Paediatric airway and adenotonsillar disease

Definition / Overview

Adenotonsillar disease encompasses recurrent and chronic infection of the palatine tonsils and pharyngeal adenoid, adenotonsillar hypertrophy causing obstructive symptoms, and the complications arising from each. Tonsillectomy (with or without adenoidectomy) remains one of the most frequently performed surgical procedures in children in Australia and New Zealand.

Three principal indications drive surgical referral:

• Recurrent tonsillitis: frequent, culture-proven or clinically confirmed episodes of acute bacterial or viral tonsillitis
• Sleep-disordered breathing (SDB) and obstructive sleep apnoea (OSA): caused by lymphoid hypertrophy narrowing the upper airway
• Peritonsillar abscess (PTA) and other infective complications

Applied Anatomy: Surgical Relevance

Palatine Tonsil

• Occupies the tonsillar fossa between the palatoglossal arch (anterior pillar) and the palatopharyngeal arch (posterior pillar)
• Arterial supply: tonsillar branch of the dorsal lingual artery (inferiorly, most significant in post-tonsillectomy haemorrhage), ascending palatine and facial arteries, ascending pharyngeal artery, and the greater palatine artery superiorly
• Nerve at risk: the glossopharyngeal nerve (CN IX) runs deep to the posterior pillar and inferior pole; injury causes ipsilateral taste loss and referred otalgia
• The parapharyngeal space and internal carotid artery lie just lateral to the tonsil capsule, separated only by the superior pharyngeal constrictor: aberrant carotid anatomy or deep dissection beyond the capsule risks catastrophic haemorrhage

Adenoid

• Located on the posterior wall of the nasopharynx at the roof, between the Eustachian tube orifices
• Lymphoid tissue here can obstruct the choanae and the Eustachian tube, contributing to otitis media with effusion (OME) and nasal obstruction
• The Eustachian tube opening is immediately lateral: overzealous adenoidectomy or thermal spread can injure this structure
• Velopharyngeal insufficiency (VPI): removal of adenoid tissue in a child with an occult or overt submucous cleft palate can unmask or create VPI; the posterior nasal spine and bifid uvula are key examination findings

Tonsillar Grading (Brodsky Scale)

Sleep-Disordered Breathing and Paediatric OSA

Spectrum

SDB in children ranges from primary snoring (no gas-exchange abnormality, no arousal) through upper airway resistance syndrome to frank obstructive sleep apnoea. OSA is defined polysomnographically as an apnoea-hypopnoea index (AHI) $\geq 1$ event/hour in children (normal $< 1$).

Pathophysiology

Adenotonsillar hypertrophy narrows the calibre of the pharyngeal airway. During sleep, pharyngeal dilator muscle tone falls, and the enlarged lymphoid tissue occludes the airway. Repeated cycles of obstruction, hypoxaemia, hypercapnia, arousal, and re-opening disrupt sleep architecture and trigger sympathoadrenal responses. Chronic intermittent hypoxaemia has downstream effects on neurocognitive development, cardiovascular regulation, growth (via IGF-1 disruption during slow-wave sleep), and enuresis.

Clinical Features

• Witnessed apnoeas, loud snoring, restless sleep, nocturnal mouth breathing
• Paradoxical inward rib-cage movement and suprasternal recession during sleep
• Daytime consequences: behavioural disturbance, inattention/hyperactivity (frequently misattributed to ADHD), poor school performance, morning headache
• Growth retardation: insufficient growth hormone release during disrupted slow-wave sleep
• Enuresis; rarely, cor pulmonale in severe longstanding cases

Indications for Polysomnography (PSG) Prior to Tonsillectomy

PSG should be obtained before proceeding to tonsillectomy when:

• The diagnosis is uncertain or tonsillar size is discordant with reported symptom severity
• Significant comorbidities exist that increase surgical risk or may independently contribute to SDB: craniofacial anomalies (e.g. Pierre Robin, Down syndrome), neuromuscular disease, sickle cell disease, mucopolysaccharidoses, or morbid obesity
• The child is under 3 years of age
• Residual SDB is anticipated post-operatively (multifactorial OSA)

OSA Severity Thresholds in Children (Paediatric PSG)

Management of Adenotonsillar Disease

Indications for Tonsillectomy: Recurrent Tonsillitis

The Paradise criteria (modified) are the standard threshold used in AU/NZ practice:

• $\geq 7$ documented episodes in the preceding 12 months, OR
• $\geq 5$ episodes/year for 2 consecutive years, OR
• $\geq 3$ episodes/year for 3 consecutive years

Each episode should meet at least one of: temperature $>38.3^\circ\text{C}$, cervical lymphadenopathy, tonsillar exudate, or positive Group A streptococcal (GAS) test.

