wolters Kluwer Health, 2014: 207.

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.
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 1357

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.
Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist’s
Manual of Surgical Procedures. 5th ed. Philadelphia, PA:
Wolters Kluwer Health, 2014: 208.

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.
Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist’s
Manual of Surgical Procedures. 5th ed. Philadelphia, PA:
Wolters Kluwer Health, 2014: 208.

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.
Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist’s
Manual of Surgical Procedures. 5th ed. Philadelphia, PA:
Wolters Kluwer Health, 2014: 209.

Question 6

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

Answer 6

Tonsillectomy is associated with severe pain, while
adenoidectomy is associated with minimal pain.
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 1360.

Question 7

How is the patient positioned for a tonsillectomy?

Answer 7

The patient is supine with the shoulders elevated on a shoulder
roll or pillow.
Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist’s
Manual of Surgical Procedures. 5th ed. Philadelphia, PA:
Wolters Kluwer Health, 2014: 208.

Question 8

How is hemostasis achieved when performing

tonsillectomy and adenoidectomy?

Answer 8

Electrocautery and gauze packs are used to achieve
hemostasis in the tonsillar bed. For adenoidectomy, packs are
placed in the nasopharynx.
Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist’s
Manual of Surgical Procedures. 5th ed. Philadelphia, PA:
Wolters Kluwer Health, 2014: 207.

Question 9

What is the incidence of postoperative vomiting in

patients undergoing tonsillectomy?

Answer 9

Up to 65% of patients undergoing tonsillectomy experience
postoperative vomiting.
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 1358.

Question 10

When is postoperative bleeding most likely to occur

following tonsillectomy?

Answer 10

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.
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 1360.

Question 11

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

Answer 11

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.
Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist’s
Manual of Surgical Procedures. 5th ed. Philadelphia, PA:
Wolters Kluwer Health, 2014: 209.

Question 12

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

Answer 12

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.
Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist’s
Manual of Surgical Procedures. 5th ed. Philadelphia, PA:
Wolters Kluwer Health, 2014: 209.

Question 13

Why is it important to avoid narcotic-induced

hypoventilation on emergence from a tonsillectomy?

Answer 13

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.
Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist’s
Manual of Surgical Procedures. 5th ed. Philadelphia, PA:
Wolters Kluwer Health, 2014: 208.

Question 14

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

Answer 14

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.
Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist’s
Manual of Surgical Procedures. 5th ed. Philadelphia, PA:
Wolters Kluwer Health, 2014: 210.

Question 15

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

Answer 15

Although aspiration and tooth damage can occur due to
tonsillectomy, the most common complication following
tonsillectomy is bleeding which occurs.
Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist’s
Manual of Surgical Procedures. 5th ed. Philadelphia, PA:
Wolters Kluwer Health, 2014: 1213.

Question 16

What is the ‘Rose’ position? The ‘Rose’ position for
tonsillectomy may be contraindicated in patients with
what disorder?

Answer 16

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.
Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist’s
Manual of Surgical Procedures. 5th ed. Philadelphia, PA:
Wolters Kluwer Health, 2014: 208-209.

Question 17

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

Answer 17

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.
Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist’s
Manual of Surgical Procedures. 5th ed. Philadelphia, PA:
Wolters Kluwer Health, 2014: 211.

Question 18

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

Answer 18

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.
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 1364.

Question 19

What are the drawbacks to a ventilating

bronchoscope?

Answer 19

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.
Butterworth JF, Mackey DC, Wasnick JD. Morgan & Mikhail’s
Clinical Anesthesiology. 5th ed. New York, NY: McGraw-Hill;
2013: 567-568.

Question 20

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

Answer 20

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.
Jaffe RA, Samuels SI. Anesthesiologist’s Manual of Surgical
Procedures. 4th ed. Philadelphia, PA: Lippincott Williams and
Wilkins, 2009: 206-207

Question 21

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

Answer 21

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.
Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist’s
Manual of Surgical Procedures. 5th ed. Philadelphia, PA:
Wolters Kluwer Health, 2014: 209.

Question 22

How can you determine whether stridor is due to

obstruction of the upper or lower airway?

Answer 22

Inspiratory stridor results from upper airway obstruction. Lower
airway obstruction results in expiratory stridor.
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 1363.

Question 23

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

Answer 23

Chronic tonsillar infection places the patient with cardiac
valvular disease at risk for endocarditis due to chronic
streptococcal bacteremia.
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 1357.

Question 24

How does airway management differ between a
patient undergoing a LeFort osteotomy and a patient
undergoing repair of a LeFort II fracture?

Answer 24

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.
Butterworth JF, Mackey DC, Wasnick JD. Morgan & Mikhail’s
Clinical Anesthesiology. 5th ed. New York, NY: McGraw-Hill;
2013: 843.

Question 25

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 25

The maximum amount of 4% cocaine solution that may be
administered for vasoconstriction of the nasal passages is 4 mL.
Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist’s
Manual of Surgical Procedures. 5th ed. Philadelphia, PA:
Wolters Kluwer Health, 2014: 275.