Paediatrics
Anaesthesia for elective ear,
nose and throat surgery in
children
Permendra Singh
Simon Whyte
Abstract
This review outlines anaesthetic considerations for commonly performed
elective ear, nose and throat procedures, which constitute a major por-
tion of the paediatric anaesthesia workload. Most routine surgery can
be performed on a daycare basis, but careful preoperative assessment
is vital to identify those patients who are unsuitable for daycare surgery
owing to complications of their presenting illness (e.g. obstructive sleep
apnoea; OSA) or other co-morbidities. Children undergoing middle ear
surgery need special attention to prevent bleeding, hypothermia and
postoperative nausea and vomiting (PONV). Adenotonsillectomy is most
commonly performed to relieve the symptoms of OSA. The main anaes-
thetic concerns are analgesia, PONV, risk of postoperative haemorrhage
and postoperative disposition. Daycare tonsillectomy involves careful
patient selection and good communication with families regarding the
postoperative phase and potential complications. Use of lasers is com-
mon in airway surgery; associated risks include airway fire and injury to
the eyes of the patient and theatre staff.
Keywords adenotonsillectomy; daycare; elective; otolaryngology;
paediatrics
Introduction
Elective ear, nose and throat (ENT) surgery in American Soci-
ety of Anesthsiology (ASA) stage 1 or 2 children takes place in
almost every hospital. The anaesthetic challenges include appro-
priate selection of day-case patients, sharing the airway with the
surgeon, managing postoperative nausea and vomiting (PONV)
and patient and personnel safety issues surrounding the use of
lasers.
Permendra Singh, MBBS, FRCA, is a Specialist Registrar in Anaesthesia.
He obtained his medical degree from India and undertook his
anaesthesia training in India and in the UK. He has completed a
fellowship in paediatric anaesthesia at the British Columbia Children’s
Hospital in Vancouver, Canada. Conflicting interests: none declared.
Simon Whyte, MBBS, FRCA, is a Paediatric Anaesthetist in Vancouver,
Canada. He obtained his medical degree in 1994 from the University
of Newcastle upon Tyne, and undertook his anaesthesia training in
Durham, Middlesbrough and Liverpool. His research interests include
perioperative long QT syndromes and advanced airway management
in children. Conflicting interests: none declared.
ANAESTHESIA AND INTENSIVE CARE MEDICINE 10:4
Preoperative assessment
In addition to the standard components of a preoperative assess-
ment (Anaesthesia and Intensive Care Medicine 2006; 7: 375–9),
the following are particularly pertinent to paediatric ENT sur-
gery: co-existing syndromes, recent upper respiratory tract infec-
tion (URTI), upper airway obstruction during sleep and bleeding
diatheses.
Any congenital, chromosomal or syndromic abnormali-
ties should be specifically identified. Commonly encountered
examples include children with Down’s syndrome, who often
require middle ear surgery (which is more challenging as they
have narrow external auditory canals) and adenotonsillectomy
for obstructive sleep apnoea; patients with branchial arch abnor-
malities, who present for reconstructive ear surgery and may be
extremely difficult to intubate; infants with cleft lips and/or pal-
ates, which may be isolated anomalies but may also be part of
syndromes whose other features (particularly cardiac) may have
an impact on the anaesthesia management.
A history of active or recently resolved upper respiratory tract
infection is commonly elicited in children scheduled for ENT sur-
gery. Fitness for anaesthesia should be assessed on a case-by-
case basis. Generally, a child with clear nasal secretions who is
systemically well, with no associated fever or chest signs is con-
sidered fit for anaesthesia.1 A cough is a sign of increased airway
irritability and portends an elevated risk of airway complications
such as breath-holding, laryngospasm and desaturation. These
risks are greater if the larynx is to be intubated or instrumented.
Other risk factors for increased airway complications include
nasal congestion, mucopurulent secretions and passive smoking.