Additional indications include:

• Peritonsillar abscess (especially recurrent or after one episode with failure of conservative management)
• PFAPA syndrome (periodic fever, aphthous stomatitis, pharyngitis, adenitis) where medical management has failed
• Unilateral tonsillar hypertrophy raising concern for neoplasm (lymphoma, SCC)

Indications for Adenoidectomy

• Adenoidal hypertrophy contributing to SDB or nasal obstruction
• Recurrent or chronic otitis media with effusion (OME): adenoidectomy at time of second grommet insertion is supported by evidence; reduces the need for further tube insertions by reducing nasopharyngeal bacterial biofilm burden
• Chronic rhinosinusitis in children where adenoid acts as a bacterial reservoir
• Adenoidectomy alone (without tonsillectomy) for SDB is appropriate when tonsils are small (grade 1+)

Pre-operative Assessment for Adenotonsillectomy

1. Clinical history: severity and frequency of SDB versus infective symptoms; comorbidities; family history of bleeding disorders
2. Physical examination: weight and growth centile; tonsillar grade; presence of retrognathia, macroglossus, or craniofacial dysmorphism; bifid uvula or submucous cleft palate
3. Coagulation screen: not routine; obtain when personal/family history of excessive bleeding, unexplained bruising, prolonged bleeding from prior procedures, or menorrhagia
4. PSG: per criteria above
5. Contraindication to adenoidectomy: submucous cleft palate or established VPI; confirm palatal integrity before proceeding

Intraoperative Considerations

Anaesthesia:

• Single intraoperative dose of intravenous dexamethasone (0.15-0.5 mg/kg, maximum 8 mg) reduces postoperative nausea, vomiting, and pain; this is strongly evidence-supported and standard of care
• NSAIDs: ibuprofen is safe and effective; does not significantly increase haemorrhage risk at standard doses in children. Ketorolac is avoided by many units for post-tonsillectomy use
• Codeine is contraindicated in children under 12 years following paediatric fatalities from ultra-rapid CYP2D6 metabolism converting codeine to toxic morphine concentrations; regulatory bodies in Australia, the UK, and North America have restricted or banned its use post-tonsillectomy
• Paracetamol remains a cornerstone; low-dose opioids (e.g. fentanyl intraoperatively, oral oxycodone judiciously) may be used with caution in higher-risk patients
• Dexmedetomidine is an alternative adjunct; provides analgesia and sedation with less respiratory depression than opioids, though pain scores may be higher

Surgical technique:

• Extracapsular (cold steel) dissection with ties or bipolar haemostasis: the historical benchmark
• Coblation (radiofrequency ablation at low temperature): reduces intraoperative blood loss and is associated with faster recovery; secondary haemorrhage rates are broadly comparable when adequately powered studies are analysed
• Electrocautery dissection: efficient; evidence suggests higher rates of secondary haemorrhage compared to cold steel in some series
• Intracapsular (partial) tonsillectomy or tonsillotomy: preferred by some units for SDB in young children to preserve immunological function and reduce haemorrhage risk; risk of tonsillar regrowth

Post-operative care and admission criteria:

Patients should be admitted overnight (not day-case) when any of the following apply:

• Age less than 3 years
• Severe OSA: AHI $\geq 10$ events/hour, oxygen saturation nadir $< 80\%$, or both
• Comorbidities including craniofacial anomalies, neuromuscular disease, obesity, sickle cell disease
• Home more than 1 hour from a hospital with paediatric surgical facilities
• Respiratory complications in recovery

Children with severe OSA may require high-dependency or ICU monitoring post-operatively. Respiratory complication rates following adenotonsillectomy for OSA approach 10% overall; however, in children with no comorbidity, complications beyond 6 hours post-operatively occur in approximately 1%, supporting day-case surgery in this select low-risk group. Complication rates in those with comorbidity remain substantially higher (around 20%) through the 6-hour window.

Post-Tonsillectomy Haemorrhage (PTH)

Post-tonsillectomy haemorrhage is the most significant and potentially life-threatening complication of tonsillectomy. It is the principal quality metric for surgical audit.

Classification

Overall PTH rate: approximately 3-5% (primary and secondary combined). Surgeons in AU/NZ are expected to calculate and audit their own primary and secondary haemorrhage rates annually.

