From the Guidelines
Class 1 tonsils are appropriate for general anesthesia during tonsillectomy procedures, and it is recommended to protect the upper airway with a cuffed tracheal tube. For these minimally enlarged tonsils that occupy less than 25% of the oropharyngeal space, general anesthesia is the standard approach using endotracheal intubation to secure the airway 1. A typical anesthetic regimen includes induction with propofol (2-3 mg/kg), fentanyl (1-2 mcg/kg), and a muscle relaxant such as rocuronium (0.6 mg/kg). Maintenance is achieved with sevoflurane (1.5-2.5%) or desflurane (4-6%) in oxygen and air. Dexamethasone (0.15-0.5 mg/kg, maximum 10 mg) should be administered early in the case to reduce postoperative nausea and vomiting while providing anti-inflammatory benefits. Adequate analgesia with acetaminophen (15 mg/kg IV) and ketorolac (0.5 mg/kg, maximum 30 mg) is important. Despite the smaller tonsil size, careful attention to hemostasis during emergence is essential, and the patient should be extubated fully awake in a lateral or semi-prone position to minimize the risk of airway obstruction or aspiration of blood.
Some of the key considerations for tonsillectomy include the potential benefits of reducing the frequency and severity of recurrent throat infections and obstructive sleep-disordered breathing (oSDB) 1, as well as the potential harms and adverse events, such as bleeding, nausea, vomiting, and rare cases of death 1. However, the current evidence suggests that the benefits of tonsillectomy outweigh the risks for many patients, particularly those with recurrent throat infections or oSDB 1.
The use of a cuffed tracheal tube is particularly important in protecting the upper airway during tonsillectomy, as it can help prevent aspiration and reduce the risk of respiratory complications 1. Overall, the key to successful tonsillectomy under general anesthesia is careful planning, attention to detail, and a thorough understanding of the potential benefits and risks of the procedure.
From the Research
General Anesthesia for Class 1 Tonsils
- Class 1 tonsils are typically small and may not require surgical removal, but if general anesthesia is necessary, several factors should be considered 2.
- General anesthesia for tonsillectomy has been shown to have a lower risk of airway complications when using a laryngeal mask airway (LMA) compared to endotracheal intubation 3, 4.
- The use of LMA can reduce the incidence of postoperative hoarse voice, laryngospasm, coughing, and sore throat compared to endotracheal intubation 3, 4.
Risks and Benefits of General Anesthesia
- General anesthesia for tonsillectomy has been associated with a higher risk of complications, such as respiratory and cardiac problems, compared to local anesthesia 2.
- However, modern general anesthetic techniques have reduced surgical risks, and the use of LMA can minimize airway complications 5, 3.
- The choice of anesthesia should be based on individual patient needs and medical history, as well as the surgeon's and anesthesiologist's preferences 2, 6.
Patient Selection and Care
- Appropriate patient selection, provision of robust analgesia, antiemesis, perioperative warming, and hydration are key factors to ensure patient comfort and allow same-day discharge 6.
- Patients undergoing tonsillectomy under general anesthesia should be closely monitored for potential complications, such as bleeding, respiratory problems, and cardiac issues 2, 6.
- A team effort and close collaboration between the anaesthetic, surgical, theatre, and ward teams are essential to achieve optimum outcomes and reduce the rate of failed discharges 6.