Pediatric Otolaryngology

Anna H. Messner MD¹

Kevin Huoh MD¹

Samuel A. Mireles MD²

Ellen Wang MD²

Gregory B. Hammer MD²

¹SURGEONS

²ANESTHESIOLOGISTS

MYRINGOTOMY AND TYMPANOSTOMY TUBE PLACEMENT

SURGICAL CONSIDERATIONS

Description: Tympanostomy (PE or pressure equalizing) tubes are placed in the patient with chronic serous otitis media (fluid in the middle ear for > 3 mo) or recurrent acute otitis media (6 or more episodes of otitis media over the prior yr). Occasionally, PE tubes are placed in a child with meningitis of otitic origin or with acute otitis media that is unresponsive to antibiotics. The patient is supine and the OR table in the 0° position. The microscope is positioned over the bed and the head turned to expose the ear. An ear speculum is inserted into the ear canal, cerumen is removed, and an incision is made in the tympanic membrane. Fluid is sometimes suctioned from the middle ear; then, a tympanostomy tube is inserted into the ear, straddling the tympanic membrane. Antibiotic ear drops frequently are inserted into the external auditory canal. Sometimes lidocaine and/or oxymetazoline drops are also inserted into the ear canal. The surgeon moves to the other side of the table, the microscope is repositioned, the head is turned, and the procedure is repeated on the other ear.

Usual preop diagnosis: Chronic serous otitis media (CSOM); recurrent acute otitis media (RAOM)

ANESTHETIC CONSIDERATIONS

PREOPERATIVE

The majority of children presenting for PE tubes are < 3 yr and generally in good health. Many of these children, however, have recurrent URI, which contributes to edema of the eustachian tubes, predisposing to episodes of acute otitis media. Intervals between URI may be brief, and scheduling surgery during these interludes is often impractical.
Children with mild URI generally can be anesthetized safely for PE tube placement because tracheal intubation is generally not performed. Surgery should be delayed for patients with acute, febrile illnesses and in those with Sx referable to the lower airways (e.g., productive cough, wheezing). Surgery need not be delayed if fever is 2° acute otitis media.

Respiratory	Surgery in patients with URI Sx referable to the extrathoracic airway alone is generally not delayed. These Sx include nasal congestion and/or discharge and mild conjunctivitis. Fever accompanied by productive cough and wheezing are Sx of lower respiratory tract involvement and should prompt rescheduling of the procedure 2-3 wk after these Sx have abated. In borderline cases (e.g., those with rales auscultated on chest exam but no other lower tract Sx), O₂ sat may be measured by pulse oximetry. Procedures in patients with SpO₂ < 95% should be deferred.
Laboratory	None
Premedication	Some practitioners advocate withholding premedication, as the duration of action of the premed may outlast the surgery. In general, however, we administer oral midazolam to patients > 9 mo (see p. D-1) and have not found a significant related delay in discharge from PACU. Parental presence in the OR may obviate the need for premedication in selected cases.

INTRAOPERATIVE

Anesthetic technique: GA via face mask

Induction	A standard inhalation induction with sevoflurane and O₂ ± N₂O is performed with routine monitoring. An oral airway commonly is inserted, as soft tissue obstruction may occur when the head is turned fully to the side during surgery. CPAP 5-8 cmH₂O also may be useful in maintaining airway patency. Following induction, a one-time dose of rectal acetaminophen (30-40 mg/kg) may be given for postop analgesia.
Maintenance	Marked agitation (“emergence delirium”) has been noted following emergence from sevoflurane and other inhaled agents. A variety of strategies have been used to minimize this phenomenon, including nasal or im fentanyl (1-2 mcg/kg) or im morphine (0.1 mg/kg). Because an IV catheter is not placed routinely, IV drugs are not usually given.
Emergence	For bilateral procedures, the potent inhaled anesthetic is D/C’d before or during the 2nd myringotomy to facilitate prompt emergence. N₂O is continued until the completion of surgery. As the patient is awakening, gentle oropharyngeal suctioning can be performed.
Blood and fluid requirements	None
Monitoring	Standard monitors (see p. D-1).
Positioning	[check mark] and pad pressure points [check mark] eyes
Complications	Laryngospasm	Secretions → laryngospasm 2° irritation of the vocal cords, especially in children with URI. Rx: 100% O₂ and CPAP or manual ventilation with PEEP ≤ 20-25 cmH₂O. Propofol 1-2 mg/kg iv may be given if iv is present to help break laryngospasm and to facilitate ventilation. If no improvement, succinylcholine (2-4 mg/kg im, or 0.5-1 mg/kg iv if iv is present) may be needed if a significant decrease in SpO₂ occurs and ventilation is not possible. Atropine (0.01 mg/kg iv or im, minimum 0.1 mg) may be given to mitigate bradycardia associated with hypoxia as well as a potential side effect of succinylcholine. Oropharyngeal suctioning and manual ventilation usually result in resolution of the laryngospasm. Rarely, tracheal intubation may be indicated for recurrent laryngospasm.