Children presenting for adenotonsillectomy typically experi-
ence varying degrees of upper airway obstruction (UAO) when
sleeping. Preoperatively, a thorough assessment of the degree
of obstruction should be obtained by history and examination
(Table 1). The diagnosis is usually informal and subjective,
based on parental reports of snoring, transient apnoeas, frequent
nocturnal awakening and, in more severe cases, daytime som-
nolence or hyperactivity, behaviour problems and altered school
performance. Most children will have histories consistent with
only mild OSA. Examination may reveal obesity, adenoidal facies
Symptoms and signs suggestive of sleep-disordered
breathing in children
Night-time Daytime symptoms Signs
symptoms
Snoring Daytime sleepiness Obesity
Apnoea Hyperactivity Tonsillar hypertrophy
Arousals or Poor concentration Mouth-breathing
wakening Failure to thrive
Enuresis
Night sweats
Difficult to rouse
in the morning
Table 1
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 Paediatrics
or obviously enlarged tonsils. A nasendoscopy may have detailed
the degree of any adenoidal obstruction of the nasopharynx. Chil-
dren with severe symptoms of OSA may have been assessed with
overnight pulse oximetry, or formal polysomnography. Plans
should be made preoperatively for children with OSA who have
risk factors for postoperative complications (Table 2) to be moni-
tored in a high-dependency setting for 24 hours postoperatively.
A history of increased bruising or easy bleeding should be
sought and investigated. Haemorrhage during or after adenoton-
sillectomy is an important complication (see below), whereas
middle ear surgery can be rendered impossible by even small
amounts of bleeding.
Common ENT procedures
Myringotomy and tympanostomy tubes
Anaesthetic considerations: this is usually performed as a day-
case procedure; therefore, emphasis should be on adequate pain
relief and quick recovery.
Preoperatively: assess for active or recent URTI (common). Many
children undergo repeated operations and may have increased
anxiety around or specific preferences for induction of anaesthe-
sia. Analgesia with oral paracetamol (acetaminophen) and/or a
non-steroidal anti-inflammatory drug (NSAID) is appropriate.
Intraoperatively: the airway can be maintained either with a
face mask or laryngeal mask airway (LMA) while the patient
breathes spontaneously. A dose of ondansetron 0.15 mg/kg may
be given intravenously (i.v.) to minimize PONV.
Postoperatively: analgesic requirements are highly variable
between children. Some may occasionally require intravenous
opioid.
Adenotonsillectomy
This common procedure is performed on a daycare basis in many
hospitals. OSA is now the commonest indication for adenotonsil-
lectomy in children, although good-quality evidence of its efficacy
is lacking.2 Careful patient selection and preoperative assessment
is vital to avoid complications. Children with OSA are more prone
Risk factors for postoperative complications in
children with obstructive sleep apnoea undergoing
adenotonsillectomy
• Age younger than 3 years
• Cardiac complications of OSA
• Failure to thrive
• Obesity
• Prematurity
• Recent respiratory infection
• Craniofacial anomalies
• Neuromuscular disorders
OSA, obstructive sleep apnoea.
Table 2
ANAESTHESIA AND INTENSIVE CARE MEDICINE 10:4
to develop airway obstruction in the postoperative period, when
the anaesthetic effects on upper airway tone and reflexes are still
compromising the airway. The development of idiopathic pulmo-
nary oedema following the relief of upper airway obstruction has
also been reported. In severe OSA, the hypoxaemia and hyper-
carbia that result from the cyclical obstruction–hypoventilation–
arousal sleep pattern in these children can produce a compensated
respiratory acidosis and pulmonary hypertension. In end-stage
disease, cor pulmonale and cardiac arrhythmias can result.
Anaesthetic considerations: presence and severity of sleep-
disordered breathing; potentially difficult airway; potential
pulmon­ary hypertension; ventilation strategy; analgesic ­strategy;
PONV prophylaxis; postoperative disposition; postoperative
bleeding.
Preoperatively: the anaesthetist should gain a sense of how bad
the child’s airway obstruction is during sleep, as this will reflect
the potential airway obstruction on induction of anaesthesia. In
a minority of patients, objective information will be available,
in the form of results from overnight pulse oximetry or formal
­polysomnography. In the vast majority, however, an impression
is gained from the subjective observations of parents. Important
signs and symptoms are detailed in Table 1. Other preoperative
enquiries should aim at eliciting any history suggestive of bleed-
ing diathesis, risk factors for PONV and active or recent tonsillitis
(which is a risk factor for postoperative haemorrhage).
