Is a flexible Laryngeal Mask Airway (LMA) suitable for tonsillectomy?

From the Guidelines

Flexible laryngeal mask airways (LMAs) are not recommended for tonsillectomy procedures due to the high risk of airway complications and aspiration. The standard approach for tonsillectomy is endotracheal intubation, which provides a secure airway, prevents aspiration of blood, and gives the surgeon unobstructed access to the surgical field. While flexible LMAs can be used in some head and neck procedures, tonsillectomy presents specific challenges that make them unsuitable, as noted in the French guidelines for airway management in children under anesthesia 1. The surgical site is in close proximity to the airway, increasing the risk of LMA displacement during the procedure. Additionally, tonsillectomy involves significant bleeding that could potentially enter the airway, and an LMA does not provide the same level of airway protection against aspiration as an endotracheal tube. Some studies have compared the use of LMA and endotracheal tubes in adenoidectomies and tonsillectomies, but these studies are limited by their small sample size and variable ventilation parameters, as seen in the study by Serpina 1. The experts suggest that the cricoid pressure maneuver during rapid sequence induction should not be performed to decrease the incidence of respiratory complications, but this does not directly impact the choice of airway device for tonsillectomy 1. For these reasons, a cuffed endotracheal tube remains the airway management device of choice for tonsillectomy procedures to ensure patient safety and optimal surgical conditions. Key considerations for airway management in tonsillectomy include:

• Preventing aspiration of blood and other debris
• Maintaining a secure airway
• Providing unobstructed access to the surgical field
• Minimizing the risk of airway complications, such as laryngospasm and desaturation, as discussed in the meta-analysis of LMA removal techniques 1.

From the Research

Suitability of Flexible Laryngeal Mask Airway (LMA) for Tonsillectomy

• The use of a flexible Laryngeal Mask Airway (LMA) for tonsillectomy has been studied in several research papers 2, 3, 4, 5, 6.
• A study published in 2012 compared the occurrence of respiratory problems during adenotonsillectomies using either a disposable LMA or an endotracheal tube (ETT) 2.
• The results showed that performing adenotonsillectomies using a LMA resulted in a lower intraoperative oxygen saturation (SpO2) compared to using a TT, and in some cases, the LMA had to be replaced with an ETT.
• Another study published in 2010 compared the use of a reinforced LMA with an ETT for adenotonsillectomies in children 3.
• The results showed that the LMA group had significantly lower maximal pain during the first 4 hours postoperatively and spent less time in the operating room after surgery.
• A systematic review and meta-analysis published in 2024 compared the safety and efficacy of the LMA versus ETT in adenotonsillectomy 4.
• The results showed that the use of LMA yielded significantly shorter operative time and emergence time, and there was no significant difference in perioperative respiratory adverse events.
• A study published in 2022 compared the effectiveness of flexible LMA insertion and endotracheal intubation in pediatric patients undergoing adenotonsillectomy surgery 5.
• The results showed that the F-LMA group had shorter insertion and recovery times, lower airway pressure measurements, and an adequate operative field of view.
• A retrospective review published in 2013 examined the predictors of failure and complications of LMA use in pediatric adenotonsillectomy 6.
• The results showed that the incidence of LMA failure was 6.8%, and patients who underwent adenoidectomy had significantly lower odds of LMA failure compared to patients who had a tonsillectomy or adenotonsillectomy.

Key Findings

• The flexible LMA can be a suitable alternative to ETT for tonsillectomy, with benefits including shorter operative time and emergence time 4, 5.
• However, the use of LMA may be associated with a higher incidence of complications, mainly due to airway obstruction following insertion of the LMA or McIvor gag placement 6.
• Appropriate patient selection, careful insertion, and avoidance of controlled ventilation may decrease the incidence of LMA failure 6.
• The ability of surgeons to work around the LMA can modify the failure rate significantly 6.