POSTOPERATIVE

Complications	Laryngospasm	Laryngospasm may occur and should be treated as described above.
Pain management	Acetaminophen 10 mg/kg po/iv q 6 h, or 30-40 mg/kg pr loading dose, followed by 20 mg/kg q 6 h Ibuprofen 10 mg/kg po Fentanyl 1 mcg/kg iv, or hydromorphone 2 mcg/kg iv	Consider previously administered po and/or pr dosing.

Suggested Readings

1. Haupert MS, Pascual C, Mohan A et al: Parental satisfaction with anesthesia without intravenous access for myringotomy. Arch Otolaryngol Head Neck Surg 2004; 130(9):1025-8.

2. Hippard HK, Govindan K, Friedman EM et al: Postoperative analgesic and behavioral effects of intranasal fentanyl, intravenous morphine, and intramuscular morphine in pediatric patients undergoing bilateral myringotomy and placement of ventilating tubes. Anesthe Analg 2012; 115(2):356-363.

3. Hoffmann KK, Thompson GK, Burke BL, et al: Anesthetic complications of tympanostomy tube placement in children. Arch Otolaryngol Head Neck Surg 2002; 128(9):1040-3.

4. Landsman IS, Werkhaven JA, Motoyama EK: Anesthesia for pediatric otorhinolaryngologic surgery. In: Davis PJ, Cladis FP, Motoyama EK, eds. Smith’s Anesthesia for Infants and Children, 8th ed. Elsevier, Philadelphia: 2011, 786-820.

5. Lee JA, Jeon YA, Noh HI, et al: The effect of ketamine with remifentanil for improving the quality of anesthesia and recovery in pediatric patients undergoing middle-ear-ventilation tube insertion. J Int Med Res 2011; 39(6):2239-46.

6. Lin YC, Tassone RF, Jahng S, et al: Acupuncture management of pain and emergence agitation in children after bilateral myringotomy and tympanostomy tube insertion. Paediatr Anaesth 2009; 19(11):1096-101.

7. Olutoye OA, Watcha ME: Eyes, ears, nose and throat surgery. In: Gregory GA, Andropoulos DB eds. Pediatric Anesthesia, 5th ed. Wiley-Blackwell, Oxford: 2012, 777-809.

8. Pappas AL, Fluder EM, Creech S et al: Postoperative analgesia in children undergoing myringotomy and placement equalization tubes in ambulatory surgery. Anesth Analg 2003; 96(6):1621-4.

9. Vornov P, Tobin MK, Bilings K, Cote CJ, Iyer A, Suresh S: Postoperative pain relief in infants undergoing myringotomy and tube placement: comparison of a novel regional anesthetic block to intranasal fentanyl-a complete analysis. Paediatr Anaesth. 2008; 8(12):1196-201.

TONSILLECTOMY AND ADENOIDECTOMY

SURGICAL CONSIDERATIONS

Description: The dissection is carried out with the patient supine, shoulders slightly elevated by a shoulder roll (typically, a rolled towel). A mouth gag is inserted, and a small suction catheter is passed through the nose and brought out the mouth to elevate the soft palate and expose the nasopharynx. The adenoids are viewed with a mirror and/ or palpated. A curette, adenotome, microdebrider, or suction electrocautery is used to remove the adenoids; then, typically, the nasopharynx is packed. There are two major types of tonsillectomy: total tonsillectomy and subtotal (partial) tonsillectomy. The traditional total tonsillectomy is performed by grasping the tonsil with Allis forceps and pulling it medially. A vertical incision is made in the anterior tonsillar pillar with a sickle knife, scissors, or electrocautery instruments; then, the tonsil is dissected from the surrounding tissue and removed. A snare may be used to amputate the inferior pole of the tonsil before removal. Hemostasis is obtained through use of packs and suction electrocautery. After hemostasis has been obtained in the tonsillar fossae, the pack is removed from the nasopharynx, and hemostasis is achieved in the nasopharynx using suction electrocautery. Tonsils can also be completely removed using radiofrequency (Coblation), bipolar scissors, bipolar forceps, or laser. The same approach and setup is used for a subtotal tonsillectomy, which can be performed using radiofrequency or a microdebrider. The literature on incisional local anesthetic injection is mixed with some studies reporting benefit and some showing no benefit. Therefore, injection is not generally recommended.