Sedative premedication is relatively contraindicated in patients
with OSA, as it may compound upper airway obstruction during
or even before induction. Analgesics such as paracetamol or a
NSAID such as ibuprofen may be given preoperatively to these
patients.3
Postoperative disposition should be agreed upon preopera-
tively. Children chosen for daycare should have good overall
medical health; no central or obstructive sleep apnoea; a normal
bleeding history and profile; adequate social circumstances; and
should preferably live near the hospital.4
Intraoperatively: induction may be by either the inhalational or
the intravenous route, though induction with propofol might be
preferred in cases where there is no obvious airway obstruction
to reduce the incidence of PONV. Fentanyl in a dose of 1–2 μg/kg
may be given to provide intraoperative analgesia. A preformed
south-facing oral RAE (Ring, Adair and Elwyn) tracheal tube or
a reinforced LMA may be used to maintain the airway. A LMA
is useful in the recovery phase since it can be left in place until
the patient’s reflexes return, whereas an endotracheal tube raises
the dilemma of extubation at a deep plane of anaesthesia ver-
sus awake extubation.5 The pros and cons of using a LMA are
listed in Table 3. Attention has to be given to careful insertion
of the operative mouth gag in either technique, ensuring that the
airway device remains unobstructed. After insertion of the gag
a manual check for ease of lung inflation should be performed
before surgery begins.
Children with significant OSA may have a compensated respi-
ratory acidosis as a result of nocturnal hypercarbia, although
this is likely to be far less common than in adults with OSA.
­Ventilating such patients to normocapnia will delay restitution of
spontaneous ventilation at the end of the procedure.
187 Crown Copyright © 2009 Published by Elsevier Ltd. All rights reserved.
 Paediatrics
Advantages and disadvantages of airway maintenance
with a laryngeal mask airway during tonsillectomy
Advantages Easy to insert
Allows for lighter level of anaesthesia
Smoother emergence without tracheal
stimulation
Disadvantages
May retract cephalad in the pharynx and
obstruct surgical view
Does not protect against secretions entering
the glottic opening
Table 3
Estimated total intravascular blood volume should be cal-
culated for each child (neonates, 90 ml/kg; infants, 80 ml/kg;
children, 70 ml/kg) and blood loss should be closely monitored.
Isotonic intraoperative fluids should be given and the intra­
venous cannula kept in situ postoperatively in case of primary
haemorrhage.
Analgesic strategies for adenotonsillectomy are the subject of
ongoing confusion and controversy. Concern has arisen over the
use of NSAIDs because of their antiplatelet effect and the poten-
tial risk of increased bleeding. A Cochrane review of this issue
concluded that there is no evidence that NSAIDs cause bleeding
that increases the need to return to theatre and that, moreover,
PONV is reduced when NSAIDs are used.6 Long-acting opioids
also cause concern because they may contribute to ongoing air-
way obstruction postoperatively. It is assumed – without much
evidence to support or refute it – that children with OSA will
exhibit the same increased sensitivity to the central nervous sys-
tem depressant effects of opioids seen in adults with OSA. For
these reasons, long-acting opioid use should be minimized as far
as possible in children undergoing adenotonsillectomy for upper
airway obstruction. Tramadol may cause fewer episodes of post-
operative desaturation than morphine.7
Postoperatively: patients should be recovered on their side in a
head-down position until fully awake. Fluids should be prescribed
postoperatively for maintenance until the child has resumed
drinking. Paracetamol and NSAIDs should be given regularly
for postoperative pain, combined with codeine (if required) in
patients with no or mild OSA.
Persistent vomiting and poor oral intake are the most com-
mon causes of unscheduled overnight admission after daycare
adenotonsillectomy. Intraoperative administration of i.v. ondan-
setron 0.05 mg/kg and dexamethasone 0.15 mg/kg are given to
prevent PONV.8 If the child has postoperative vomiting despite
antiemetic prophylaxis then maintenance intravenous fluid ther-
apy should be continued and rescue antiemetics given from a
different pharmacological class from those used for prophylaxis.