Risk Factors for Secondary PTH

• Electrocautery or powered techniques at high energy settings (higher thermal tissue damage)
• Inadequate post-operative hydration leading to dry slough
• Local wound infection (GAS most common)
• Age: adolescents and adults have higher rates than young children
• Active infection at time of surgery

Assessment and Resuscitation

Primary survey: Airway-Breathing-Circulation

1. Assess the airway first: blood in the pharynx from PTH can cause aspiration, laryngospasm, or complete airway obstruction; the child may present with haematemesis (swallowed blood) or bright red oral bleeding
2. Establish IV access; send FBC, coagulation studies, group and crossmatch
3. IV fluid resuscitation: 10-20 mL/kg normal saline bolus if haemodynamically compromised
4. Continuous pulse oximetry and cardiac monitoring
5. Keep nil by mouth; aspirate stomach contents (consider nasogastric tube)
6. Notify the on-call anaesthetist and most senior available surgeon immediately
7. Contact the operating theatre: all active PTH must be treated as a potential surgical emergency

Estimating blood loss in children:

• Total blood volume: $\approx 80\,\text{mL/kg}$ in children
• Haemodynamic compromise occurs once $>25\%$ of circulating volume is lost
• Tachycardia and pallor are early signs; hypotension is a late and ominous sign in children

Management by Severity

Return to Theatre: Anaesthetic Considerations

This is a high-risk scenario. Key principles:

• Full stomach must be assumed (swallowed blood)
• Modified rapid sequence induction (RSI) with in-line suction immediately available
• Positioning: consider lateral (tonsil position) with head-down tilt to reduce aspiration risk until airway secured; this is sometimes called the "position of comfort" for bleeding tonsil
• Pre-oxygenate thoroughly; the child may be hypovolaemic and desaturate rapidly
• A smaller-than-expected endotracheal tube may be required if pharyngeal oedema or clot is present
• Have a surgical airway plan confirmed before induction
• Avoid awake fibreoptic intubation in young children unless all other options are exhausted; it is rarely practical

Surgical Haemostasis at EUA

• Evacuate clot thoroughly before identifying the bleeding point
• Bipolar diathermy to a visible vessel in the tonsillar fossa
• Figure-of-eight suture ligature for persistent arterial bleeding
• Tonsillar fossa packing is a temporising measure only
• Angiography and embolisation are rarely required but should be available at a major centre if surgical haemostasis fails

Peritonsillar Abscess (Quinsy)

Pathophysiology

PTA represents suppuration in the space between the tonsil capsule and the superior pharyngeal constrictor muscle, involving the peritonsillar salivary glands (Weber glands). The most common organism is GAS; however, PTA is frequently polymicrobial with anaerobes (Fusobacterium, Bacteroides species). It is the most common deep neck space infection in adults and older adolescents.

Clinical Features

• Severe unilateral sore throat, odynophagia, trismus
• Hot potato voice (muffled, plummy quality from pharyngeal oedema)
• Uvular deviation towards the contralateral side
• Peritonsillar bulge (superior pole) with displaced tonsil medially and anteriorly
• Drooling, inability to swallow secretions

Management

1. Assess airway; involve anaesthetics early if trismus is severe or signs of impending airway compromise
2. Intravenous antibiotics: amoxicillin-clavulanate IV, or benzylpenicillin plus metronidazole for broader anaerobic cover
3. Intravenous steroids (dexamethasone 0.1-0.15 mg/kg IV): reduce oedema, improve symptoms, and facilitate drainage
4. Drainage: needle aspiration (first-line in cooperative patients) or incision and drainage; success rates are equivalent; aspiration is better tolerated
5. Quinsy tonsillectomy (immediate tonsillectomy): reserved for systemic toxicity, impending airway compromise, failure of drainage, or prior PTA history
6. Interval tonsillectomy: indicated after a second PTA or at patient/parent request

Complications of Adenotonsillar Surgery: Summary

Consent and Communication of Risk

When consenting families for adenotonsillectomy:

• Explain the indication clearly: recurrent infection versus OSA; different natural histories and benefits from surgery
• Quote your own institutional haemorrhage rates (primary and secondary); the national benchmark of 3-5% for secondary PTH should be referenced
• Specifically warn about the risk of return to theatre for haemorrhage and that this may occur up to 2 weeks post-operatively
• Discuss the possibility of admission rather than day-case surgery for high-risk patients
• Address pain management: 7-10 days of analgesic requirement; soft diet; avoidance of aspirin-containing products
• For adenoidectomy: warn of VPI risk and screen for submucous cleft palate beforehand; inform of the possibility of the adenoid regrowing in young children
• Acknowledge that surgery for OSA does not guarantee resolution: multifactorial contributors (obesity, craniofacial anatomy) may require further management (CPAP, orthodontic referral)
• Document the consent discussion contemporaneously

Audit, Governance, and Surgical Quality

• Surgeons in Australia and New Zealand performing tonsillectomy are expected to maintain prospective data on their primary and secondary haemorrhage rates, broken down by technique (dissection versus coblation versus diathermy) and energy settings
• Regular morbidity and mortality review within the department is standard practice; adverse outcomes involving PTH should be presented and peer-reviewed
• Trainees must be directly supervised until competency in tonsillectomy is formally assessed and documented
• Introduction of new techniques (e.g. coblation) requires appropriate proctored training before independent practice

Key Clinical Decision Points: Summary Table