Usual preop diagnosis: Obstructive sleep apnea (OSA); chronic tonsillitis and/or adenoiditis; tonsillar and adenoid hypertrophy; asymmetric enlargement of tonsils (to r/o cancer)

▪ SUMMARY OF PROCEDURE

Position	Supine, shoulder roll, head extended; table turned 90°; surgeon at head of table
Incision	Intraoral mucosal
Special instrumentation	Mouth gag (McIvor, Crowe-Davis, Dingman)
Unique considerations	Observe for compression of ETT or accidental extubation when mouth gag is manipulated. Patients with Down syndrome may need to be evaluated preop for possible atlantoaxial subluxation, as the neck is typically extended. A single dose of dexamethasone (0.5 mg/kg) is recommended for children undergoing tonsillectomy.
Antibiotics	Not used routinely.
Surgical time	30 min
EBL	10-200 mL. Monitor closely.
Postop care	Lateral position; suction in midline only. Most commonly, PACU → home. Overnight stay, if < 2 yr, severe OSA, or other comorbidities.
Mortality	Rare
Morbidity	Bleeding: 2-3% Aspiration: Rare Tooth damage: Rare
Pain score	Adenoidectomy, 3-5; tonsillectomy, 6-9

ANESTHETIC CONSIDERATIONS

PREOPERATIVE

Although most children presenting for tonsillectomy and/or adenoidectomy are healthy, a variety of medical problems may coexist. Severe adenoidal hyperplasia may cause nasopharyngeal obstruction, obligate mouth breathing, failure to thrive 2° poor feeding, and disturbances of speech and sleep. Chronic nasal obstruction may result in narrowing of the upper airway and dental and facial changes (so-called adenoidal facies). Tonsillar hyperplasia may cause airway obstruction, OSA, CO₂ retention, cor pulmonale, and failure to thrive. Most of these changes are reversible with removal of the adenoids and tonsils. Children presenting for adenoidectomy/tonsillectomy also frequently have URI (see Anesthetic Considerations for Myringotomy and Tympanostomy Tube Placement p. 1210).

Respiratory	See discussion under Anesthetic Considerations for Myringotomy and Tympanostomy Tube Placement (see p. 1210).
Dental	Examination of the airway should include inspection of the teeth. Parents should be advised that loose teeth may be dislodged during placement of the mouth gag or laryngoscopy.
Cardiovascular	In children with severe OSA, CXR and EKG should be done to evaluate the presence of cor pulmonale. If significant RVH and/or cardiomegaly are present, consider ECHO and consultation by pediatric cardiologist.
Hematologic	A careful Hx is taken for Sx of easy bruising or bleeding. If present, a CBC with Plt count, as well as PT, INR, PTT, and bleeding time are performed. In patients with a negative Hx, we order no preop lab tests.
Premedication	Children with severe OSA (airway obstruction) who are very anxious may receive a reduced dose of oral midazolam (see p. D-1) in a well-monitored environment (e.g., with an experienced RN or member of the anesthesia team present). SpO₂ should be monitored following administration of premedication.