Post-tonsillectomy haemorrhage can be life threatening. This
affects about 1–2% of children in the first 24 hours, although
only about 0.06% need general anaesthesia for haemostasis.9
Close watch should be kept for bleeding, dehydration and hypo-
volaemia. Vomiting can lead to exacerbation of bleeding from the
ANAESTHESIA AND INTENSIVE CARE MEDICINE 10:4
tonsillectomy site; continued presence of blood in the vomitus
should prompt the surgeon to look for primary bleeding at the
operative site.
Length of stay: protracted emesis and primary haemorrhage
have the greatest incidence in the first 6 hours after surgery.
Duration of postoperative stay in the hospital can vary, depend-
ing on the individual patient and the surgeon. Parents should be
given clear written and verbal guidelines regarding when and
how to seek medical assistance postoperatively.
Middle ear surgery: mastoidectomy, myringoplasty and coch-
lear implantation
Anaesthetic considerations: minimize bleeding; PONV prophy-
laxis; potentially long surgery with attendant risks of pressure
injuries and hypothermia; difficult airway access; facial nerve
monitoring.
Preoperatively: assess for bleeding diatheses and risk factors for
PONV.
Intraoperatively: control of bleeding allows the surgeon to oper-
ate through the microscope in a bloodless field. Avoid hyperten-
sion and hypercarbia.
Preservation of the facial nerve is attained by use of facial
nerve monitoring and requires neuromuscular function. If neuro-
muscular block is needed to facilitate smooth intubation, choose
a dose and an agent that ensures the return of function before the
need for neuromuscular monitoring arises.
Long duration of surgery means that hypothermia is a risk.
Temperature monitoring and methods to prevent heat loss are
recommended.
Airway access is difficult during the surgery, demanding
meticulous attention to securing airway devices and breathing
circuit connections and to preventing disconnections.
Dural breach is a possible complication during middle ear sur-
gery that needs careful attention in the form of antibiotic cover
and vigilant postoperative observation.
Prevention of PONV: middle ear surgery is associated with a
high risk of PONV. Single-agent prophylaxis with ondansetron
0.15 mg/kg is always indicated and dual therapy (dexametha-
sone 0.15 mg/kg and ondansetron 0.05 mg/kg) should be given
if other risk factors are present.8 Other strategies to mitigate the
risk include good hydration, the use of total intravenous anaes-
thesia and avoidance of long-acting opioids.
Avoidance of graft displacement: when the middle ear has
been closed by a myringoplasty, termination of N2O will result in
negative middle ear pressure being applied to the graft. Avoiding
the use of N2O or switching it off about 20 minutes before the ear
is closed avoids the pressure on the newly applied graft.
Postoperatively: ongoing prevention or control of PONV and
timely analgesic interventions are the main considerations, along
with wound observation for bleeding and cerebrospinal fluid
leakage.
Surgery for congenital ear defects
Anaesthetic considerations: congenital ear defects may be asso-
ciated with Treacher Collins syndrome or Goldenhar syndrome,
in which either the first or the second branchial arch ­derivatives
188 Crown Copyright © 2009 Published by Elsevier Ltd. All rights reserved.
 Paediatrics
develop abnormally. These syndromes can pose difficulty with
tracheal intubation (see pages 201–6, in this issue). The children
present for single- or multi-stage reconstructive ear surgery, and
for insertion of temporal screws to enable ­attachment of bone-
anchored hearing aids.
Preoperatively: clarify the nature and components of the underly-
ing syndromes. Focused evaluation of the affected organ systems
should be based on syndrome components. Thorough evaluation
of the airway is mandatory to evaluate potential difficulty with
bag–valve–mask ventilation (severe mandibular hypoplasia can
make this very difficult), laryngoscopy and LMA insertion. Review
the previous anaesthetic records when available, and formulate
airway management plans accordingly. Anticholinergic agents
can be administered at this time to reduce airway secretions.