INTRAOPERATIVE

Anesthetic technique: GA with ETT or LMA

Induction	Standard inhalation induction (see p. D-1) is common, but IV induction with propofol can be faster and safer, especially in patients with severe OSA; airway obstruction is common in these patients and usually is alleviated with placement of an oral airway and administration of CPAP: 10-20 cmH₂O. An IV catheter should be placed as soon as possible. Propofol (2 mg/kg) is usually given to facilitate intubation. If needed rocuronium (0.5 mg/kg) may be used. Glycopyrrolate (4-6 mcg/kg) may be used if needed to reduce secretions. If intubation is planned, an oral ETT (standard or RAE) is used and taped securely to the midline position to facilitate placement of the mouth gag. A cuffed ETT is commonly used because, in combination with a throat pack, it minimizes the risk of entry of blood and oral secretions into the trachea during surgery. Care should be exercised that the inferior part of the endotracheal tube is long enough for the cuff to pass beyond the vocal cords. A short tube may easily dislodge with changes in head position, or the cuff may cause vocal cord trauma. Bilateral breath sounds and chest excursion should be confirmed after placement of the mouth gag, which may cause kinking and obstruction of the ETT. An LMA (flexible or reinforced LMA) can be used as an alternative to the ETT in healthy, nonobese patients without OSA, with advantages of reduced airway irritation and total procedure time. Problems with the LMA include inadequate surgical exposure and leaking or kinking resulting in conversion to an ETT.
Maintenance	Standard maintenance (see p. D-3). An intermediate-acting NMR (e.g., rocuronium 0.6-1.0 mg/kg or vecuronium 0.1 mg/kg) may be given to facilitate tracheal intubation if needed. Opioids (e.g., fentanyl 2-3 mcg/kg, hydromorphone 3 mcg/kg or morphine 0.02-0.05 mg/kg) are given for postop analgesia. Acetaminophen (30-40 mg/kg) may be given PR after induction (↓ dose if PO acetaminophen given with premedication). IV acetaminophen (10 mg/kg) may also be used. Dexmedetomidine (1 mcg/kg bolus over 10 min, followed by 0.4-0.7 mcg/kg/h infusion) can be used as an adjunct to reduce opioid requirements and emergence agitation. The use of propofol, ± remifentanil, instead of anesthetic vapor, may ↓ the incidence of PONV, which is common following tonsillectomy/adenoidectomy. Ondansetron (0.1 mg/kg, up to 1 mg) and dexamethasone (0.5 mg/kg) are given to reduce airway edema and PONV. Although controversial because of potential postoperative hemorrhage, perioperative use of NSAIDs can also be given to reduce PONV. Administration of 30 mL/kg of IV fluids (lactate Ringer or normal saline) has been associated with reduced PONV.
Emergence	Blood and secretions should be suctioned from the oropharynx and stomach following the completion of surgery. The patient should be fully awake before tracheal extubation, which may be performed supine or in the lateral position with the head down. Verify removal of throat packs. Alternatively, extubating under deep anesthesia decreases coughing, but requires vigilance to avoid airway obstruction and aspiration at emergence and during transport to PACU.
Blood and fluid requirements	IV: 22 or 20 ga × 1 NS/LR @ 5-10 mL/h	Blood loss is typically ˜4 mL/kg and may accumulate in the stomach → N/V (unless prevented by antiemetics).
Monitoring	Standard monitors (see p. D-1).
Positioning	[check mark] and pad pressure points [check mark] eyes
Complications	Airway obstruction ETT dislodgement/kinking	Usually caused by insertion/manipulation of mouth gag.

POSTOPERATIVE

Complications

Airway obstruction

Hemorrhage

Retention of throat pack → airway obstruction. Remove with Magill forceps. Recurrent airway obstruction may require application of positive pressure via face mask (CPAP vs manual ventilation with PEEP) ± placement of an oral airway. Severe postop airway obstruction is more common in patients < 2 yr. In these patients, admission to PICU may be necessary. CPAP via face mask or nasal mask may be helpful. On rare occasions, tracheal intubation and mechanical ventilation are required until swelling of the airway resolves.

Bleeding may occur in the immediate postop period or several days later. Patients present with anemia and hypovolemia, as well as airway compromise and a full stomach 2° swallowed blood. IV fluids, including blood, should be given before induction. Rapid-sequence intubation (see p. B-5) should be performed with cricoid pressure in preparation for surgical treatment.

Pain management

Fentanyl 1 mcg/kg iv

Hydromophone 2 mcg/kg iv or

Morphine 0.025-0.05 mg/kg iv

May be given incrementally in PACU. Subsequently, acetaminophen (10 mg/kg po) alternating with ibuprofen (10 mg/kg po) may be used. *NB: Codeine should NOT be used, as some patients may be ultrarapid metabolizers (due to cytochrome P_4SO2D6 variant), and this may lead to respiratory depression and death.