Intraoperatively: anaesthesia for short operations can be main-
tained with a LMA, but the anaesthetist must have a plan for
managing the airway in an emergency. In case of anticipated
difficult intubation and for long operations involving ear recon-
struction, endotracheal intubation should be the first choice for
securing the airway. Lengthy operations require usual attention
to fluid and electrolyte balance, glucose homeostasis, thermo-
regulation and pressure area care. Invasive arterial monitoring
is appropriate.
Postoperatively: ongoing management of pain, PONV if present
and maintenance of fluid balance.
Laser surgery of the larynx
The laser (light amplification by stimulated emission of radia-
tion) has been used in ENT surgery since the introduction of the
carbon dioxide laser for laryngeal surgery. Table 4 shows the
commonly used lasers for airway surgery.
Anaesthetic considerations: the details of the airway pathology
for which laser therapy is indicated must be appreciated. Laser
safety protocols should be followed. Postoperative disposition
should be planned.
Preoperatively: the anatomical location of the lesion, degree
of airway obstruction and its nature – fixed/dynamic/both –
should be evaluated. This information will help determine the
Characteristics of lasers used for airway surgery
Laser Colour Wavelength Tissue
medium (nm) penetration (mm)
CO2 Far infrared 10,600 < 0.25
Nd:YAG Near infrared 1064 2–6
KTP Green 532 0.5–2.0
Argon Blue/green 488/515 0.5–2.0
KTP, potassium titanyl phosphate; Nd:YAG, neodymium-doped yttrium
aluminium garnet.
Table 4
ANAESTHESIA AND INTENSIVE CARE MEDICINE 10:4
a­ nticipated degree of difficulty in maintaining an airway during
anaesthesia, whether the patient can and/or should be intubated,
and whether a spontaneously ventilating technique is required.
Infective pathologies, such as laryngeal papillomatosis, require
regularly repeated surgery, and past anaesthetic records are a
valuable source of information. Obstructing airway pathologies
in neonates and infants, such as congenital cysts or laryngo- or
tracheomalacia, are extremely challenging to manage and justify
critical care-level monitoring postoperatively.
Intraoperatively: deaths resulting from the use of medical lasers
have been associated with upper airway surgery, when the tra-
cheal tube has been ignited. Since nitrous oxide is a better oxidiz-
ing agent than oxygen, an inspired oxygen concentration below
30% in nitrogen or helium is recommended. Laser-resistant
tracheal tubes can be used, but are not available for very small
infants. These are constructed of a flexible stainless-steel spiral,
with twin distal cuffs that are filled with saline. Alternatively,
conventional polyvinylchloride (PVC) tubes may be wrapped
with adhesive metal tape. Oxygen insufflation without resorting
to tracheal intubation can be useful to provide a clear view of an
unobstructed glottis. For satisfactory insufflation technique, an
adequate depth of anaesthesia is vital to avoid adverse events
such as coughing, bucking and laryngospasm. Topical lidocaine
sprayed on the cords is essential for the success of this technique.
If the depth of anaesthesia is too great the patient may become
apnoeic or develop cardiovascular instability. Careful titration of
propofol and remifentanil infusions can be used for this proce-
dure, although volatile anaesthetics have traditionally been used.
Other standard laser precautions should be observed: the patient’s
eyes should be taped shut and covered with moist gauze pads.
Any exposed facial hair on the patient (e.g. eyebrows) should be
coated with aqueous lubricating jelly to make it non-combustible.
During lower airway surgery, the laser fibre tip should be kept
in constant view, and should be activated only when clear of the
bronchoscope or tracheal tube. Only the person using the laser
should activate it; it should be placed in standby mode whenever
it is not in active use. The operating theatre should be designated
a ‘laser controlled area’ and warning signs placed at all entry
points. While the laser is in use, windows should be covered and
doors secured to prevent injury to passers by. All personnel in the
theatre should wear appropriate eye protection.
Postoperatively: the location and level of postoperative care is
determined by the patient’s age and pathology. Bleeding and
oedema are typically minimal after laser surgery and obstructive
symptoms often show immediate improvement. ◆
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